Mohammed T. Abou-Saleh

OTHER NEUROTIC DISORDERS 581common sense dictates, and empirical data confirm, that multimodaltreatment is most advisable. Psychosocial intervention andpharmacotherapy each has its place. At all ages, the psychotherapyof PTSD starts with the retelling of the story of the eventsbefore, during and after the traumatic episode. The goal is tointegrate the experience with the person’s life history; the methodis to frame the events from the perspective of the intact self, ratherthan leave them relegated to the weakened self of the past. It isparticularly important in older patients, given the chronologicaldistance from the event, to differentiate objective properties of thetrauma from the fantasy attributions it accumulates over time 19 .Group therapy has been found to be particularly useful.Matching patients by age and by setting of trauma enhancesfeelings of understanding and group identification 20 . The focus ofthe group is on recurring memories, and benefits patients byrelieving long-held guilt through objective evaluation of thetraumatic incident, as well as enhancing their ability to toleratelife stressors 18,21,22 .Antidepressants can offer symptomatic relief by diminishingdysphoria, intrusive thoughts, insomnia and nightmares. Inparticular, selective serotonin reuptake inhibitors (SSRIs) canbe effective, especially in reducing avoidant symptoms 24,25 .b-Adrenergic blocking agents have been used in younger PTSDpatients for relief of symptoms of autonomic arousal, tremors andstartle reactions 26 . Older patients, however, are less likely todisplay a clinical profile of hyperarousal, and are more susceptibleto the cardiovascular complications and organic mood disordersassociated with adrenergic blockade. Benzodiazepines should beavoided as much as possible, since they can cause paradoxicalexcitation and frequently induce subtle cognitive impairment inaging individuals 27 .ADJUSTMENT DISORDERThe diagnosis of adjustment disorder refers to a state of subjectivedistress or emotional disturbance, interfering with social functioningor performance, arising in a period of adaptation to asignificant life change or subsequent to a stressful life event. It isassumed that the condition would not have arisen without thestressor. In ICD-10, onset is usually within 1 month of thestressor; in DSM-IV, it can be within 3 months of the stressor. Inboth ICD-10 and DSM-IV, duration of symptoms does notexceed 6 months, except in the case where the stressor is chronic(e.g. a chronic general medical condition) or the stressor hasenduring consequences (e.g. the financial and emotional difficultiesresulting from a divorce) 3 .Clinical FeaturesSymptoms of adjustment disorder may include: depressed mood,anxiety, worry, impairment in performance of daily routines andinability to cope or plan ahead. Adjustment disorders can bespecified as brief depressive reaction, prolonged depressivereaction, adjustment disorder with predominant disturbance ofother emotions, adjustment disorder with predominant disturbanceof conduct, or adjustment disorder with mixed disturbanceof emotions and conduct.The precipitating events for adjustment disorders can affectsocial network or values, and may involve the individual, hisgroup or community. Common events causing such symptoms inolder patients include physical illness or injury, placement in anursing home and retirement. The events, while subjectivelyprofoundly meaningful, are of considerably smaller magnitudethan those precipitating acute stress reaction and PTSD.Individual predisposition and vulnerability to these stressful lifeevents thus plays a greater role in the occurrence of adjustmentdisorders. Poor pre-stressor social and coexisting physicalproblems 28 , current dementia 29 and a history of a past psychiatricdisorder 30 all increase vulnerability to adjustment disorders.TherapyThe cornerstone of treatment for adjustment disorders is focalpsychotherapy. Based on a psychodynamic understanding ofemotions and behavior, focal therapy identifies the most specificnidus of current distress and views it in the context of the patient’score conflicts or deficits. The therapy is of relatively briefduration, usually 6–20 sessions. The major techniques employedare clarification and confrontation 31 .Quite frequently, the precipitating event can be framed as anarcissistic threat or injury. In psychotherapy, the patient willcome to view the therapist as a self-object, looking for restorationof the self-esteem provided by the lost function, role or friend.The therapist helps restore the wholeness of self by allowing thepatient to modify his/her expectations of him/herself andenvironment 32 .DISSOCIATIVE AND CONVERSION DISORDERSIn the last three decades of the nineteenth century, dissociationwas studied extensively by Janet and conversion by Freud. DSM-Iincorporated the concepts of dissociation and conversion into itsclassification scheme. Conversion reaction was assigned tohysterical neurosis, and amnesia was placed in the category ofdissociative reaction. In DSM-II they were united under theheading of hysterical neurosis, but divided into conversion typeand dissociative type. In DSM-III, DSM-III-R and DSM-IV thetwo conditions were renamed and separated once again. Hysteria,conversion type, became conversion disorder and was assigned tosomatoform disorders. Hysteria, dissociative type, was expandedinto the dissociative disorders 33 . ICD-10, however, continues tocontain both under the heading of dissociative disorders.DISSOCIATIVE AMNESIADissociative amnesia is characterized by loss of memory, usuallyof important recent events, that is too great to be explained byordinary forgetfulness or fatigue; and amnesia, either partial orcomplete, for recent events that are of a traumatic or stressfulnature. The amnesia is usually partial and selective. The extentand completeness of the amnesia varies from day to day andbetween inquirers, but a persistent common core cannot berecalled in the waking state. Complete, generalized amnesia is rareand is usually part of a dissociative fugue. Affective states inamnesia are varied but severe depression is rare. Perplexity,distress and varying degrees of attention-seeking behavior may beevident, but calm acceptance is also sometimes striking. Purposelesslocal wandering may occur, but is rarely accompanied by selfneglectand rarely lasts more than a day or two. Often indissociative amnesia, new learning is preserved 34 . Disturbingexternal circumstances causing despair or anxiety may predisposean individual, but a single event is usually at the center of thesyndrome.Dissociative amnesia is uncommonly reported in the elderly,but has been seen in World War I combat soldiers 35 and soldiersin other conflicts. In most patients the amnesia is short-lived, 75%of cases lasting between 24 h and 5 days 36 . Its features resemblethose of more frequently observed disorders. Organic amnesia isusually anterograde 34 . In postconcussional syndromes there may