19.7 The Neuroses
Obsessive - Compulsive Disorder
Mild Depressive Disorder [neurotic depression, reactive depression]
Care Needs and Mobility Considerations
These mental illnesses are also referred to as psychoneuroses. The symptoms and disabilities associated with them are very often less severe than those encountered in the psychoses. Like the latter, however, they occur in people whose mental and intellectual development had been proceeding normally. They also differ very substantially from the psychoses in that the affected person neither loses touch with reality nor experiences disturbed thought processes. Anxiety is a symptom which they all have in common.
Anxiety is an unpleasant emotional state characterized by fearfulness and unwanted and distressing physical symptoms. It is a normal and appropriate response to stress but becomes a recognisable illness when it is disproportionate to the severity of the stress, continues after the stressor has gone, or occurs in the absence of any external stressful event. Neuroses with anxiety as the chief symptom are common: around 16% of the population are affected by some form of an anxiety illness at any one time.
19.7.3 Generalised Anxiety Disorder
(i) Anxiety disorders are not the same as the more fleeting stress reactions where anxiety occurs suddenly to stressful life events or follows some weeks later such events as loss of job, moving house, or divorce, etc. These are either acute stress reactions or adjustment reactions to stress which are generally self-limiting.
(ii) Generalised anxiety disorder affects 2-5% of the population but accounts for almost 30% of mental health problems in general practice. It is characterised by irrational worries, muscle tension, fearful feelings and physical symptoms such as rapid pulse or sweating. The disorder and its effects are mild in the very great majority of people who are prone to it. The symptoms are unpleasant but they are not likely to impair the person's ability to attend to bodily functions unaided nor are they likely to place the person or others at risk of substantial danger.
(i) Although panic may occur as part of different mental illnesses, panic disorder is the occurrence of unpredictable attacks of anxiety with pronounced increases in heart rate and forceful beating of the heart (ie palpitations) with sweating. Tremor may occur together with feelings of light headedness which may be due to overbreathing (hyperventilation). Common features are fears of dying and an urgent desire to flee.
(ii) Whilst subjectively most distressing for the person affected by the panic disorder its occurrence is unlikely to put the person or others at risk of substantial danger. The brevity and nature of the mental and physical disturbances it causes should not prevent a person attending to their bodily functions.
19.7.5 Phobic Anxiety Disorders
(i) Persons affected by these disorders recognise that their fears of particular situations or objects are excessive but are most difficult to control. Acute anxiety attacks, with or without panic disorder, occur on being confronted with the particular situation or object at the centre of their fears.
Agoraphobia
(ii) Agoraphobia tends to start between the ages of 15 and 35 and is twice as common in women as in men. Affected persons experience acute anxiety and, sometimes, panic when they are in, or anticipate being in, open spaces or in places where escape might be difficult or help might not be available. They have an intense desire to be somewhere else. Anxiety producing situations are avoided and just thinking about going into such situations may produce anxiety.
(iii) Although people affected in this way may well be distressed by being out alone, or at the thought of going out alone, this does not necessarily mean that they need supervision in order to take advantage of the faculty of walking out of doors. In each case it will be necessary to determine what function the other person provides and what would happen should that person not be there. It will be important to distinguish between whether the disabled person could not, or would prefer not to walk out of doors without the presence of another person".
(iv) Some people with agoraphobia feel better when accompanied by someone out of doors, and indeed may often be unable to face going out unless accompanied by another person. However, rarely would they be in danger should an attack occur when unaccompanied. There would be no need for guidance; though reassurance and support may be provided to some people to prevent panic attacks or to provide comfort and reassurance should they occur.
Social Phobia
(v) Social phobia is a persistent fear of performing in social situations, especially where strangers are present or where the person fears embarrassment. Their avoidance of these situations may interfere with their daily routine, work, or social life. These situations are predictable and the anxiety experienced is not likely to pose a risk of danger. Personal attention to bodily functions is unaffected.
Specific (Isolated) Phobias
(vi) This is an irrational fear of specific objects (ie spiders) or situations (ie enclosed spaces - claustrophobia). Some surveys suggest that up to 9% of the population will have a specific phobia of some kind.
(vii) The fear of being left alone in the house may bind a person to another, usually the spouse, by day and by night. If left alone they become anxious, distressed or may panic. They may not, however, be in substantial danger. A persistent agitated state may be a presenting symptom of an underlying depressive illness (agitated depression).
Post Traumatic Stress Disorder (PTSD)
(viii) Anxiety and other symptoms may briefly follow any traumatic event. Post traumatic stress disorder (PTSD) is a specific condition which may arise as a result of direct exposure to an extremely severe, life-threatening traumatic event such as a major disaster or similar catastrophe. Severe physical assault may also result in PTSD.
(ix) PTSD needs to be distinguished from milder forms of stress reaction. Characteristic symptoms are vivid "flashbacks" in which the person relives the traumatic event; avoidance of situations which remind the person of the event; and personality changes such as irritability or blunting of the emotions. These, and symptoms of anxiety and/or depression, are particularly intense and prolonged. Symptoms must have been present for at least one month for a diagnosis of PTSD to be made, and they may last for up to two years; in some cases they will be lifelong. Confirmation of the diagnosis, and an opinion on prognosis, should be sought from the hospital or other specialist providing treatment.
(x) The effects of PTSD will depend on the features of anxiety and/or depression which are found in the individual person. Reference should thus be made to the relevant sections of this chapter.
19.7.6 Obsessive - Compulsive Disorder
(i) People with this disorder have obsessional thinking, compulsive behaviour and varying degrees of anxiety or depression.
(ii) Obsessional thoughts are words, ideas, and beliefs, recognised by the person as his own, which intrude in a compelling way into the person's mind and which he tries to exclude.
(iii) Obsessional rituals can include senseless behaviour such as washing the hands 20 or more times a day or having to check repeatedly that the gas has been turned off or a door has been locked, etc. The people are aware that these rituals are illogical but unless they perform them their feelings of anxiety can become unbearable.
(iv) Depending upon the type of obsessive thought or compulsive behaviour the life style of the person may be restructured to a varying extent. It is, however, unlikely that the manifestations of the disorder would place the person or others at risk of danger. The need for care from another in connection with bodily functions is most unlikely.
19.7.7 Mild Depressive Disorder [neurotic depression, reactive depression]
(i) The reader is advised to refer to the "Introduction" to the section on Severe Depressive Disorder for a description of depression. That section also distinguishes mild depressive disorder from severe [psychotic] depression.
(ii) In mild depressive disorder there are symptoms which can be broadly categorized as "neurotic" (ie: as a result of a neurosis rather than a psychosis) These include anxiety, phobias, obsessional symptoms. In addition to these symptoms, people with mild depressive disorders will also have a degree of low mood, lack of energy, and irritability. Biological (physical) symptoms such as poor appetite and weight loss etc, may be found, but are usually much less severe than those which occur in people with major depressive disorder. Delusions and hallucinations do not occur.
(iii) These forms of mild depression are often brief, starting at a time of personal misfortune and subsiding when fortunes have changed or new adjustment has been made to the prevailing situation. Sometimes, however, the symptoms may persist for months or years.
(iv) The magnitude of change in mood, its duration, and the effects of associated neurotic symptoms rarely result in significant or prolonged care needs. People with mild depressive disorder should not require guidance or supervision when walking out of doors. If anxiety is evident as the principal feature of an individual person's mild depression then reference should be made to the section of this chapter on Anxiety
19.7.8 Care Needs and Mobility Considerations- The Neuroses
(i) As with physical illnesses the care and mobility needs can vary considerably between people who have the different types of neurosis, and can vary just as much between people who have the same type of neurosis (ie. anxiety, panic disorder, mild depressive disorder, etc). Each case must be considered on the basis of the manifestation of the mental health problem and the needs that may bring in each individual.
(ii) Anxiety (with or without panic episodes) is likely to be the principal feature among people who are affected by the different neuroses. Even in mild depressive disorder anxiety is a prominent symptom. The mental symptoms, and sometimes physical accompaniments, of anxiety can be highly distressing but they are unlikely to require attention from another in connection with bodily functions. Moreover the effects of anxiety or panic episodes are unlikely to place the person or others at risk of danger.
(iii) Even in those people with agoraphobia or social phobias who demand to be accompanied, these events will be predictable and intermittent and not amount to a need for supervision. Although reassurance and comfort may be welcomed by the affected person when walking outdoors, there would be no need for guidance by virtue of the heightened anxiety state or panic episode should these occur. Furthermore, the affected person's mental and behavioural responses to the onset of acute anxiety and/or panic when outdoors, whether or not accompanied, are not likely to lead to danger to the person or others. Claims that the panic episodes could result in the person becoming disorientated and not knowing how to get to a particular destination, or that there is a risk of an impulsive action (eg: running out under a bus) are most unlikely consequences of even severe panic episodes.
(iv) In people with mild depressive disorder the degree of mood change, its variability and duration, and the effects of accompanying anxiety, rarely result in significant care needs.
(i) Information obtained from someone who is caring for, and familiar with the disabled person is likely to provide a fuller picture of the needs which may arise in those people with mental health problems falling into the group of neurotic illnesses.
(ii) Few of those people affected by one of the anxiety illnesses or mild depressive disorder will have been under the care of a consultant psychiatrist. The majority of these people with the milder forms of mental health problems are managed by the general practitioner. A factual report from the general practitioner supplemented, if necessary, by a report from the community psychiatric nurse will be helpful.
(iii) With regard to the risk of danger a relative's fears may not always provide the necessary evidence of a need for supervision - whether this be when the person is walking outdoors or in the home environment. Assumptions about care needs cannot be based solely on the common manifestations of a particular diagnosis.
(iv) In those cases where it appears that the claim pack has been inadequately or inappropriately completed by or on behalf of someone described as having a mental illness or mental health problems, it would be helpful if a report were obtained from an examining medical practitioner.