Psychopharmacology: Somatoform Disorders

A. Constipation

The symptoms of anxiety can be classified in numerous ways, but are
commonly thought of as psychological and somatic. The somatic, or
physical, symptoms of anxiety are primarily the result of autonomic
arousal and include gastrointestinal symptoms (dry mouth, epigastric
discomfort and diarrhoea, not constipation (A)), respiratory (shortness of
breath (B), hyperventilation), cardiovascular (palpitations (D), tachycardia)
and genitourinary (urgency of micturition, impotence, occasionally
menstrual disturbances). Other common symptoms include tremor (E),
headache and sleep disturbances. The psychological symptoms of anxiety
include intense worries or fear (C), irritability, hypersensitivity to noise
and poor concentration. The focus of the thoughts or fears depends on the
nature of the anxiety problem and is discussed further below. There may
also be avoidance of the anxiety-provoking stimulus/stimuli.

A. Agoraphobia

This is a fairly difficult question, at least in part because anxiety disorders
often overlap. It is important, both from a prognostic and management
point of view, to accurately identify the type of anxiety disorder, as
well as exclude any other co-morbidities, such as depression, which is
common in anxiety disorders. As a rule, try to identify the source of
the anxiety-provoking stimulus. In this case, it appears to be a fear of
leaving the house and being outside, driven by negative thoughts such
as ‘I might faint or not be able to get home’. This is extremely suggestive
of agoraphobia (A), where the fear focuses on being out of the house, on
public transport, in crowds, or other situations that the sufferer views as
difficult to escape from. There is nearly always avoidance (e.g. going out
less), and ‘anticipatory’ anxiety, where the thought of leaving the house
brings on symptoms of anxiety

C. Lorazepam

Benzodiazepines are often used in the short-term management of anxiety
and, despite concerns over their potential for dependence and abuse, they
continue to be extensively prescribed. Overall, they should be avoided
where possible but may be prescribed in short bursts for severe anxiety,
although with caution and preferably with specialist advice. Regardless of
this, lorazepam (C) would not be an appropriate choice of benzodiazepines
because of its short duration. Diazepam, with a longer half-life, would be
a more appropriate choice

D. Men are less likely to report symptoms of social phobia than women

While the epidemiology of social phobia suggests that men are
approximately as likely as women to suffer with social phobia, they are
less likely (D) to report symptoms or seek professional advice (as for
many other mental health problems). Beta-blockers (A), while they do
not have any role in tackling the source of social phobia, are often used
for symptomatic relief in unavoidable stressful social situations, such as
family gatherings, presenting something at work etc. They should only
be used, however, as part of the overall management of social phobia
which should include psychological interventions. Genetic factors do
play a role in social phobia (B), and possibly even more so than other
anxiety disorders. Both population and twin studies confirm this. It is
now thought that avoidant personality disorder is aetiologically related
to social phobia although more work needs to be carried out on this.
While most cases of social phobia are triggered by a significant anxietyprovoking
social situation, it may also develop in the absence of such
a ‘critical’ event (C). Social phobia usually manifests in the late teens
or in the third decade (E). However, as stated above, there is growing
recognition of its likely relationship to certain personality types and
disorders.

E. The presence of major depression excludes a diagnosis of GAD

Anxiety and depression are both very common, and both are risk factors
for the other. While the symptoms may overlap, particularly in milder
cases, this does not imply that one diagnosis ‘trumps’ the other (E). GAD
is one of the most common psychiatric diagnoses, with prevalence rates
usually quoted in the region of 3 per cent of adults, although when
ICD-10 criteria are used it appears to lead to higher prevalence rates than
using DSM-IV criteria. It is thought to affect more women than men,
even when accounting for lower consultation rates in men (A). GAD is
often mistaken for a physical disorder, particularly in the elderly (B).
These patients may be started on potentially harmful medications, such as
antihypertensives, rate-controlling drugs etc. A thorough history should
help prevent this. The converse, of course, is also true (D). Perhaps the
most quoted (although by no means the most common) is the patient
presenting with ‘anxiety’ who actually has a phaeochromocytoma.
Many disorders, including hyperthyroidism, hypoglycaemia and cardiac
arrythmias, may mimic the symptoms of anxiety. Equally, anxiety may
be triggered by physical symptoms, or excessive worry about physical
health. Just because GAD is ‘generalized’ this does not mean that it may
not be triggered by a particularly stressful life event (C), and in fact this
is often the case.

A. Cognitive theories propose that anxiety is the result of distorted
thinking, such as catastrophizing and labelling

There are numerous theories of anxiety, but you should be familiar with
the basics of the more common theoretical viewpoints. Cognitive theory
has been studied extensively in anxiety (A), and looks at the distortions in
cognitive processes that people with anxiety appear to hold. These include
catastrophizing (‘If I go outside, I’m sure I’ll have a heart attack’) and
labelling (‘I am just an awkward, boring person’). The fact that CBT is such
an effective treatment for anxiety disorders also provides indirect evidence
of the role of cognitive distortions in anxiety. Freud believed that anxiety
was the result of intrapsychic, unconscious conflict (B). Broadly speaking,
he believed that anxiety occurs when the ego is overwhelmed by different
types of conflict or excitation. Most neurobiological studies of anxiety
implicate non-dopaminergic pathways (C), particularly noradrenaline,
GABA and serotonin. Dopaminergic pathways may be involved in certain
anxiety disorders, e.g. OCD. Secure attachment would not lead to anxiety
disorders (D) in psychoanalytic theory. Childhood attachment problems,
conversely, may lead to the resurgence of anxiety problems in adulthood,
particularly around separation. The adaptive theory (E) states that anxiety
exists as an evolutionary advantage, commonly referred to as the ‘fight or
flight’ response. The Yerkes–Dodson law may be considered an extension
of this, where performance plotted against anxiety results in a bell-shaped
curve – up to a point, some anxiety may increase performance.

A. OCD affects women and men equally

OCD, unlike most other anxiety disorders, seems to affect men and
women equally (A). The mean age of onset is in the third decade,
although there is often a considerable lag of some years before people
present for assessment, often because of poor understanding of the
nature of the disorder. OCD is probably one of the less common anxiety
disorders (B), although it is now thought to be much more common than
previous estimates, with figures nowadays at around 2–3 per cent for
lifetime prevalence.

A. Antidepressants do not have a role in the management of OCD

Antidepressants, particularly SSRIs, form the mainstay of the
pharmacotherapy of OCD (A). They have significant anti-obsessional
properties. The tricyclic antidepressant clomipramine has also been used
to treat OCD as it has a potent serotonergic reuptake blocking action.
Also, depression is a common co-morbid condition in OCD which will
warrant its own assessment and management. Although it may appear
counterintuitive and even cruel to prevent patients from carrying out
their rituals, this is the most common psychological approach to treating
the condition and is known as exposure and response prevention (B).

A. Amnesia may be a form of dissociation

These disorders are difficult to understand and research into them is only
just beginning to uncover any meaningful answers. Their classification,
diagnosis and management is generally regarded to be unsatisfactory.
However, there can be no doubt that psychological factors can lead to
physical symptoms and vice versa. Broadly speaking, dissociation refers
to a loss of integration between consciousness, memory, perception,
identity and bodily movements. There are different forms this may take,
with amnesia being one of them (A).

A. Diminished startle response

Post-traumatic stress disorder, while not as poorly understood as the
somatoform disorders, is still often missed or even misdiagnosed. It
actually has relatively well-defined and circumscribed clinical features,
which follow a catastrophic or hugely stressful event. Patients suffering
with PTSD show an exaggerated sensitivity and level of psychological
arousal, which may present as an exaggerated startle response (A), poor
sleep and concentration (D), and irritability or anger. Hypervigilance
(C) will also often be present. There is nearly always some form of
remembering the event, usually in vivid nightmares or flashbacks (B).
If sufferers are put in a situation that reminds them of the event, this
will cause extreme distress. This is partly why those with PTSD exhibit
avoidance (E) of similar situations, in this case, driving again.