ADVERTISEMENTS:
Here is a compilation of essays on ‘Neurosis Disorders’ for class 11 and 12. Find paragraphs, long and short essays on ‘Neurosis Disorders’ for school and college students.
Essay on Neurosis Disorders
Essay Contents:
- Essay on Anxiety States
- Essay on Phobic Disorders
- Essay on Obsessive Compulsive Disorder
- Essay on Hysterical Neurosis
- Essay on Neurasthenia
- Essay on Hypochondriasis
- Essay on Reaction to Stress and Adjustment Disorders
- Essay on Grief Reaction
1. Essay on Anxiety States (Anxiety Neurosis):
Anxiety states are among the most common neurotic syndromes. They consist of a combination of physical and psychological manifestations of anxiety, not attributable to real danger, which occur either in attacks (panic disorder) or as a persisting state (generalized anxiety disorder).
Anxiety neurosis has been known by many names viz:—cardiac neurosis, Da Costa’s syndrome, Nervous exhaustion, Neurocirculatory asthenia, Soldier’s heart, Nervous tachycardia, vasomotor neurosis, vasoregulatory asthenia, disordered action of the heart, somatization psychogenic cardiovascular reaction, somatization psychogenic asthenic reaction. Le nevrose d’ angoisse.
Historical Background:
The term ‘anxiety neurosis’ was first used by Sigmund Freud in 1895.
Epidemiology:
Prevalence of about 2-4% in normal population. This constituted about 25-30% of psychiatric consultation in general practice and about 8-10% of psychiatric outpatients.
Clinical Description:
(See Table 18.2)
Panic Disorder:
It is characterized by recurrent anxiety (panic) attacks that occur at times unpredictable through certain situation e.g., driving a car.
The panic attacks are manifested by the sudden onset of intense apprehension, fear or terror, often associated with feelings of impending doom. The common symptoms experienced during an attack are dyspnoea, palpitations, chest pain or discomfort, choking or smothering sensations, dizziness, vertigo or unsteady feelings, feelings of unreality (depersonalization or derealization), paresthesias, hot and cold flashes, sweating, faintness, trembling or shaking and fear of dying, going crazy or doing something uncontrolled during the attacks. Attacks usually last minutes, more rare hours.
Generalized Anxiety Disorder:
‘The essential feature is generalized, persistent anxiety of at least one month duration without the specific symptoms that characterize phobic disorders or panic disorder, or obsessive compulsive disorder.
There are signs of:
i. Motor tension:
Shakiness, jitteriness, jumpiness, trembling, tension, muscleaches, fatiguability and inability to relax.
ii. Autonomic hyperactivity:
Sweating, heart pounding or racing, cold, clammy hands, dry mouth, dizziness, light-headedness, paresthesias (tingling in hands or feet), upset stomach, hot or cold spells.
iii. Apprehensive expectations:
The individual continually feels anxious, worries, ruminates, and anticipates that something bad will happen to himself.
iv. Vigilance and scanning:
Apprehensive expectation may cause hyperattentiveness, impatient or irritable, distractibility, difficulty in concentrating, insomnia, difficulty in falling asleep, interrupted sleep and fatigue on awakening.
Special Variants:
i. Hyperventilation syndrome:
Symptomatology includes periodic attacks of respiratory distress, giddiness, paresthesia, weakness, numbness and tingling, especially around the lips and fingertips, palpitations, chest pain, weakness and momentary loss of consciousness and even tetany. These effects appear to be related to decreased pCO2 leading to respiratory alkalosis (due to hyperventilation), decreased free ionized calcium and decreased cerebral blood flow. Either, breath holding or the bag treatment in which the patient breathes in the accumulation of CO2 from a bag held over the mouth and nose can be used for management of acute symptomatology.
ii. Post Traumatic neurosis:
This disorder is seen in veterans exposed to battle front conditions, natural disasters, car wrecks, fire, rape, torture, riots or internment in a concentration camp. Excessive alcohol and drug use are common and suicidal ideation or attempts are also common. They are treated with abreactive or restitutive therapies or drugs.
Etiology:
I. Biological Theories:
(1) Catecholeamine theory:
Elevated plasma levels of epinephrine and monoamine oxidase (that catabolizes catecholeamines)
(2) Locus coeruleus theory:
This nucleus is located in the pons and contains more than 50 per cent of all noradrenergic neurons in the entire nervous system. Electrical stimulation of the animal locus coeruleus produces marked fear and anxiety response.
(3) Carbon dioxide hypersensitivity:
Giving these patients a mixture of 5% carbon dioxide in room air to breathe causes panic attacks.
(4) Lactate panicogenic metabolic theory:
The infusion of 10 mg/kg of 0.5 molar sodium lactate infused over 20 minutes will provoke a panic attack in most patients with panic disorder but not in normal.
II. Genetic Theory:
Anxiety states occur in about 2% of the general population and about 15% to 25% of the relatives of patients with anxiety. In a twin study, 41% of monozygotic and 4% of dizygotic twin pairs were concordant for anxiety neurosis.
III. Psychoanalytic Theories:
Psychoanalytic theories describe the anxiety states as the result of castration-anxiety (Sigmund Freud); aberrant function of the biological substrate that underlies normal human separation anxiety (Melanie Klein); failed repression (Freud) or the outcome of failure to master the hypothesized development stage of separation-individuation.
IV. Learning Theories:
Anxiety may be regarded as a fearful response which has become attached by conditioning to a stimulus which is not normally anxiety provoking.
Differential Diagnosis:
It must be differentiated from:
(a) Functional Psychiatric Disorders:
Functional Psychiatric Disorders e.g., phobia, hyperventilation, chronic anxiety state, early schizophrenia, mania, agitated depression etc.
(b) Neuropsychiatric:
Neuropsychiatric., e.g., Presenile dementia, cerebral tumor etc.
(c) Medicopsychiatric:
Medicopsychiatric e.g., Hyperthyroidism, Hypoparathyroidism, Mitral valve prolapse, prophiria, drugs (stimulants, sedative withdrawal) etc.
Management:
1. Pharmacotherapy:
a. Antidepressants:
Both tricyclics and MAO inhibitors have been used.
b. Benzodiazepines:
These are safe and effective anxiolytics but because of the risk of dependence, they should be stopped after a few weeks.
c. Other medications:
Beta adrenergic blocking drugs like propranolol, are useful in a variety of anxiety disorders.
2. Psychological Treatment:
(a) Supportive Psychotherapy:
Discussion and reassurance are often sufficient.
(b) Psychodynamic psychotherapy:
It might be helpful in identifying the significant unconscious conflict.
(c) Cognitive behaviour therapy:
Behavioural treatment of panic attacks involves breathing retraining to eliminate both acute and chronic hyperventilation, relaxation and cognitive restructuring to give physical symptoms a more benign interpretation.
Prognosis:
Most anxiety states are brief and resolve spontaneously. If they last more than a few months, the outcome is poor.
2. Essay on Phobic Disorders:
Phobias are characterized by intense, persistent irrational and recurrent fear of a specific object, place, or situation that results in a compelling desire to avoid the dreaded place, activity or situation (the phobic stimulus). The fear is recognized by the individual as excessive or irrational in proportion to the actual dangerousness of the object.
History:
‘Phobos’ was a Greek God who frightened one’s enemies. ‘Phobia’ first appeared in medical terminology in Rome 2000 years ago. Westphal described agoraphobia.
Clinical Presentation:
(See Table 18.3)
Related to External Stimuli:
(a) Agoraphobia:
It is the most severe and pervasive form and is the most common, among those seeking treatment.
The clinical picture consists of:
a) Fear of being alone
b) Fear of leaving home
c) Fear of being away from home
Typical fears are of using public transportation (buses, trains, subways, planes); being in crowds, theaters, elevators, restaurants, markets and departmental stores; waiting in line, travelling a distance from home.
In addition to panic attacks, multiple phobias, chronic anxiety, depersonalization, secondary depression, multiple somatic complaints and alcohol, barbiturates or antianxiety medications abuse may occur.
(b) Social Phobia:
In social phobia, the essential feature is a persistent, irrational fear of and compelling desire to avoid situations in which the individual may be exposed to scrutiny by others. Typical social phobias are of speaking, eating or writing in public; using public lavatories and attending parties or interviews.
Spontaneous panic attacks may occur.
Individuals are prone to be episodic abuse of alcohol, barbiturates and antianxiety medication.
Social phobias constitute about 5 to 10% of phobic patients seen by psychiatrists. It often begins in late childhood or early adolescence and is more often diagnosed in females.
(c) Simple Phobia:
It is the most common type of phobic disorder in the general population. The central feature is a persistent irrational fear of and compelling desire to avoid an object or a situation other than Agoraphobia or social phobia.
The most common simple phobias involve animals. Other simple phobias are claustrophobia (fear of closed spaces) and acrophobia (fear of heights).
They are common in children and may persist into adult life.
Related to Internal Stimuli:
Illness Phobia (Nosophobia):
It constitutes about 10 to 20% of phobic patients consulting psychiatrists. It occurs equally in both sexes.
Etiology:
(i) Psychoanalytic Theory:
Freud hypothesized that phobic symptoms occur as a part of the resolution of a conflict between the impulses for libidinal or aggressive gratification and the ego’s recognition of potential danger that could result from this gratification. Ego uses repression and displacement to avoid the anxiety produced by both intrapsychic conflict and potential external danger.
(ii) Conditioned Reflex Theories:
Phobic anxiety in conditioned response acquired through association of the phobic object (the conditioned stimulus) with a noxious experience (the unconditioned stimulus).
(iii) Biological Theories:
Social phobic symptoms are accompanied in perhaps 50 percent of cases by a surge of plasma epinephrine distinguishing them from panic attacks, in which adrenaline surge is not regularly seen. Phenlylethylamine (PEA) or similar endogenous amines may be involved in mood response to social approval and disapproval.
About 32 per cent of first-degree relatives of agoraphobics had an anxiety disorder. Nine percent of the first-degree relatives had agoraphobia.
Differential Diagnosis:
Schizophrenia, major depression, obsessive compulsive disorder, paranoid and avoidant personality disorder.
Management:
Pharmacotherapy:
The tricyclic antidepressant, imipramine, the MAO inhibitor, Phenelzine and the high potency bendodiazepine Alprazolam have been shown to be effective blockers of spontaneous panic attacks. Beta- blocker, propranolol, is effective in social phobias particularly when used acutely prior to a performance.
Behaviour Therapy:
(i) Systematic desensitization:
It involves gradual exposure to phobic stimulus along hierarchy of increasing intensity until patient habituates and avoidance response is extinguished. Relaxation training is used before situational exposure.
(ii) Flooding (implosion):
It involves supervised maximum exposure to feared stimulus until anxiety reduction/exhaustion.
(iii) Modeling:
It involves observation of therapist (model) engaging in non- avoidance behaviour with the feared stimulus.
(iv) Paradoxical Intention:
It is another type of therapy conceived by FrankI to help patients overcome their phobic fears by deliberately exaggerating them.
Psychotherapy:
a. Supportive:
It consists of learning coping strategies and readjustment of life-style.
b. Psycho dynamic:
It is aimed at exploring conflicts.
3. Essay on Obsessive Compulsive Disorder:
This is an uncommon form of neurosis in which the outstanding symptoms are of obsessional thoughts or compulsive behaviours. Obsessions are recurrent persistent ideas, thoughts, images or impulses that are ego-dystonic, that is, they are not experienced as voluntarily produced but rather as thoughts that invade consciousness and are experienced as senseless or repugnant. Attempts are made to ignore, or suppress them. Compulsions are repetitive and seemingly purposeless behaviours that are performed according to certain rules or in a stereotyped fashion.
The various terms used for obsessive compulsive disorder are—obsessional state; obsessional ruminative state; constitutional syndrome or neurosis; compulsion neurosis; Phobic rumination state; psychasthenia. The term ‘Anancastic’or ‘Anancasm’. includes obsessive, compulsions, obsessive compulsive neurosis and obsessional personality.
Historical Background:
Jean Pierre Falret named it as ‘The illness of doubt’. Morel (in 1866) first used the term ‘Obsessive compulsive neuroses’.
Epidemiology:
Of general population, 0.05% suffers from this disorder at a particular time. Obsessive compulsive disorder constitutes less than 5 percent of psychiatric inpatients and outpatients.
This disorder usually begins in adolescence or early adulthood. Sex prevalence is usually equal.
Clinical Presentation:
A. Obsessions:
(i) Obsessional doubts:
This form of obsession is most common.
(ii) Obsessional thoughts:
These are usually unpleasant and repetitively intrude into consciousness (words, phrases, rhymes), interfering with the normal train of thought.
(iii) Obsessional images:
Vividly imagined scenes, often of a violent, sexual or disgusting nature (images of a child being killed, cars colliding, parents having sexual intercourse) that repeatedly come to mind.
(iv) Obsessional convictions:
Notions that are often based on the magical formula of thoughts-equals-act (‘Thinking ill of my son will cause him to die’).
(v) Obsessional rumination:
The subject is often religion or metaphysics- why and where; of questions which are as unanswerable as they are endlessly ponderable, (e.g., Who created world? What is the purpose of life?).
(vi) Obsessional impulses:
Typically related to self-injury (leaping from a window).
(vii) Obsessional fears:
B. Compulsions are of two types:
i. Yielding compulsion.
ii. Controlling compulsion.
Complications:
The common complications include—depression and the abuse of alcohol and antianxiety medications.
Etiology:
Psychoanalytic Theory:
Psychoanalytic theorists suggest that obsessive compulsive disorder develops when defense mechanisms fail to contain the obsessional character’s anxiety.
The following defense mechanisms are used:
(i) Isolation:
Gruesome thought or fantasy, but denies any feelings of anxiety or disgust associated with it.
(ii) Undoing:
An act can be undone by its opposite such as turning on and then turning off a light switch.
(iii) Reaction formation:
People might behave in a passive or masochistic manner which opposes his impulses.
(iv) Regression:
In obsessive compulsive disorder, regression is theorized to take place from a genital oedipal phase to an earlier, never fully relinquished anti-sadistic phase.
(v) Ambivalence:
In obsessive compulsive neurosis, strong aggressive impulses are thought to reemerge towards love objects.
Learning Theory:
Two stage learning theory of obsessive compulsive disorder is important. In stage 1, anxiety is classically conditioned to a specific environmental event (classical conditioning). The person then engages in compulsive rituals (escape/avoidance responses) in order to decrease anxiety. If successful in reducing anxiety, the compulsive behaviour is more likely to occur in the future (Stage 2 or operant conditioning).
Organic Factors:
Obsessional symptoms are frequent in patients following head injury, or encephalitis lethargica.
Biochemical Theories:
Serotonin has been implicated in mediating impulsivity, suicidally, aggression, anxiety, social dominance and learning. Dysregulation neurotransmitter could contribute to the repetitive obsessions and ritualistic behaviour seen in OCD patients.
Genetic:
About 80 to 90 percent of monozygotic twins are concordant for obsessional illness versus a concordance rate in dizygotic twins of no more than 50 per cent.
Early Experience:
Imitative learning, major life events such as pregnancy, delivery, illness, death of a close relative, frustration, overwork etc. may act as precipitants.
Differential Diagnosis:
(i) Schizophrenia:
An obsession is ego- dystonic, resisted and recognized as having an internal origin. A delusion is not resisted and is believed to be external.
(ii) Depression:
Depression may present with obsessions.
(iii) Phobic disorder:
Also, unlike the phobias, OCD patient can never avoid the obsession.
(iv) Obsessive personality disorders:
These can distinguished by the absence of any recognizable time of onset and the life long history of marked obsessional behaviour.
(v) Physical illnesses:
Obsessions have been observed in the following organic conditions:
Encephalitis lethargica,
Especially during oculogyric crises,
Early stages of arteriosclerotic dementia,
Post traumatic and post encephalitic stages,
Hearing loss with tinnitus,
Hypothyroidism and
Certain drugs like isoniazid, alcohol etc.
See Table 18.5 below:
Management:
Behaviour Therapy:
(i) Exposure procedures that aim to decrease the anxiety associated with obsessions.
(ii) Response prevention techniques that aim to decrease the frequency of rituals or obsessive thoughts.
Pharmacotherapy:
The most promising antidepressant clomipramine is mainly antiobsessional irrespective of depressive symptoms. The other specific 5 HT reuptake blockers Zimelidine, Fluoxetine, Sertraline and Fluvoxamine have also been demonstrated as specific antiobsessional.
Psychotherapy:
Exploratory/Interpretative/Insight psychotherapy is contraindicated. Supportive psychotherapy is helpful for acute cases and for dealing with obsessive character traits of perfectionism, doubting, procrastination and indecisiveness.
Psychosurgery:
It may lead to striking reduction in tension and distress. Cingulectomy is preferred over lobotomy.
Electroconvulsive Therapy (ECT):
The role of ECT in OCD without depression is not known and is relatively contraindicated.
Outcome:
See Table 18.6:
4. Essay on Hysterical Neurosis:
Hysteria is a mental disorder in which motives, of which the patient seems unaware, produce restriction of the field of consciousness, loss of memory or dramatic personality change (which may be called ‘dissociative states’) or disturbances of motor or sensory function (which may be called ‘conversion symptoms’).
Historical Background:
This is derived from a Greek word ‘Hystera’ meaning womb or uterus. Freud used the word ‘conversion’. Janet coined the terms ‘dissociation’ and ‘la belle indifference’ (literally ‘beautiful indifference’).
Epidemiology:
Hysteria constitutes about 5-15% of psychiatric consultation services in general hospitals. The disorder is diagnosed much more frequently in women than men. It may be seen in any age-group.
Clinical Picture:
The common physical (conversion) and mental (dissociation) symptoms of hysteria are given in Table 18.7.
Complications:
The most frequent and important complications of hysteria are repeated surgical operations, drug dependence, marital separation or divorce, depression and suicide attempts.
Etiology:
Psychoanalytic Theories:
Hysterical symptoms may therefore develop:
a) To permit expression:
To permit expression although in a masked form of a forbidden wish or impulse.
b) To impose punishment:
To impose punishment on oneself, via the disabling symptom for a forbidden wish
c) To remove oneself:
To remove oneself from an overwhelming threatening life situation.
Learning Theory:
The symptom is an ‘adaptation’ to a frustrating life experience.
Genetics:
There is no convincing evidence for a genetic aetiology.
Diagnosis:
The diagnosis of hysteria can be mistaken in three ways:
(i) The symptoms are of a physical disease which has not yet been detected (e.g., Porphyria).
(ii) Undiscovered neurological disease may ‘release’ hysterical symptoms in some unknown way (e.g., Multiple sclerosis, deep or midline brain tumours etc.).
(iii) Genuine physical disease may stimulate hysterical elaboration of symptoms in vulnerable personalities.
Differential Diagnosis:
(i) Some physical disorders such as multiple sclerosis, systemic lupus erythematosus, acute intermittent porphyria, Polyradiculopathy, cervical spondylosis, parietal or thalamic lesions.
(ii) Undiagnosed physical disorder
(iii) Somatization disorder
(iv) Psychosexual dysfunctions
(v) Psychogenic pain
(vi) Hypochondriasis: In hypochondriasis, typically there are physical symptoms, but there is no actual loss or distortion of bodily function.
(vii) Factitious disorder with physical symptoms
(viii) Malingering:
See Table 18.8:
(ix) Histrionic personality disorder:
The patient with hysterical personality is characterized by the features that she is demanding, emotionally immature, manipulative, attention seeking, narcissistic, dependent and seductive or suggestible (Mnemonic ‘Demands’).
For differences between hysterical and epileptic fit see Table 18.9 below:
Management:
Immediate management involves reassurance and the suggestion of recovery combined with resolution of any stressful circumstances that provoked the reaction. The approach involves minimizing the factors which reinforce or reward the behaviour (i.e., reducing ‘secondary gain’) and encouraging normal behaviour, (i.e., reducing ‘Primary gain’).
With the use of Suggestion, Abreaction, hypnosis or the effect of intravenous barbiturates, the patient is encouraged to relieve the stressful events which provoked hysteria and to express the accompanying emotions.
Outcome:
The prognosis for conversion disorders that are associated with recent onset, clearly identifiable precipitating events, good premorbid condition and the absence of severe associated psychopathology is usually favourable and the spontaneous remission of symptoms tends to be the rule rather than the exception.
5. Essay on Neurasthenia (Fatigue Syndrome):
History:
The term was given by Beard. Freud (1864) first separated anxiety neurosis from neurasthenia.
Clinical Picture:
In one type, the main feature is a complaint of increased fatiguability after mental effort, often associated with some decrease in occupational performance or coping efficiency in daily tasks.
In the other type, the emphasis is on feelings of bodily or physical weakness and exhaustion after only minimal effort, accompanied by a feeling of muscular aches and pain and inability to relax.
In both types, a variety of other unpleasant feelings are common, such as dizziness, tension headaches, feelings of general instability, worry about decreasing mental and bodily well-being, irritability, anhedonia, insomnia or hypersomnia and varying minor degrees of both depression and anxiety are common.
Differential Diagnosis:
(i) Psychiatric disorders.
(ii) Somatoform disorders.
(iii) Physical Disease e.g., aftermath of a physical illness (particularly influenza, viral hepatitis or infectious mononucleosis).
(iv) Drugs, e.g., beta-blockers, antipsychotics, antidepressants, anticonvulsants, drugs causing myopathy (alcohol, lithium, cimetidine etc.) and other drugs abuse.
Management:
Bed rest, leave from office, short course of antianxiety drugs and psychotherapy have been used successfully in the treatment of this disorder.
6. Essay on Hypochondriasis: (Hypochondriacal Disorder):
Hypochondriasis is defined as a persistent preoccupation with a fear or belief of having one or more serious disease(s), based on person’s own interpretation of normal body function or a major physical abnormality.
Other important features are:
1. Complete physical examination and investigations do not show presence of any significant abnormality.
2. The fear or belief persists despite assurance to the contrary by showing normal reports to the patient.
3. The fear or belief is not a delusion. Patient may agree, regarding the possibility of his exaggerating the graveness of situation, at that time.
4. Preoccupation with medical terms and syndromes is common. Repeated change of physicians is common.
The usual age of onset is the late third decade. The course is usually chronic with remissions and relapses. Obsessive personality traits and narcissistic personality features are frequently seen in addition to associated anxiety and depression.
Etiology:
The cause of hypochondriasis is not known.
The important theories are mentioned below:
1. Psychodynamic Theory:
Hypochondriasis is believed to be based on a narcissistic personality, caused by a narcissistic libido. Here other parts of body become erotogenic zones, which act as substitutes for genitals. Hypochondriac organs symbolize the genitals. This is only a theoretical construct.
2. As a Symptom of Depression.
Hypochondriacal symptoms are commonly present in major depression. In fact according to some, hypochondriasis is almost always a part of another psychiatric syndrome, most commonly a mood disorder. Thus, hypochondriasis has been visualized as a masked depression or depressive equivalent. However, this has not been proven till now.
Treatment:
The treatment is often difficult.
It consists of:
1. Supportive psychotherapy.
2. Treatment of associated or underlying depression and/or anxiety, if present.
7. Essay on Reaction to Stress and Adjustment Disorders:
This category in ICD-10 consists of those disorders which are temporally related to an exceptionally stressful life event (acute stress reaction and post-traumatic stress disorder) or a significant life change (adjustment disorders) immediately before the onset.
1. Acute Stress Reaction:
According to ICD-10, in this disorder there is an immediate and clear temporal relationship between an exceptional stressor (e.g., death of a loved one, natural catastrophe, accident, rape) and the onset of symptoms. The symptoms show a mixed and changing picture. This disorder is more likely to develop in presence of physical exhaustion and in extremes of age. It is more commonly seen in females and people with poor coping skills.
The symptoms range from a ‘dazed’ condition, anxiety, depression, anger, despair, over activity or withdrawal, and constriction of the field of consciousness. The symptoms resolve rapidly (with in few hours usually) of removal from stressful environment is possible. If the stress continues or cannot be reversed, resolution of symptoms begins after 1 -2 days and is usually minimal after about 3 days.
Treatment:
The treatment consists of removal of the patient from the stressful environment and helping the patient to ‘pass through’ the stressful experience. IV benzodiazepines (e.g., clonazepam or diazepam) may be needed in patients with marked agitation.
2. Post-Traumatic Stress Disorder (PTSD):
According to ICD-10, this disorder arises as a delayed and/protracted response to an exceptionally stressful or catastrophic life event or situation which is likely to cause pervasive distress in almost any person (e.g., disasters, war, rape or torture, serious accident). The symptoms of PTSD may develop, after a period of latency, within 6 months after the stress or may be delayed beyond this period.
PTSD is characterized by recurrent and intrusive recollections of the stressful event either in flashbacks (images, thoughts, or perceptions) and/or in dreams. There is an associated sense of re-experiencing of the stressful event. There is marked avoidance of the events or situations that arouse recollections of the stressful event, along with marked symptoms of anxiety and increased arousal.
The other important clinical features include partial amnesia for some aspects of the stressful event, feeling of numbness, and anhedonia (inability to experience pleasure).
Treatment:
The treatment consists of the following measures:
a. Prevention:
Anticipation of disasters in the high risk areas, with the training of personnel in disaster management.
b. Disaster management:
The speed of providing help is of paramount importance. This is also a preventive measure.
c. Supportive psychotherapy.
d. Drug treatment:
Antidepressants and benzodiazepines are useful in treatment if anxiety and/or depression are important components of the clinical picture.
3. Adjustment Disorders:
Adjustment disorders are one of the most common psychiatric disorders seen in clinical practice. They are most frequently seen in adolescents and women. Although adjustment disorder is often precipitated by one or more stressors, it often represents a maladaptive response to the stressful life event(s).
In ICD-10, this disorder is characterized by those disorders which occur within 1 month of a significant life change (stressor). This disorder usually occurs in those individuals who are vulnerable due to poor coping skills or personality factors. It is assumed that the disorder would not have arisen in the absence of the stressor(s). The duration of the disorder is usually less than 6 months, except in the case of prolonged depressive reaction.
The various subtypes include brief depressive reaction, prolonged depressive reaction, mixed anxiety and depressive reaction, with predominant disturbance of other emotions, with mixed disturbance of emotions and conduct. Most patients recover within a period of three months.
Treatment:
1. Supportive psychotherapy remains the treatment of choice.
2. Crisis intervention is useful in some patients, by helping to quickly resolve the stressful like situation which has led to the adjustment disorder.
3. Stress management training.
4. Coping skills training.
5. Drug treatment may be needed in some patients for the management of anxiety (benzodiazepines) and/or depressive symptoms (antidepressants).
8. Essay on Grief Reaction:
Grief is the normal response of an individual to the loss of a loved object, e.g., a close relative or a friend, material values or non-material things such as reputation and self-esteem.
Grief is a universal phenomenon which is usually transient and self-limiting. Uncomplicated grief is not a psychiatric disorder and does not usually require psychiatric treatment. However, as physicians (and rarely psychiatrists) are sometimes called to intervene in cases with complications, the condition is discussed here.
Following the loss, there is often a state of shock. The grieved person feels a sense of bewilderment or numbness, or he may completely deny the loss. Although most commonly this state lasts for a few hours, sometimes it may extend up to 2 weeks.
When the full extent of loss is realized, various physical and mental symptoms appear. These include repeated sighing and crying, difficulty in breathing, choking sensation, weakness, poor concentration and poor appetite. These symptoms usually last for 4-6 weeks but may sometimes extend up to 6 months.
Preoccupation with the memory of the deceased is a characteristic feature. This is associated with vivid mental images, vivid dreams and idealization of the deceased (ignoring his negative qualities). These preoccupations are of a comforting nature. This is often associated with a ‘sense of presence’ of the deceased in the surroundings and a misinterpretation of voices and faces of others as that of the lost person. Rarely, fleeting hallucinations may occur.
The grieved person often becomes depressed (see Table 18.10) and becomes slightly withdrawn socially. Guilt feelings, hostility towards others, panic attacks, sense of futility, tiredness, neglect of work and self, insomnia and suicidal ideas may occur. The person may identify with the deceased, taking on his qualities, mannerisms and characteristics.
Morbid or Pathological Grief:
When there is an exaggeration of one or more symptoms of normal grief, or the duration becomes prolonged beyond 6 months without spontaneous recovery, grief becomes morbid.
The various subtypes are chronic grief (duration more than 6 months); delayed grief (onset after 2 weeks of loss); inhibited grief (denial of loss); excessive anxiety, guilt, anger or religiosity grief; identification with the deceased; over-idealization of deceased and anniversary reactions (grief reaction on death anniversary).
Complicated Grief:
Here, grief is complicated by specific neurotic or psychotic illness, in addition to grief reaction symptoms. The various subtypes are hysterical, phobic, obsessive-compulsive, manic or acute psychotic episode.
Stages of Grief:
See Table 18.11.
Treatment:
1. Normal grief does not require psychiatric treatment as it resolves spontaneously. Occasionally, mild anixiolytic or hypnotic may be needed for short-term use.
2. In morbid and (especially) complicated grief, medication may be needed depending on the presenting clinical features.
3. The emphasis should be on:
i. Making the person face for the loss by counteracting denial.
ii. Ventilation of feelings (catharsis).
iii. Ensuring the presence of significant others.
iv. Bringing together similarly grieved persons, to encourage communication, share experiences of the loss and to offer companionship, and social and emotional support.
v. Reinforcement of goal-directed activities.