30 - Other neurotic disorders

Other neurotic disorders

© SPMM Course begins in adolescence and is chronic with some fluctuations over time. It can occur as part of other psychiatric disorders such as depression or schizophrenia, or may be associated with social phobia or personality disorders Men and women are equally affected by hypochondriasis. In hypochondriasis patient looks for diagnosis, not symptom relief; he/she names the suspected disorder and may be more or less convinced about having the disorder. Somatoform autonomic syndrome refers to recurrent symptoms of autonomic arousal, such as palpitations, sweating, tremor, flushing, which often occur alongside other subjective symptoms referred to a specific organ or system despite having no evidence of structural or functional deficit in these systems. Patients refuse to be reassured regarding the absence of a physical illness despite the reassurances of different doctors. In somatoform pain syndrome, the major complaint is of persistent, severe, and distressing pain that is not explained by a physiological process or a physical disorder. Globus hystericus, psychogenic pruritus, psychogenic torticollis, teeth grinding (bruxism) and psychogenic dysmenorrhea are also included as  ‘other  somatoform  disorders’. Other neurotic disorders Neurasthenia, depersonalization-derealisation syndrome and other specified neurotic disorders (most of the culture-bound syndromes such as latah, dhat, koro) are included here. Psychogenic syncope and writer’s  cramp  are also described in this category. Neurasthenia is classified in F48 of ICD-10 as a neurotic disorder with either persistent and distressing complaints of increased fatigue after mental effort or persistent and distressing complaints of bodily weakness and exhaustion after minimal effort. This must be accompanied by at least two of the following features: 
- feelings of muscular aches and pains, dizziness
, tension headaches, 
 sleep disturbance, inability to relax, irritability
, dyspepsia. The diagnosis can only be made if other disorders classified in F40-47 section or depression cannot account for the presenting symptoms. Neurasthenia is the closest ICD-10 equivalent of Chronic Fatigue Syndrome. Depersonalization-derealization syndrome is diagnosed when either depersonalization or derealization symptoms are present in the presence of full insight (i.e. an acceptance of the subjective and spontaneous nature of the symptoms) and a clear sensorium. Depersonalization refers  to  the  perception  that  one’s feelings and/or experiences are detached, distant, not his or her own, lost (as if phenomenon). Derealization refers to the perception that objects, people, and/or surroundings seem unreal, distant, artificial, colourless or lifeless. Note that DSM classifies this condition as a dissociation disorder.

© SPMM Course Comparing and contrasting various disorders with somatic features Dissociation 1. Mental effects of a conflict 2. E.g. Amnesia, Loss of identity, alter personality

Conversion 1. Physical effects of a conflict 2. Paralysis, blindness, ataxia, anaesthesia, aphonia, seizures Somatoform/somatisation 1. Production of a symptom (positive) 2. Pain, vomiting, etc. 3. GIT and Musculoskeletal 4. Polysymptomatic Conversion 1. Loss of function (negative) 2. Paralysis, blindness, loss of balance, etc. 3. Neurological 4. Monosymptomati Hypochondriasis 1. Preoccupied with diagnosis 2. Concern: ‘One  dreadful  disease.' 3. Gastrointestinal features most common Somatisation 1. Preoccupied with symptoms 2. Concern: ‘One  excellent cure.' 3. Musculo-skeletal symptoms most common Malingering 1. Clearly intentional 2. Often monetary benefits 3. Military, compensation claims, etc. Factitious 1. ‘Truly puzzling’  with  ‘no  cause.' 2. Only gain is sick role 3. Seen in paramedical professionals 4. Munchaussen is severe form – wide doctor shopping is seen Factitious Disorders and Malingering DSM-IV considered factitious disorder and malingering in a separate chapter. In ICD-10, factitious disorders are considered along with personality disorders (F68). Malingering is not an ICD 10 mental disorder category but is coded in Z76.5. Munchausen by proxy is not coded in Chapter V of ICD10 but is discussed in T74.8.