Chapter 19
Neurotic, Stress-Related and
Somatoform Disorders
128
,Chapter 19: Neurotic, Stress-Related and Somatoform Disorders
Introduction
• The traditional division between neurosis and psychosis that was evident in ICD-9, is not used in ICD-10.
However, the term ‘neurotic’ is still retained in ICD-10 for occasional use and occurs for instance in the
heading of a major group of disorders called the neurotic, stress related and somatoform disorders.
• The term ‘psychotic’ has been retained in ICD-10, as a convenient descriptive term, such as in the acute and
transient psychotic disorders. Its use indicates the presence of hallucinations, delusions or a limited number of
severe abnormalities of behaviour, such as gross excitement and over-activity, marked psychomotor
retardation and catatonic behaviour.
Comparison between neurosis and psychosis
Neurosis Psychosis
Insight • Present. • Absent.
Personality • Only a part of the personality is • The whole personality is
involved in the disorder. involved in the disorder.
Ability to distinguish • Present. • Absent (i.e. constructs a false environment
subjective experiences from based on misconceptions).
reality
Epidemiology
• All of the conditions under the category of neurotic, stress-related and somatoform disorders are more
common in females than males with the exception of the following conditions which are equally common in
females and males:
o Social phobia.
o Needle phobia and illness phobia (under the category of specific phobia).
o Obsessive compulsive disorder.
o Hypochondriacal disorder.
Hamilton Anxiety Rating Scale (HAM-A)
• The HAM-A is an observer rating scale which is used to measure the severity of a patient’s anxiety and to
monitor his response to medication.
Biological management of anxiety disorders
1. SSRIs (see Chapter 11 for details)
• SSRIs are the first line biological management of anxiety disorders.
• The initial effects of antidepressants take longer to occur than benzodiazepines which act more rapidly.
• Antidepressants can increase anxiety in the initial stages of treatment.
2. SNRIs (see Chapter 11 for details)
3. Tricyclic antidepressants (see Chapter 11 for details)
4. Benzodiazepines
• A course of benzodiazepines should not be started unless there are exceptional circumstances due to their
potential to cause dependence. If benzodiazepines are started, it is important to write on the kardex the
date that they should be stopped.
• Benzodiazepines should only be prescribed for short-term use (maximum of two to four weeks).
• It is recommended that patients are not discharged from hospital on benzodiazepines.
• A small number of people with severely disabling anxiety may benefit from long-term treatment with a
benzodiazepine. Long-term studies suggest that people maintain the benefits of benzodiazepines over time
and that doses do not escalate.
• Decrease REM sleep.
• Increase fast wave activity on EEG.
• Well tolerated.
• Safe in overdose.
Note: flumazenil is a benzodiazepine antagonist which may be used in benzodiazepine overdose.
Note: dependence is less likely to develop with longer acting (e.g. diazepam), rather than shorter acting
benzodiazepines (e.g. alprazolam or lorazepam).
5. Pregabalin
• Used for the treatment of generalised anxiety disorder.
• Also used for the treatment of neuropathic pain and as an adjunctive therapy for partial seizures with
or without secondary generalisation.
129
, • Side effects of benzodiazepines:
Amnesia. Ataxia. Decline in cognition.
Note: all areas of cognitive function improve after
discontinuation but they do not achieve the level of
controls (long-term effect on cognition).
Confusion (greater in the elderly Disinhibition and Decreased psychomotor
(i.e. long-term reactions and co-ordination.
effect on cognition).
than in younger individuals). aggression (rare side
effects).
Benzodiazepines may cause some Sedation. Increased risk of cleft palate if used during the first
respiratory depression (especially trimester of pregnancy.
in the elderly) but not to the same Note: benzodiazepines do not cause weight gain.
extent as barbiturates.
• Rapid benzodiazepine withdrawal is associated with:
Anxiety. Depersonalization. Derealization. Diaphoresis. Disorientation.
Hyperacusis. Nausea. Paraesthesia. Rebound insomnia. Sense of imbalance (as if on a rocking
boat), which may impair mobility.
Increased Tinnitus. Tremor. Visual Loss of appetite and weight loss.
sensitivity to light hallucinations.
and sound.
Note: tapering the dose of benzodiazepines reduces the intensity of withdrawal.
ICD-10 classification of neurotic, stress related and somatoform disorders
1. Phobic anxiety disorders
A. Agoraphobia.
i. Without panic disorder.
ii. With panic disorder.
B. Social phobia.
C. Specific (isolated) phobia.
2. Other anxiety disorders
A. Panic disorder.
B. Generalised anxiety disorder.
C. Mixed anxiety and depressive disorder.
3. Obsessive compulsive disorder
4. Reaction to severe stress, and adjustment disorders
A. Acute stress reaction.
B. Post-traumatic stress disorder.
C. Adjustment disorder.
5. Dissociative (conversion) disorders
A. Dissociative amnesia.
B. Dissociative fugue.
C. Dissociative stupor.
D. Trance and possession disorders.
E. Dissociative disorders of movement and sensation.
F. Dissociative motor disorders.
G. Dissociative convulsions.
H. Dissociative anaesthesia and sensory loss.
I. Mixed dissociative (conversion) disorders.
J. Other dissociative (conversion) disorders.
i. Ganser’s syndrome.
ii. Multiple personality disorder.
6. Somatoform disorders
A. Somatization disorder.
B. Undifferentiated somatoform disorder.
C. Hypochondriacal disorder.
D. Somatoform autonomic dysfunction.
E. Persistent somatoform pain disorder.
7. Other neurotic disorders
A. Neurasthenia.
B. Depersonalization-derealization syndrome.
130
Neurotic, Stress-Related and
Somatoform Disorders
128
,Chapter 19: Neurotic, Stress-Related and Somatoform Disorders
Introduction
• The traditional division between neurosis and psychosis that was evident in ICD-9, is not used in ICD-10.
However, the term ‘neurotic’ is still retained in ICD-10 for occasional use and occurs for instance in the
heading of a major group of disorders called the neurotic, stress related and somatoform disorders.
• The term ‘psychotic’ has been retained in ICD-10, as a convenient descriptive term, such as in the acute and
transient psychotic disorders. Its use indicates the presence of hallucinations, delusions or a limited number of
severe abnormalities of behaviour, such as gross excitement and over-activity, marked psychomotor
retardation and catatonic behaviour.
Comparison between neurosis and psychosis
Neurosis Psychosis
Insight • Present. • Absent.
Personality • Only a part of the personality is • The whole personality is
involved in the disorder. involved in the disorder.
Ability to distinguish • Present. • Absent (i.e. constructs a false environment
subjective experiences from based on misconceptions).
reality
Epidemiology
• All of the conditions under the category of neurotic, stress-related and somatoform disorders are more
common in females than males with the exception of the following conditions which are equally common in
females and males:
o Social phobia.
o Needle phobia and illness phobia (under the category of specific phobia).
o Obsessive compulsive disorder.
o Hypochondriacal disorder.
Hamilton Anxiety Rating Scale (HAM-A)
• The HAM-A is an observer rating scale which is used to measure the severity of a patient’s anxiety and to
monitor his response to medication.
Biological management of anxiety disorders
1. SSRIs (see Chapter 11 for details)
• SSRIs are the first line biological management of anxiety disorders.
• The initial effects of antidepressants take longer to occur than benzodiazepines which act more rapidly.
• Antidepressants can increase anxiety in the initial stages of treatment.
2. SNRIs (see Chapter 11 for details)
3. Tricyclic antidepressants (see Chapter 11 for details)
4. Benzodiazepines
• A course of benzodiazepines should not be started unless there are exceptional circumstances due to their
potential to cause dependence. If benzodiazepines are started, it is important to write on the kardex the
date that they should be stopped.
• Benzodiazepines should only be prescribed for short-term use (maximum of two to four weeks).
• It is recommended that patients are not discharged from hospital on benzodiazepines.
• A small number of people with severely disabling anxiety may benefit from long-term treatment with a
benzodiazepine. Long-term studies suggest that people maintain the benefits of benzodiazepines over time
and that doses do not escalate.
• Decrease REM sleep.
• Increase fast wave activity on EEG.
• Well tolerated.
• Safe in overdose.
Note: flumazenil is a benzodiazepine antagonist which may be used in benzodiazepine overdose.
Note: dependence is less likely to develop with longer acting (e.g. diazepam), rather than shorter acting
benzodiazepines (e.g. alprazolam or lorazepam).
5. Pregabalin
• Used for the treatment of generalised anxiety disorder.
• Also used for the treatment of neuropathic pain and as an adjunctive therapy for partial seizures with
or without secondary generalisation.
129
, • Side effects of benzodiazepines:
Amnesia. Ataxia. Decline in cognition.
Note: all areas of cognitive function improve after
discontinuation but they do not achieve the level of
controls (long-term effect on cognition).
Confusion (greater in the elderly Disinhibition and Decreased psychomotor
(i.e. long-term reactions and co-ordination.
effect on cognition).
than in younger individuals). aggression (rare side
effects).
Benzodiazepines may cause some Sedation. Increased risk of cleft palate if used during the first
respiratory depression (especially trimester of pregnancy.
in the elderly) but not to the same Note: benzodiazepines do not cause weight gain.
extent as barbiturates.
• Rapid benzodiazepine withdrawal is associated with:
Anxiety. Depersonalization. Derealization. Diaphoresis. Disorientation.
Hyperacusis. Nausea. Paraesthesia. Rebound insomnia. Sense of imbalance (as if on a rocking
boat), which may impair mobility.
Increased Tinnitus. Tremor. Visual Loss of appetite and weight loss.
sensitivity to light hallucinations.
and sound.
Note: tapering the dose of benzodiazepines reduces the intensity of withdrawal.
ICD-10 classification of neurotic, stress related and somatoform disorders
1. Phobic anxiety disorders
A. Agoraphobia.
i. Without panic disorder.
ii. With panic disorder.
B. Social phobia.
C. Specific (isolated) phobia.
2. Other anxiety disorders
A. Panic disorder.
B. Generalised anxiety disorder.
C. Mixed anxiety and depressive disorder.
3. Obsessive compulsive disorder
4. Reaction to severe stress, and adjustment disorders
A. Acute stress reaction.
B. Post-traumatic stress disorder.
C. Adjustment disorder.
5. Dissociative (conversion) disorders
A. Dissociative amnesia.
B. Dissociative fugue.
C. Dissociative stupor.
D. Trance and possession disorders.
E. Dissociative disorders of movement and sensation.
F. Dissociative motor disorders.
G. Dissociative convulsions.
H. Dissociative anaesthesia and sensory loss.
I. Mixed dissociative (conversion) disorders.
J. Other dissociative (conversion) disorders.
i. Ganser’s syndrome.
ii. Multiple personality disorder.
6. Somatoform disorders
A. Somatization disorder.
B. Undifferentiated somatoform disorder.
C. Hypochondriacal disorder.
D. Somatoform autonomic dysfunction.
E. Persistent somatoform pain disorder.
7. Other neurotic disorders
A. Neurasthenia.
B. Depersonalization-derealization syndrome.
130
