Despite the increased clinical awareness of neurotic disorders, many of them still remain unrecognized and untreated. In a minority of patients who still receive treatment for neuroses, it is usually carried out only in the form of prescription medications with anxiolytic and hypnotic effects, and only a very small number of patients are being subjected to psychological interference in some form or another. This excessive trust in medicines and neglect of alternative methods are unsuccessful, as the latter are much safer and can be more effective if long-term treatment of neurotic symptoms is necessary.
Since most cases of neurotic disorders are detected in the primary care system, it is there that the main efforts should be focused on their detection and treatment. The specialized psychiatric service plays a very limited role in the treatment of these patients, in particular with long-term courses of treatment, but it serves as a valuable source of experience and should focus its work on training the personnel of the primary health care system and general hospitals in choosing the right therapeutic strategies. For example, one of the groups of patients who are misdiagnosed by a large majority of medical professionals is the so-called "fallen in spirit" with long-lasting mood disorders and hypochondriacal concerns, persistent insomnia and dependence on anxiolytics and hypnotics. Although it would be too optimistic to hope for a complete cure in these cases, much here still can be done with a firm and consistent strategy. First, there must be one person (ideally a general practitioner), responsible for coordinating various aspects of care, and this should be understandable to everyone involved in this process, especially the patient. The doctor-coordinator is obliged to perform two main functions: rationalize the ongoing medical treatment and prevent unnecessary research or treatment procedures. If somatic complaints prevail, the patient should better recommend regular examinations of his doctor than the consultation of specialists on his request. There is a small problem in how not to get involved in a dispute about the causes of complaints - the best tactic here is simply to express an understanding of the patient's suffering, to accept that he needs help, and to reassure him that this help Will be given to him. When a positive relationship is established with the patient, he can be gradually involved in the process of studying his cognitive sphere and psychodynamics.
The effectiveness of cognitive-behavioral therapy (CBT) in neurotic disorders in adult patients has been proved. CBT was also used in patients with advanced age with depression, generalized anxiety and panic disorder with encouraging results. The CBT includes both a cognitive and behavioral approach to conceptualizing and modifying mental and behavioral disorders that characterize neurotic disorders. Although theoretically these approaches are different, in practice they are rarely carried out in isolation, and a procedure such as an alarm management training is based on both models. Cognitive therapy includes the definition, assessment, control and modification of negative thoughts, cognitive distortions and erroneous judgments, which is observed with anxiety and depression. For example, in an elderly anxious patient, this technique may consist in questioning the erroneous attribution of their vegetative anxiety symptoms to a somatic disease or automatic thoughts about their increased vulnerability that support agoraphobic avoidance. Behavioral therapy, on the other hand, is based on the concepts of conditioning, reinforcement or avoidance that underlie clinical strategies such as desensitization for phobic disorders and addiction to obsessive meditation. The advantages of groups in the treatment of neuroses are their profitability and that the effect achieved is maintained by communication between members of the group, which often continues even after the formal treatment is over.
Certain knowledge of psychodynamics can be very useful in treating neuroses, especially if the existing disorders include difficulties in discussing certain aspects of one's personality, as well as inappropriate or maladaptive use of protective mechanisms.
Medications play an important role in the treatment of neuroses, but in practice even today their application remains insufficiently substantiated, thorough and differentiated. Before the appointment of any psychotropic drug must take into account a number of important factors. First, will the drug have a negative effect on the somatic state of the patient? Secondly, it should be provided, whether the drug will enter into interaction with other medicines and substances (including alcohol), which the patient takes? Third, what are the pharmacokinetic and pharmacodynamic features that can be expected in a given patient? Fourthly, will the patient take medication the way they are prescribed to him? When all these issues are resolved, it is also necessary to take into account the possible risk of suicide.
Despite the fact that the clinical mode of treatment of nerve in recent years has turned away from the use of benzodiazepines, they are still prescribed in quite large quantities as tranquilizers and hypnotics. Important problems associated with prolonged use of benzodiazepines include dependence formation, memory impairment, poor motor coordination, respiratory center depression and paradoxical stimulation. Patients of late age are particularly sensitive to these side effects, while the accumulation of drugs with a long half-life also leads to drowsiness, delirium, incontinence of urine and feces, falls and fractures. Despite these problems, benzodiazepines still take their place in the treatment of transient short-term anxiety symptoms. It is preferable to use drugs with a short half-life and without active metabolites - such as, for example, oxazepam, although it is important to remember: in patients taking such drugs, the risk of developing withdrawal states at the completion of therapy is increased. It is necessary to avoid prolonged use of benzodiazepines in old age, therefore patients who take them for a long time should try to stop receiving them at the first opportunity.
The most frequent and least permissible reason for the appointment of benzodiazepines in the treatment of neuroses is complaints of insomnia. Very often, such complaints are nothing more than an excessive concern of the patient due to non-pathological changes in the nature and duration of sleep caused by age, and all that is required in these cases is explanation and encouragement. In those cases where sleep disorders are associated with deeper causes, such as depression, pain, or difficulty breathing, treatment should be directed not at insomnia, but at eliminating these causes. Psychophysiological insomnia, caused by stress and anxiety during the period of going to bed, it is better to initially treat using sleep hygiene training programs to help the patient establish routine procedures for sleeping. Sleeping pills should be prescribed only in cases where sleep hygiene programs are ineffective or when there is reason to believe that insomnia is transient.
Where there are signs of depression, the treatment of neurosis shows a trial 6-8-week course of antidepressants. Generalized anxiety and panic disorder also respond to these medications. Tricyclic drugs are quite effective, but the use is limited due to the complications that they can cause in somatically sick patients, as well as their toxicity in case of an overdose; The exception in this respect is lofepramine. The emergence of selective serotonin reuptake inhibitors has changed the tactics of treating depression, since they are safe even in seriously somatic patients and in patients with suicidal tendencies. Drugs with serotonin-blocking action also have, in all probability, a specific effect in OCD and are effective at a late age. Inhibitors of monoamine oxidase (MAOI) are also relatively well tolerated by elderly patients, although their use has decreased in recent years. The specific MAO-B inhibitor, moclobemide, was recently presented as a drug with significantly lower peripheral activity than previous MAO inhibitors, so fewer dietary restrictions are required. Whether he can play a special role in the treatment of neurotic depression is not yet known.
Short courses of neuroleptic drugs in the treatment of neuroses, such as haloperidol or zuclopenthixol, can be used to treat severe anxiety in patients of advanced age, especially effective in cases where anxiety is associated with the psychotic experiences of the patient - for example, in delirium. However, the risk of developing extrapyramidal side effects such as parkinsonism and tardive dyskinesia associated with the treatment of neurosis with neuroleptics even in small doses means that they are not indicated for long-term treatment of anxiety at a late age.
These drugs are sometimes used in the treatment of neuroses to eliminate sympathicotonic somatic symptoms of anxiety in cases where they particularly annoy the patient.
Antihistamines, such as hydroxyzine, have long been used as anxiolytics in the treatment of neuroses at a late age. Their effectiveness is probably determined primarily by their sedative effect. These drugs are relatively safe, although they can cause hypotension.
Buspirone is a newly appeared azapyrone anxiolytic with an action different from that of benzodiazepines, and does not have the property of cross-tolerance with them. Its short-term use in the treatment of neuroses does not cause the effect of "recoil," dependence or cancellation. In contrast to other anxiolytics, the effect of buspirone appears only after a period of about two weeks, so its role in the treatment of acute anxiety is limited. It is indicated for the treatment of severe chronic generalized anxiety and in patients at risk of dependence or substance abuse.
The use of barbiturates and similar preparations, such as meprobamate and glutetimide, in the treatment of neurosis becomes much more limited, but there are still a few people who continue to receive these drugs. Their use is associated with many problems - physical dependence, dangerous withdrawal states, the development of delirium and paradoxical arousal.