- 1 The
ICD-10
Classification of Mental
and Behavioural
Disorders
Clinical descriptions and
diagnostic guidelines
World Health Organization
- 2 -
Preface
In the early 1960s, the Mental Health Programme of the World Health Organization
(WHO) became actively engaged in a programme aiming to improve the diagnosis and
classification of mental disorders. At that time, WHO convened a series of meetings to
review knowledge, actively involving representatives of different disciplines, various
schools of thought in psychiatry, and all parts of the world in the programme. It
stimulated and conducted research on criteria for classification and for reliability of
diagnosis, and produced and promulgated procedures for joint rating of videotaped
interviews and other useful research methods. Numerous proposals to improve the
classification of mental disorders resulted from the extensive consultation process, and
these were used in drafting the Eighth Revision of the International Classification of
Diseases (ICD-8). A glossary defining each category of mental disorder in ICD-8 was
also developed. The programme activities also resulted in the establishment of a network
of individuals and centres who continued to work on issues related to the improvement
of psychiatric classification (1, 2).
The 1970s saw further growth of interest in improving psychiatric classification
worldwide. Expansion of international contacts, the undertaking of several international
collaborative studies, and the availability of new treatments all contributed to this trend.
Several national psychiatric bodies encouraged the development of specific criteria for
classification in order to improve diagnostic reliability. In particular, the American
Psychiatric Association developed and promulgated its Third Revision of the Diagnostic
and Statistical Manual, which incorporated operational criteria into its classification
system.
In 1978, WHO entered into a long-term collaborative project with the Alcohol, Drug
Abuse and Mental Health Administration (ADAMHA) in the USA, aiming to facilitate
further improvements in the classification and diagnosis of mental disorders, and
alcohol- and drug-related problems (3). A series of workshops brought together scientists
from a number of different psychiatric traditions and cultures, reviewed knowledge in
specified areas, and developed recommendations for future research. A major
international conference on classification and diagnosis was held in Copenhagen,
Denmark, in 1982 to review the recommendations that emerged from these workshops
and to outline a research agenda and guidelines for future work (4).
Several major research efforts were undertaken to implement the recommendations of
the Copenhagen conference. One of them, involving centres in 17 countries, had as its
aim the development of the Composite International Diagnostic Interview, an instrument
suitable for conducting epidemiological studies of mental disorders in general population
groups in different countries (5). Another major project focused on developing an
assessment instrument suitable for use by clinicians (Schedules for Clinical Assessment
in Neuropsychiatry) (6). Still another study was initiated to develop an instrument for the
assessment of personality disorders in different countries (the International Personality
Disorder Examination) (7).
In addition, several lexicons have been, or are being, prepared to provide clear
definitions of terms (8). A mutually beneficial relationship evolved between these
projects and the work on definitions of mental and behavioural disorders in the Tenth
Revision of the International Classification of Diseases and Related Health Problems
- 3 (ICD-10)
(9). Converting diagnostic criteria into diagnostic algorithms incorporated in
the assessment instruments was useful in uncovering inconsistencies, ambiguities and
overlap and allowing their removal. The work on refining the ICD-10 also helped to
shape the assessment instruments. The final result was a clear set of criteria for ICD-10
and assessment instruments which can produce data necessary for the classification of
disorders according to the criteria included in Chapter V(F) of ICD-10.
The Copenhagen conference also recommended that the viewpoints of the different
psychiatric traditions be presented in publications describing the origins of the
classification in the ICD-10. This resulted in several major publications, including a
volume that contains a series of presentations highlighting the origins of classification in
contemporary psychiatry (10).
The preparation and publication of this work, Clinical descriptions and diagnostic
guidelines, are the culmination of the efforts of numerous people who have contributed
to it over many years. The work has gone through several major drafts, each prepared
after extensive consultation with panels of experts, national and international psychiatric
societies, and individual consultants. The draft in use in 1987 was the basis of field trials
conducted in some 40 countries, which constituted the largest ever research effort of this
type designed to improve psychiatric diagnosis (11, 12). The results of the trials were
used in finalizing these guidelines.
This work is the first of a series of publications developed from Chapter V(F) of ICD-10.
Other texts will include diagnostic criteria for researchers, a version for use by general
health care workers, a multiaxial presentation, and "crosswalks" - allowing crossreference
between corresponding terms in ICD-10, ICD-9 and ICD-8.
Use of this publication is described in the Introduction, and a subsequent section of the
book provides notes on some of the frequently discussed difficulties of classification.
The Acknowledgements section is of particular significance since it bears witness to the
vast number of individual experts and institutions, all over the world, who actively
participated in the production of the classification and the guidelines. All the major
traditions and schools of psychiatry are represented, which gives this work its uniquely
international character. The classification and the guidelines were produced and tested in
many languages; it is hoped that the arduous process of ensuring equivalence of
translations has resulted in improvements in the clarity, simplicity and logical structure
of the texts in English and in other languages.
A classification is a way of seeing the world at a point in time. There is no doubt that
scientific progress and experience with the use of these guidelines will ultimately require
their revision and updating. I hope that such revisions will be the product of the same
cordial and productive worldwide scientific collaboration as that which has produced the
current text.
Norman Sartorius
Director, Division of Mental Health
World Health Organization
References
- 4 -
1.Kramer, M. et al. The ICD-9 classification of mental disorders: a review of its
developments and contents. Acta psychiatrica scandinavica, 59:241-262 (1979).
2.Sartorius, N. Classification: an international perspective. Psychiatric annals, 6: 22-35
(1976).
3.Jablensky, A. et al. Diagnosis and classification of mental disorders and alcohol- and
drug-related problems: a research agenda for the 1980s. Psychological medicine,
13:907-921 (1983).
4.Mental disorders, alcohol- and drug-related problems: international perspectives on
their diagnosis and classification. Amsterdam, Excerpta Medica, 1985
(International Congress Series, No. 669).
5.Robins, L. et al. The composite international diagnostic interview. Archives of general
psychiatry, 45: 1069-1077 (1989).
6.Wing, J.K. et al. SCAN: schedules for clinical assessment in neuropsychiatry. Archives
of general psychiatry, 47: 589-593 (1990).
7.Loranger, A.W. et al. The WHO/ADAMHA international pilot study of personality
disorders: background and purpose. Journal of personality disorders, 5(3):
296-306 (1991).
8.Lexicon of psychiatric and mental health terms. Vol. 1. Geneva, World Health
Organization, 1989.
9.International Statistical Classification of Diseases and Related Health Problems.
Tenth Revision. Vol. 1: Tabular list, 1992. Vol. 2: Instruction Manual, 1993. Vol.
3: Index (in press). Geneva, World Health Organization.
10.Sartorius, N. et al. (ed.) Sources and traditions in classification in psychiatry.
Toronto, Hogrefe and Huber, 1990.
11.Sartorius, N. et al. (ed.) Psychiatric classification in an international perspective.
British journal of psychiatry, 152 (Suppl. 1) (1988).
12.Sartorius, N. et al. Progress towards achieving a common language in psychiatry:
results from the field trials of the clinical guidelines accompanying the WHO
Classification of Mental and Behavioural Disorders in ICD-10. Archives of
general psychiatry, 1993, 50:115-124.
- 5 -
Acknowledgements
Many individuals and organizations have contributed to the production of the
classification of mental and behavioural disorders in ICD-10 and to the development of
the texts that accompany it. The field trials of the ICD-10 proposals, for example,
involved researchers and clinicians in some 40 countries; it is clearly impossible to
present a complete list of all those who participated in this effort. What follows is a
mention of individuals and agencies whose contributions were central to the creation of
the documents composing the ICD-10 family of classifications and guidelines.
The individuals who produced the initial drafts of the classification and guidelines are
included in the list of principal investigators on pages 312-325: their names are marked
by an asterisk. Dr A. Jablensky, then Senior Medical Officer in the Division of Mental
Health of WHO, in Geneva, coordinated this part of the programme and thus made a
major contribution to the proposals. Once the proposals for the classification were
assembled and circulated for comment to WHO expert panels and many other
individuals, including those listed below, an amended version of the classification was
produced for field tests. These were conducted according to a protocol produced by
WHO staff with the help of Dr J. Burke, Dr J.E. Cooper, and Dr J. Mezzich and involved
a large number of centres, whose work was coordinated by Field Trial Coordinating
Centres (FTCCs). The FTCCs (listed on pages xi-xii) also undertook the task of
producing equivalent translations of the ICD in the languages used in their countries.
Dr N. Sartorius had overall responsibility for the work on the classification of mental and
behavioural disorders in ICD-10 and for the production of accompanying documents.
Throughout the phase of field testing and subsequently, Dr J.E. Cooper acted as chief
consultant to the project and provided invaluable guidance and help to the WHO
coordinating team. Among the team members were Dr J. van Drimmelen, who has
worked with WHO from the beginning of the process of developing ICD-10 proposals,
and Mrs J. Wilson, who conscientiously and efficiently handled the innumerable
administrative tasks linked to the field tests and other activities related to the projects. Mr
A. L'Hours provided generous support, ensuring compliance between the ICD-10
development in general and the production of this classification, and Mr G. Gemert
produced the index.
A number of other consultants, including in particular Dr A. Bertelsen, Dr H. Dilling, Dr
J. López-Ibor, Dr C. Pull, Dr D. Regier, Dr M. Rutter and Dr N. Wig, were also closely
involved in this work, functioning not only as heads of FTCCs for the field trials but also
providing advice and guidance about issues in their area of expertise and relevant to the
psychiatric traditions of the groups of countries about which they were particularly
knowledgeable.
Among the agencies whose help was of vital importance were the Alcohol, Drug Abuse
and Mental Health Administration in the USA, which provided generous support to the
activities preparatory to the drafting of ICD-10, and which ensured effective and
productive consultation between groups working on ICD-10 and those working on the
fourth revision of the American Psychiatric Association's Diagnostic and Statistical
Manual (DSM-IV) classification; the WHO Advisory Committee on ICD-10, chaired by
Dr E. Strömgren; and the World Psychiatric Association which, through its President, Dr
- 6 C.
Stefanis, and the special committee on classification, assembled comments of
numerous psychiatrists in its member associations and gave most valuable advice during
both the field trials and the finalization of the proposals. Other nongovernmental
organizations in official and working relations with WHO, including the World
Federation for Mental Health, the World Association for Psychosocial Rehabilitation, the
World Association of Social Psychiatry, the World Federation of Neurology, and the
International Union of Psychological Societies, helped in many ways, as did the WHO
Collaborating Centres for Research and Training in Mental Health, located in some 40
countries.
Governments of WHO Member States, including in particular Belgium, Germany, the
Netherlands, Spain and the USA, also provided direct support to the process of
developing the classification of mental and behavioural disorders, both through their
designated contributions to WHO and through contributions and financial support to the
centres that participated in this work.
The ICD-10 proposals are thus a product of collaboration, in the true sense of the word,
between very many individuals and agencies in numerous countries. They were
produced in the hope that they will serve as a strong support to the work of the many
who are concerned with caring for the mentally ill and their families, worldwide.
No classification is ever perfect: further improvements and simplifications should
become possible with increases in our knowledge and as experience with the
classification accumulates. The task of collecting and digesting comments and results of
tests of the classification will remain largely on the shoulders of the centres that
collaborated with WHO in the development of the classification. Their addresses are
listed below because it is hoped that they will continue to be involved in the
improvement of the WHO classifications and associated materials in the future and to
assist the Organization in this work as generously as they have so far.
Numerous publications have arisen from Field Trial Centres describing results of their
studies in connection with ICD-10. A full list of these publications and reprints of the
articles can be obtained from Division of Mental Health, World Health Organization,
1211 Geneva 27, Switzerland.
Field Trial Coordinating Centres and Directors
Dr A. Bertelsen, Institute of Psychiatric Demography, Psychiatric Hospital, University of
Aarhus, Risskov, Denmark
Dr D. Caetano, Department of Psychiatry, State University of Campinas, Campinas,
Brazil
Dr S. Channabasavanna, National Institute of Mental Health and Neurosciences,
Bangalore, India
Dr H. Dilling, Psychiatric Clinic of the Medical School, Lübeck, Germany
Dr M. Gelder, Department of Psychiatry, Oxford University Hospital, Warneford
Hospital, Headington, England
- 7 Dr
D. Kemali, University of Naples, First Faculty of Medicine and Surgery, Institute of
Medical Psychology and Psychiatry, Naples, Italy
Dr J.J. López-Ibor Jr, López-Ibor Clinic, Pierto de Hierro, Madrid, Spain
Dr G. Mellsop, The Wellington Clinical School, Wellington Hospital, Wellington, New
Zealand
Dr Y. Nakane, Department of Neuropsychiatry, Nagasaki University, School of
Medicine, Nagasaki, Japan
Dr A. Okasha, Department of Psychiatry, Ain-Shams University, Cairo, Egypt
Dr C. Pull, Department of Neuropsychiatry, Centre Hospitalier de Luxembourg,
Luxembourg, Luxembourg
Dr D. Regier, Director, Division of Clinical Research, National Institute of Mental
Health, Rockville, MD, USA
Dr S. Tzirkin, All Union Research Centre of Mental Health, Institute of Psychiatry,
Academy of Medical Sciences, Moscow, Russian Federation
Dr Xu Tao-Yuan, Department of Psychiatry, Shanghai Psychiatric Hospital, Shanghai,
China
Former directors of field trial centres
Dr J.E. Cooper, Department of Psychiatry, Queen's Medical Centre, Nottingham,
England
Dr R. Takahashi, Department of Psychiatry, Tokyo Medical and Dental University,
Tokyo, Japan
Dr N. Wig, Regional Adviser for Mental Health, World Health Organization, Regional
Office for the Eastern Mediterranean, Alexandria, Egypt
Dr Yang De-sen, Hunan Medical College, Changsha, Hunan, China
- 8 -
Introduction
Chapter V, Mental and behavioural disorders, of ICD-10 is to be available in several
different versions for different purposes. This version, Clinical descriptions and
diagnostic guidelines, is intended for general clinical, educational and service use.
Diagnostic criteria for research has been produced for research purposes and is designed
to be used in conjunction with this book. The much shorter glossary provided by Chapter
V(F) for ICD-10 itself is suitable for use by coders or clerical workers, and also serves as
a reference point for compatibility with other classifications; it is not recommended for
use by mental health professionals. Shorter and simpler versions of the classifications for
use by primary health care workers are now in preparation, as is a multiaxial scheme.
Clinical descriptions and diagnostic guidelines has been the starting point for the
development of the different versions, and the utmost care has been taken to avoid
problems of incompatibility between them.
Layout
It is important that users study this general introduction, and also read carefully the
additional introductory and explanatory texts at the beginning of several of the individual
categories. This is particularly important for F23.-(Acute and transient psychotic
disorders), and for the block F30-F39 (Mood [affective] disorders). Because of the
long-standing and notoriously difficult problems associated with the description and
classification of these disorders, special care has been taken to explain how the
classification has been approached.
For each disorder, a description is provided of the main clinical features, and also of any
important but less specific associated features. "Diagnostic guidelines" are then provided
in most cases, indicating the number and balance of symptoms usually required before a
confident diagnosis can be made. The guidelines are worded so that a degree of
flexibility is retained for diagnostic decisions in clinical work, particularly in the
situation where provisional diagnosis may have to be made before the clinical picture is
entirely clear or information is complete. To avoid repetition, clinical descriptions and
some general diagnostic guidelines are provided for certain groups of disorders, in
addition to those that relate only to individual disorders.
When the requirements laid down in the diagnostic guidelines are clearly fulfilled, the
diagnosis can be regarded as "confident". When the requirements are only partially
fulfilled, it is nevertheless useful to record a diagnosis for most purposes. It is then for
the diagnostician and other users of the diagnostic statements to decide whether to record
the lesser degrees of confidence (such as "provisional" if more information is yet to
come, or "tentative" if more information is unlikely to become available) that are implied
in these circumstances. Statements about the duration of symptoms are also intended as
general guidelines rather than strict requirements; clinicians should use their own
judgement about the appropriateness of choosing diagnoses when the duration of
particular symptoms is slightly longer or shorter than that specified.
The diagnostic guidelines should also provide a useful stimulus for clinical teaching,
since they serve as a reminder about points of clinical practice that can be found in a
fuller form in most textbooks of psychiatry. They may also be suitable for some types of
- 9 research
projects, where the greater precision (and therefore restriction) of the diagnostic
criteria for research are not required.
These descriptions and guidelines carry no theoretical implications, and they do not
pretend to be comprehensive statements about the current state of knowledge of the
disorders. They are simply a set of symptoms and comments that have been agreed, by a
large number of advisors and consultants in many different countries, to be a reasonable
basis for defining the limits of categories in the classification of mental disorders.
Principal differences between Chapter V(F) of ICD-10
and Chapter V of ICD-9
General principles of ICD-10
ICD-10 is much larger than ICD-9. Numeric codes (001-999) were used in ICD-9,
whereas an alphanumeric coding scheme, based on codes with a single letter followed by
two numbers at the three-character level (A00-Z99), has been adopted in ICD-10. This
has significantly enlarged the number of categories available for the classification.
Further detail is then provided by means of decimal numeric subdivisions at the
four-character level.
The chapter that dealt with mental disorders in ICD-9 had only 30 three-character
categories (290-319); Chapter V(F) of ICD-10 has 100 such categories. A proportion of
these categories has been left unused for the time being, so as to allow the introduction
of changes into the classification without the need to redesign the entire system.
ICD-10 as a whole is designed to be a central ("core") classification for a family of
disease- and health-related classifications. Some members of the family of classifications
are derived by using a fifth or even sixth character to specify more detail. In others, the
categories are condensed to give broad groups suitable for use, for instance, in primary
health care or general medical practice. There is a multiaxial presentation of Chapter
V(F) of ICD-10 and a version for child psychiatric practice and research. The "family"
also includes classifications that cover information not contained in the ICD, but having
important medical or health implications, e.g. the classification of impairments,
disabilities and handicaps, the classification of procedures in medicine, and the
classification of reasons for encounter between patients and health workers.
- 10 Neurosis
and psychosis
The traditional division between neurosis and psychosis that was evident in ICD-9
(although deliberately left without any attempt to define these concepts) has not been
used in ICD-10. However, the term "neurotic" is still retained for occasional use and
occurs, for instance, in the heading of a major group (or block) of disorders F40-F48,
"Neurotic, stress-related and somatoform disorders". Except for depressive neurosis,
most of the disorders regarded as neuroses by those who use the concept are to be found
in this block,and the remainder are in the subsequent blocks. Instead of following the
neurotic-psychotic dichotomy, the disorders are now arranged in groups according to
major common themes or descriptive likenesses, which makes for increased convenience
of use. For instance, cyclothymia (F34.0) is in the block F30-F39, Mood [affective]
disorders, rather than in F60-F69, Disorders of adult personality and behaviour;
similarly, all disorders associated with the use of psychoactive substances are grouped
together in F10-F19, regardless of their severity.
"Psychotic" has been retained as a convenient descriptive term, particularly in F23,
Acute and transient psychotic disorders. Its use does not involve assumptions about
psychodynamic mechanisms, but simply indicates the presence of hallucinations,
delusions, or a limited number of severe abnormalities of behaviour, such as gross
excitement and overactivity, marked psychomotor retardation, and catatonic behaviour.
Other differences between ICD-9 and ICD-10
All disorders attributable to an organic cause are grouped together in the block F00-F09,
which makes the use of this part of the classification easier than the arrangement in the
ICD-9.
The new arrangement of mental and behavioural disorders due to psychoactive substance
use in the block F10-F19 has also been found more useful than the earlier system. The
third character indicates the substance used, the fourth and fifth characters the
psychopathological syndrome, e.g. from acute intoxication and residual states; this
allows the reporting of all disorders related to a substance even when only
three-character categories are used.
The block that covers schizophrenia, schizotypal states and delusional disorders
(F20-F29) has been expanded by the introduction of new categories such as
undifferentiated schizophrenia, postschizophrenic depression, and schizotypal disorder.
The classification of acute short-lived psychoses, which are commonly seen in most
developing countries, is considerably expanded compared with that in the ICD-9.
Classification of affective disorders has been particularly influenced by the adoption of
the principle of grouping together disorders with a common theme. Terms such as
"neurotic depression" and "endogenous depression" are not used, but their close
equivalents can be found in the different types and severities of depression now specified
(including dysthymia (F34.1)).
- 11 The
behavioural syndromes and mental disorders associated with physiological
dysfunction and hormonal changes, such as eating disorders, nonorganic sleep disorders,
and sexual dysfunctions, have been brought together in F50-F59 and described in greater
detail than in ICD-9, because of the growing needs for such a classification in liaison
psychiatry.
Block F60-F69 contains a number of new disorders of adult behaviour such as
pathological gambling, fire-setting, and stealing, as well as the more traditional disorders
of personality. Disorders of sexual preference are clearly differentiated from disorders of
gender identity, and homosexuality in itself is no longer included as a category.
Some further comments about changes between the provisions for the coding of
disorders specific to childhood and mental retardation can be found on pages 18-20.
Problems of terminology
Disorder
The term "disorder" is used throughout the classification, so as to avoid even greater
problems inherent in the use of terms such as "disease" and "illness". "Disorder" is not
an exact term, but it is used here to imply the existence of a clinically recognizable set of
symptoms or behaviour associated in most cases with distress and with interference with
personal functions. Social deviance or conflict alone, without personal dysfunction,
should not be included in mental disorder as defined here.
Psychogenic and psychosomatic
The term "psychogenic" has not been used in the titles of categories, in view of its
different meanings in different languages and psychiatric traditions. It still occurs
occasionally in the text, and should be taken to indicate that the diagnostician regards
obvious life events or difficulties as playing an important role in the genesis of the
disorder.
"Psychosomatic" is not used for similar reasons and also because use of this term might
be taken to imply that psychological factors play no role in the occurrence, course and
outcome of other diseases that are not so described. Disorders described as
psychosomatic in other classifications can be found here in F45.- (somatoform
disorders), F50.- (eating disorders), F52.- (sexual dysfunction), and F54.- (psychological
or behavioural factors associated with disorders or diseases classified elsewhere). It is
particularly important to note category F54.- (category 316 in ICD-9) and to remember
to use it for specifying the association of physical disorders, coded elsewhere in ICD-10,
with an emotional causation. A common example would be the recording of
psychogenic asthma or eczema by means of both F54 from Chapter V(F) and the
appropriate code for the physical condition from other chapters in ICD-10.
Impairment, disability, handicap and related terms
- 12 The
terms "impairment", "disability" and "handicap" are used according to the
recommendations of the system adopted by WHO.1
Occasionally, where justified by
clinical tradition, the terms are used in a broader sense. See also pages 8 and 9 regarding
dementia and its relationships with impairment, disability and handicap.
Some specific points for users
Children and adolescents
Blocks F80-F89 (disorders of psychological development) and F90-F98 (behavioural
and emotional disorders with onset usually occurring in childhood and adolescence)
cover only those disorders that are specific to childhood and adolescence. A number of
disorders placed in other categories can occur in persons of almost any age, and should
be used for children and adolescents when required. Examples are disorders of eating
(F50.-), sleeping (F51.-) and gender identity (F64.-). Some types of phobia occurring in
children pose special problems for classification, as noted in the description of F93.1
(phobic anxiety disorder of childhood).
Recording more than one diagnosis
It is recommended that clinicians should follow the general rule of recording as many
diagnoses as are necessary to cover the clinical picture. When recording more than one
diagnosis, it is usually best to give one precedence over the others by specifying it as the
main diagnosis, and to label any others as subsidiary or additional diagnoses. Precedence
should be given to that diagnosis most relevant to the purpose for which the diagnoses
are being collected; in clinical work this is often the disorder that gave rise to the
consultation or contact with health services. In many cases it will be the disorder that
necessitates admission to an inpatient, outpatient or day-care service. At other times, for
example when reviewing the patient's whole career, the most important diagnosis may
well be the "life-time" diagnosis, which could be different from the one most relevant to
the immediate consultation (for instance a patient with chronic schizophrenia presenting
for an episode of care because of symptoms of acute anxiety). If there is any doubt about
the order in which to record several diagnoses, or the diagnostician is uncertain of the
purpose for which information will be used, a useful rule is to record the diagnoses in the
numerical order in which they appear in the classification.
Recording diagnoses from other chapters of ICD-10
The use of other chapters of the ICD-10 system in addition to Chapter V(F) is strongly
recommended. The categories most relevant to mental health services are listed in the
Annex to this book.
1
International classification of impairments,
disabilities and handicaps. Geneva, World Health
Organization, 1980.
- 13 Notes
on selected categories
in the classification of mental and
behavioural disorders in ICD-10
In the course of preparation of the ICD-10 chapter on mental disorder, certain categories
attracted considerable interest and debate before a reasonable level of consensus could be
achieved among all concerned. Brief notes are presented here on some of the issues that
were raised.
Dementia (F01-F03) and its relationships with
impairment, disability and handicap
Although a decline in cognitive abilities is essential for the diagnosis of dementia, no
consequent interference with the performance of social roles, either within the family or
with regard to employment, is used as a diagnostic guideline or criterion. This is a
particular instance of a general principle that applies to the definitions of all the disorders
in Chapter V(F) of ICD-10, adopted because of the wide variations between different
cultures, religions, and nationalities in terms of work and social roles that are available,
or regarded as appropriate. Nevertheless, once a diagnosis has been made using other
information, the extent to which an individual's work, family, or leisure activities are
hindered or even prevented is often a useful indicator of the severity of a disorder.
This is an opportune moment to refer to the general issue of the relationships between
symptoms, diagnostic criteria, and the system adopted by WHO for describing
impairment, disability, and handicap.2
In terms of this system, impairment (i.e. a "loss or
abnormality... of structure or function") is manifest psychologically by interference with
mental functions such as memory, attention, and emotive functions. Many types of
psychological impairment have always been recognized as psychiatric symptoms. To a
lesser degree, some types of disability (defined in the WHO system as "a restriction or
lack... of ability to perform an activity in the manner or within the range considered
normal for a human being") have also conventionally been regarded as psychiatric
symptoms. Examples of disability at the personal level include the ordinary, and usually
necessary, activities of daily life involved in personal care and survival related to
washing, dressing, eating, and excretion. Interference with these activities is often a
direct consequence of psychological impairment, and is influenced little, if at all, by
culture. Personal disabilities can therefore legitimately appear among diagnostic
guidelines and criteria, particularly for dementia.
In contrast, a handicap ("the disadvantage for an individual... that prevents or limits the
performance of a role that is normal...for that individual") represents the effects of
impairments or disabilities in a wide social context that may be heavily influenced by
culture. Handicaps should therefore not be used as essential components of a diagnosis.
2
International classification of impairments,
disabilities and handicaps. Geneva, World Health
Organization, 1980.
- 14 Duration
of symptoms required for
schizophrenia (F20.-)
Prodromal states
Before the appearance of typical schizophrenic symptoms, there is sometimes a period of
weeks or months - particularly in young people - during which a prodrome of
nonspecific symptoms appears (such as loss of interest, avoiding the company of others,
staying away from work, being irritable and oversensitive). These symptoms are not
diagnostic of any particular disorder, but neither are they typical of the healthy state of
the individual. They are often just as distressing to the family and as incapacitating to the
patient as the more clearly morbid symptoms, such as delusions and hallucinations,
which develop later. Viewed retrospectively, such prodromal states seem to be an
important part of the development of the disorder, but little systematic information is
available as to whether similar prodromes are common in other psychiatric disorders, or
whether similar states appear and disappear from time to time in individuals who never
develop any diagnosable psychiatric disorder.
If a prodrome typical of and specific to schizophrenia could be identified, described
reliably, and shown to be uncommon in those with other psychiatric disorders and those
with no disorders at all, it would be justifiable to include a prodrome among the optional
criteria for schizophrenia. For the purposes of ICD-10, it was considered that insufficient
information is available on these points at present to justify the inclusion of a prodromal
state as a contributor to this diagnosis. An additional, closely related, and still unsolved
problem is the extent to which such prodromes can be distinguished from schizoid and
paranoid personality disorders.
Separation of acute and transient psychotic disorders
(F23.-) from schizophrenia (F20.-)
In ICD-10, the diagnosis of schizophrenia depends upon the presence of typical
delusions, hallucinations or other symptoms (described on pages 86-89), and a minimum
duration of 1 month is specified.
Strong clinical traditions in several countries, based on descriptive though not
epidemiological studies, contribute towards the conclusion that, whatever the nature of
the dementia praecox of Kraepelin and the schizophrenias of Bleuler, it, or they, are not
the same as very acute psychoses that have an abrupt onset, a short course of a few
weeks or even days, and a favourable outcome. Terms such as "bouffée délirante",
"psychogenic psychosis", "schizophreniform psychosis", "cycloid psychosis" and "brief
reactive psychosis" indicate the widespread but diverse opinion and traditions that have
developed. Opinions and evidence also vary as to whether transient but typical
schizophrenic symptoms may occur with these disorders, and whether they are usually or
always associated with acute psychological stress (bouffée délirante, at least, was
originally described as not usually associated with an obvious psychological precipitant).
- 15 Given
the present lack of knowledge about both schizophrenia and these more acute
disorders, it was considered that the best option for ICD-10 would be to allow sufficient
time for the symptoms of the acute disorders to appear, be recognized, and largely
subside, before a diagnosis of schizophrenia was made. Most clinical reports and
authorities suggest that, in the large majority of patients with these acute psychoses,
onset of psychotic symptoms occurs over a few days, or over 1-2 weeks at most, and that
many patients recover with or without medication within 2-3 weeks. It therefore seems
appropriate to specify 1 month as the transition point between the acute disorders in
which symptoms of the schizophrenic type have been a feature and schizophrenia itself.
For patients with psychotic, but non-schizophrenic, symptoms that persist beyond the
1-month point, there is no need to change the diagnosis until the duration requirement of
delusional disorder (F22.0) is reached (3 months, as discussed below).
A similar duration suggests itself when acute symptomatic psychoses (amphetamine
psychosis is the best example) are considered. Withdrawal of the toxic agent is usually
followed by disappearance of the symptoms over 8-10 days, but since it often takes 7-10
days for the symptoms to become manifest and troublesome (and for the patient to
present to the psychiatric services), the overall duration is often 20 days or more. About
30 days, or 1 month, would therefore seem an appropriate time to allow as an overall
duration before calling the disorder schizophrenia, if the typical symptoms persist. To
adopt a 1-month duration of typical psychotic symptoms as a necessary criterion for the
diagnosis of schizophrenia rejects the assumption that schizophrenia must be of
comparatively long duration. A duration of 6 months has been adopted in more than one
national classification, but in the present state of ignorance there appear to be no
advantages in restricting the diagnosis of schizophrenia in this way. In two large
international collaborative studies on schizophrenia and related disorders3
, the second of
which was epidemiologically based, a substantial proportion of patients were found
whose clear and typical schizophrenic symptoms lasted for more than 1 month but less
than 6 months, and who made good, if not complete, recoveries from the disorder. It
therefore seems best for the purposes of ICD-10 to avoid any assumption about
necessary chronicity for schizophrenia, and to regard the term as descriptive of a
syndrome with a variety of causes (many of which are still unknown) and a variety of
outcomes, depending upon the balance of genetic, physical, social, and cultural
influences.
There has also been considerable debate about the most appropriate duration of
symptoms to specify as necessary for the diagnosis of persistent delusional disorder
(F22.-). Three months was finally chosen as being the least unsatisfactory, since to delay
3
The international pilot study of schizophrenia.
Geneva, World Health Organization, 1973 (Offset
Publication, No. 2).
Sartorius, N. et al. Early manifestations and first
contact incidence of schizophrenia in different cultures.
A preliminary report on the initial evaluation phase of
the WHO Collaborative Study on Determinants of Outcome of
Severe Mental Disorders, Psychological medicine, 16: 909-
928 (1986).
- 16 the
decision point to 6 months or more makes it necessary to introduce another
intermediate category between acute and transient psychotic disorders (F23.-) and
persistent delusional disorder. The whole subject of the relationship between the
disorders under discussion awaits more and better information than is at present
available; a comparatively simple solution, which gives precedence to the acute and
transient states, seemed the best option, and perhaps one that will stimulate research.
The principle of describing and classifying a disorder or group of disorders so as to
display options rather than to use built-in assumptions, has been used for acute and
transient psychotic disorders (F23.-); these and related points are discussed briefly in the
introduction to that category (pages 97-99).
The term "schizophreniform" has not been used for a defined disorder in this
classification. This is because it has been applied to several different clinical concepts
over the last few decades, and associated with various mixtures of characteristics such as
acute onset, comparatively brief duration, atypical symptoms or mixtures of symptoms,
and a comparatively good outcome. There is no evidence to suggest a preferred choice
for its usage, so the case for its inclusion as a diagnostic term was considered to be weak.
Moreover, the need for an intermediate category of this type is obviated by the use of
F23.- (acute and transient psychotic disorders) and its subdivisions, together with the
requirement of 1 month of psychotic symptoms for a diagnosis of schizophrenia. As
guidance for those who do use schizophreniform as a diagnostic term, it has been
inserted in several places as an inclusion term relevant to those disorders that have the
most overlap with the meanings it has acquired. These are: "schizophreniform attack or
psychosis, NOS" in F20.8 (other schizophrenia), and "brief schizophreniform disorder or
psychosis" in F23.2 (acute schizophrenia-like psychotic disorder).
Simple schizophrenia (F20.6)
This category has been retained because of its continued use in some countries, and
because of the uncertainty about its nature and its relationships to schizoid personality
disorder and schizotypal disorder, which will require additional information for
resolution. The criteria proposed for its differentiation highlight the problems of defining
the mutual boundaries of this whole group of disorders in practical terms.
Schizoaffective disorders (F25.-)
The evidence at present available as to whether schizoaffective disorders (F25.-) as
defined in the ICD-10 should be placed in block F20-F29 (schizophrenia, schizotypal
and delusional disorders) or in F30-F39 (mood [affective] disorders) is fairly evenly
balanced. The final decision to place it in F20-F29 was influenced by feedback from the
field trials of the 1987 draft, and by comments resulting from the worldwide circulation
of the same draft to member societies of the World Psychiatric Association. It is clear
that widespread and strong clinical traditions exist that favour its retention among
schizophrenia and delusional disorders. It is relevant to this discussion that, given a set of
affective symptoms, the addition of only mood-incongruent delusions is not sufficient to
change the diagnosis to a schizoaffective category. At least one typically schizophrenic
- 17 symptom
must be present with the affective symptoms during the same episode of the
disorder.
Mood [affective] disorders (F30-F39)
It seems likely that psychiatrists will continue to disagree about the classification of
disorders of mood until methods of dividing the clinical syndromes are developed that
rely at least in part upon physiological or biochemical measurement, rather than being
limited as at present to clinical descriptions of emotions and behaviour. As long as this
limitation persists, one of the major choices lies between a comparatively simple
classification with only a few degrees of severity, and one with greater details and more
subdivisions.
The 1987 draft of ICD-10 used in the field trials had the merit of simplicity, containing,
for example, only mild and severe depressive episodes, no separation of hypomania from
mania, and no recommendation to specify the presence or absence of familiarly clinical
concepts, such as the "somatic" syndrome or affective hallucinations and delusions.
However, feedback from many of the clinicians involved in the field trials, and other
comments received from a variety of sources, indicated a widespread demand for
opportunities to specify several grades of depression and the other features noted above.
In addition, it is clear from the preliminary analysis of field trial data that in many
centres the category of "mild depressive episode" often had a comparatively low
inter-rater reliability.
It has also become evident that the views of clinicians on the required number of
subdivisions of depression are strongly influenced by the types of patient they encounter
most frequently. Those working in primary care, outpatient clinics and liaison settings
need ways of describing patients with mild but clinically significant states of depression,
whereas those whose work is mainly with inpatients frequently need to use the more
extreme categories.
Further consultations with experts on affective disorders resulted in the present versions.
Options for specifying several aspects of affective disorders have been included, which,
although still some way from being scientifically respectable, are regarded by
psychiatrists in many parts of the world as clinically useful. It is hoped that their
inclusion will stimulate further discussion and research into their true clinical value.
Unsolved problems remain about how best to define and make diagnostic use of the
incongruence of delusions with mood. There would seem to be both enough evidence
and sufficient clinical demand for the inclusion of provisions for mood-congruent or
mood-incongruent delusions to be included, at least as an "optional extra".
Recurrent brief depressive disorder
Since the introduction of ICD-9, sufficient evidence has accumulated to justify the
provision of a special category for the brief episodes of depression that meet the severity
criteria but not the duration criteria for depressive episode (F32.-). These recurrent states
are of unclear nosological significance and the provision of a category for their recording
- 18 should
encourage the collection of information that will lead to a better understanding of
their frequency and long-term course.
Agoraphobia and panic disorder
There has been considerable debate recently as to which of agoraphobia and panic
disorder should be regarded as primary. From an international and cross-cultural
perspective, the amount and type of evidence available does not appear to justify
rejection of the still widely accepted notion that the phobic disorder is best regarded as
the prime disorder, with attacks of panic usually indicating its severity.
Mixed categories of anxiety and depression
Psychiatrists and others, especially in developing countries, who see patients in primary
health care services should find particular use for F41.2 (mixed anxiety and depressive
disorder), F41.3 (other mixed disorders), the various subdivisions of F43.2 (adjustment
disorder), and F44.7 (mixed dissociative [conversion] disorder). The purpose of these
categories is to facilitate the description of disorders manifest by a mixture of symptoms
for which a simpler and more traditional psychiatric label is not appropriate but which
nevertheless represent significantly common, severe states of distress and interference
with functioning. They also result in frequent referral to primary care, medical and
psychiatric services. Difficulties in using these categories reliably may be encountered,
but it is important to test them and - if necessary - improve their definition.
Dissociative and somatoform disorders, in relation
to hysteria
The term "hysteria" has not been used in the title for any disorder in Chapter V(F) of
ICD-10 because of its many and varied shades of meaning. Instead, "dissociative" has
been preferred, to bring together disorders previously termed hysteria, of both
dissociative and conversion types. This is largely because patients with the dissociative
and conversion varieties often share a number of other characteristics, and in addition
they frequently exhibit both varieties at the same or different times. It also seems
reasonable to presume that the same (or very similar) psychological mechanisms are
common to both types of symptoms.
There appears to be widespread international acceptance of the usefulness of grouping
together several disorders with a predominantly physical or somatic mode of
presentation under the term "somatoform". For the reasons already given, however, this
new concept was not considered to be an adequate reason for separating amnesias and
fugues from dissociative sensory and motor loss.
If multiple personality disorder (F44.81) does exist as something other than a
culture-specific or even iatrogenic condition, then it is presumably best placed among the
dissociative group.
- 19 -
Neurasthenia
Although omitted from some classification systems, neurasthenia has been retained as a
category in ICD-10, since this diagnosis is still regularly and widely used in a number of
countries. Research carried out in various settings has demonstrated that a significant
proportion of cases diagnosed as neurasthenia can also be classified under depression or
anxiety: there are, however, cases in which the clinical syndrome does not match the
description of any other category but does meet all the criteria specified for a syndrome
of neurasthenia. It is hoped that further research on neurasthenia will be stimulated by its
inclusion as a separate category.
Culture-specific disorders
The need for a separate category for disorders such as latah, amok, koro, and a variety of
other possibly culture-specific disorders has been expressed less often in recent years.
Attempts to identify sound descriptive studies, preferably with an epidemiological basis,
that would strengthen the case for these inclusions as disorders clinically distinguishable
from others already in the classification have failed, so they have not been separately
classified. Descriptions of these disorders currently available in the literature suggest that
they may be regarded as local variants of anxiety, depression, somatoform disorder, or
adjustment disorder; the nearest equivalent code should therefore be used if required,
together with an additional note of which culture-specific disorder is involved. There
may also be prominent elements of attention-seeking behaviour or adoption of the sick
role akin to that described in F68.1 (intentional production or feigning of symptoms or
disabilities), which can also be recorded.
Mental and behavioural disorders associated with the
puerperium (F53.-)
This category is unusual and apparently paradoxical in carrying a recommendation that it
should be used only when unavoidable. Its inclusion is a recognition of the very real
practical problems in many developing countries that make the gathering of details about
many cases of puerperal illness virtually impossible. However, even in the absence of
sufficient information to allow a diagnosis of some variety of affective disorder (or, more
rarely, schizophrenia), there will usually be enough known to allow diagnosis of a mild
(F53.0) or severe (F53.1) disorder; this subdivision is useful for estimations of workload,
and when decisions are to be made about provision of services.
The inclusion of this category should not be taken to imply that, given adequate
information, a significant proportion of cases of postpartum mental illness cannot be
classified in other categories. Most experts in this field are of the opinion that a clinical
picture of puerperal psychosis is so rarely (if ever) reliably distinguishable from affective
disorder or schizophrenia that a special category is not justified. Any psychiatrist who is
of the minority opinion that special postpartum psychoses do indeed exist may use this
category, but should be aware of its real purpose.
- 20 Disorders
of adult personality (F60.-)
In all current psychiatric classifications, disorders of adult personality include a variety
of severe problems, whose solution requires information that can come only from
extensive and time-consuming investigations. The difference between observations and
interpretation becomes particularly troublesome when attempts are made to write
detailed guidelines or diagnostic criteria for these disorders; and the number of criteria
that must be fulfilled before a diagnosis is regarded as confirmed remains an unsolved
problem in the light of present knowledge. Nevertheless, the attempts that have been
made to specify guidelines and criteria for this category may help to demonstrate that a
new approach to the description of personality disorders is required.
After initial hesitation, a brief description of borderline personality disorder (F60.31) was
finally included as a subcategory of emotionally unstable personality disorder (F60.3),
again in the hope of stimulating investigations.
Other disorders of adult personality and behaviour (F68)
Two categories that have been included here but were not present in ICD-9 are F68.0,
elaboration of physical symptoms for psychological reasons, and F68.1, intentional
production or feigning of symptoms or disabilities, either physical or psychological
[factitious disorder]. Since these are, strictly speaking, disorders of role or illness
behaviour, it should be convenient for psychiatrists to have them grouped with other
disorders of adult behaviour. Together with malingering (Z76.5), which has always been
outside Chapter V of the ICD, the disorders from a trio of diagnoses often need to be
considered together. The crucial difference between the first two and malingering is that
the motivation for malingering is obvious and usually confined to situations where
personal danger, criminal sentencing, or large sums of money are involved.
Mental retardation (F70-F79)
The policy for Chapter V(F) of ICD-10 has always been to deal with mental retardation
as briefly and as simply as possible, acknowledging that justice can be done to this topic
only by means of a comprehensive, possibly multiaxial, system. Such a system needs to
be developed separately, and work to produce appropriate proposals for international use
is now in progress.
- 21 Disorders
with onset specific to childhood
F80-F89 Disorders of psychological development
Disorders of childhood such as infantile autism and disintegrative psychosis, classified in
ICD-9 as psychoses, are now more appropriately contained in F84.-, pervasive
developmental disorders. While some uncertainty remains about their nosological status,
it has been considered that sufficient information is now available to justify the inclusion
of the syndromes of Rett and Asperger in this group as specified disorders. Overactive
disorder associated with mental retardation and stereotyped movements (F84.4) has been
included in spite of its mixed nature, because evidence suggests that this may have
considerable practical utility.
F90-F98 Behavioural and emotional disorders with
onset usually occurring in childhood and adolescence
Differences in international opinion about the broadness of the concept of hyperkinetic
disorder have been a well-known problem for many years, and were discussed in detail
at the meetings between WHO advisors and other experts held under the auspices of the
WHO-ADAMHA joint project. Hyperkinetic disorder is now defined more broadly in
ICD-10 than it was in ICD-9. The ICD-10 definition is also different in the relative
emphasis given to the constituent symptoms of the overall hyperkinetic syndrome; since
recent empirical research was used as the basis for the definition, there are good reasons
for believing that the definition in ICD-10 represents a significant improvement.
Hyperkinetic conduct disorder (F90.1) is one of the few examples of a combination
category remaining in ICD-10, Chapter V(F). The use of this diagnosis indicates that the
criteria for both hyperkinetic disorder (F90.-) and conduct disorder (F91.-) are fulfilled.
These few exceptions to the general rule were considered justified on the grounds of
clinical convenience in view of the frequent coexistence of those disorders and the
demonstrated later importance of the mixed syndrome. However, it is likely that The
ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic criteria for
research (DCR-10) will recommend that, for research purposes, individual cases in these
categories be described in terms of hyperactivity, emotional disturbance, and severity of
conduct disorder (in addition to the combination category being used as an overall
diagnosis).
Oppositional defiant disorder (F91.3) was not in ICD-9, but has been included in ICD-10
because of evidence of its predictive potential for later conduct problems. There is,
however, a cautionary note recommending its use mainly for younger children.
The ICD-9 category 313 (disturbances of emotion specific to childhood and
adolescence) has been developed into two separate categories for ICD-10, namely
emotional disorders with onset specific to childhood (F93.-) and disorders of social
functioning with onset specific to childhood and adolescence (F94.-). This is because of
the continuing need for a differentiation between children and adults with respect to
various forms of morbid anxiety and related emotions. The frequency with which
emotional disorders in childhood are followed by no significant similar disorder in adult
life, and the frequent onset of neurotic disorders in adults are clear indicators of this
- 22 need.
The key defining criterion used in ICD-10 is the appropriateness to the
developmental stage of the child of the emotion shown, plus an unusual degree of
persistence with disturbance of function. In other words, these childhood disorders are
significant exaggerations of emotional states and reactions that are regarded as normal
for the age in question when occurring in only a mild form. If the content of the
emotional state is unusual, or if it occurs at an unusual age, the general categories
elsewhere in the classification should be used.
In spite of its name, the new category F94.- (disorders of social functioning with onset
specific to childhood and adolescence) does not go against the general rule for ICD-10 of
not using interference with social roles as a diagnostic criterion. The abnormalities of
social functioning involved in F94.- are of a limited number and contained within the
parent-child relationship and the immediate family; these relationships do not have the
same connotations or show the same cultural variations as those formed in the context of
work or of providing for the family, which are excluded from use as diagnostic criteria.
A number of categories that will be used frequently by child psychiatrists, such as eating
disorders (F50.-), nonorganic sleep disorders (F51.-), and gender identity disorders
(F64.-), are to be found in the general sections of the classifications because of their
frequent onset and occurrence in adults as well as children. Nevertheless, clinical
features specific to childhood were thought to justify the additional categories of feeding
disorder of infancy (F98.2) and pica of infancy and childhood (F98.3).
Users of blocks F80-F89 and F90-F98 also need to be aware of the contents of the
neurological chapter of ICD-10 (Chapter VI(G)). This contains syndromes with
predominantly physical manifestations and clear "organic" etiology, of which the
Kleine-Levin syndrome (G47.8) is of particular interest to child psychiatrists.
Unspecified mental disorder (F99)
There are practical reasons why a category for the recording of "unspecified mental
disorder" is required in ICD-10, but the subdivision of the whole of the classificatory
space available for Chapter V(F) into 10 blocks, each covering a specific area, posed a
problem for this requirement. It was decided that the least unsatisfactory solution was to
use the last category in the numerical order of the classification, i.e. F99.
Deletion of categories proposed for earlier drafts
of ICD-10
The process of consultation and reviews of the literature that preceded the drafting of
Chapter V(F) of ICD-10 resulted in numerous proposals for changes. Decisions on
whether to accept or reject proposals were influenced by a number of factors. These
included the results of the field tests of the classification, consultations with heads of
WHO collaborative centres, results of collaboration with nongovernmental
organizations, advice from members of WHO expert advisory panels, results of
translations of the classification, and the constraints of the rules governing the structure
of the ICD as a whole.
- 23 It
was normally easy to reject proposals that were idiosyncratic and unsupported by
evidence, and to accept others that were accompanied by sound justification. Some
proposals, although reasonable when considered in isolation, could not be accepted
because of the implications that even minor changes to one part of the classification
would have for other parts. Some other proposals had clear merit, but more research
would be necessary before they could be considered for international use. A number of
these proposals included in early versions of the general classification were omitted from
the final version, including "accentuation of personality traits" and "hazardous use of
psychoactive substances". It is hoped that research into the status and usefulness of these
and other innovative categories will continue.
- 24 List
of categories
F00-F09
Organic, including symptomatic, mental disorders
F00 Dementia in Alzheimer's disease
F00.0Dementia in Alzheimer's disease with early onset
F00.1Dementia in Alzheimer's disease with late onset
F00.2Dementia in Alzheimer's disease, atypical or mixed type
F00.9Dementia in Alzheimer's disease, unspecified
F01Vascular dementia
F01.0Vascular dementia of acute onset
F01.1Multi-infarct dementia
F01.2Subcortical vascular dementia
F01.3Mixed cortical and subcortical vascular dementia
F01.8Other vascular dementia
F01.9Vascular dementia, unspecified
F02Dementia in other diseases classified elsewhere
F02.0Dementia in Pick's disease
F02.1Dementia in Creutzfeldt-Jakob disease
F02.2Dementia in Huntington's disease
F02.3Dementia in Parkinson's disease
F02.4Dementia in human immunodeficiency virus [HIV] disease
F02.8Dementia in other specified diseases classified elsewhere
F03Unspecified dementia
A fifth character may be added to specify dementia in F00-F03, as follows:
.x0 Without additional symptoms
.x1 Other symptoms, predominantly delusional
.x2 Other symptoms, predominantly hallucinatory
.x3 Other symptoms, predominantly depressive
.x4 Other mixed symptoms
F04Organic amnesic syndrome, not induced by alcohol and other substances
F05Delirium, not induced by alcohol and other psychoactive substances
F05.0Delirium, not superimposed on dementia, so described
F05.1Delirium, superimposed on dementia
F05.8Other delirium
F05.9Delirium, unspecified
F06Other mental disorders due to brain damage and dysfunction and to physical
disease
F06.0Organic hallucinosis
F06.1Organic catatonic disorder
- 25 F06.2Organic
delusional [schizophrenia-like] disorder
F06.3Organic mood [affective] disorders
.30 Organic manic disorder
.31 Organic bipolar affective disorder
.32 Organic depressive disorder
.33 Organic mixed affective disorder
F06.4Organic anxiety disorder
F06.5Organic dissociative disorder
F06.6Organic emotionally labile [asthenic] disorder
F06.7Mild cognitive disorder
F06.8Other specified mental disorders due to brain damage and dysfunction and to
physical disease
F06.9Unspecified mental disorder due to brain damage and dysfunction and to physical
disease
F07Personality and behavioural disorder due to brain disease, damage and
dysfunction
F07.0Organic personality disorder
F07.1Postencephalitic syndrome
F07.2Postconcussional syndrome
F07.8Other organic personality and behavioural disorder due to brain disease, damage
and dysfunction
F09Unspecified organic or symptomatic mental disorder
- 26 -
F10--F19
Mental and behavioural disorders due to
psychoactive substance use
F10.-Mental and behavioural disorders due to use of alcohol
F11.-Mental and behavioural disorders due to use of opioids
F12.-Mental and behavioural disorders due to use of cannabinoids
F13.-Mental and behavioural disorders due to use of sedatives or hypnotics
F14.-Mental and behavioural disorders due to use of cocaine
F15.-Mental and behavioural disorders due to use of other stimulants, including
caffeine
F16.-Mental and behavioural disorders due to use of hallucinoeens
F17.-Mental and behavioural disorders due to use of tobacco
F18.-Mental and behavioural disorders due to use of volatile solvents
F19.-Mental and behavioural disorders due to multiple drug use and use of other
psychoactive substances
Four- and five-character categories may be used to specify the clinical conditions, as
follows:
F1x.0 Acute intoxication
.00 Uncomplicated
.01 With trauma or other bodily injury
.02 With other medical complications
.03 With delirium
.04 With perceptual distortions
.05 With coma
.06 With convulsions
.07 Pathological intoxication
F1x.1 Harmful use
F1x.2 Dependence syndrome
.20 Currently abstinent
.21 Currently abstinent, but in a protected
environment
.22 Currently on a clinically supervised
maintenance or replacement regime [controlled dependence]
.23 Currently abstinent, but receiving treatment
with aversive or blocking drugs
.24 Currently using the substance [active
- 27 -
dependence]
.25 Continuous use
.26 Episodic use [dipsomania]
F1x.3 Withdrawal state
.30 Uncomplicated
.31 With convulsions
F1x.4 Withdrawal state with delirium
.40 Without convulsions
.41 With convulsions
F1x.5 Psychotic disorder
.50 Schizophrenia-like
.51 Predominantly delusional
.52 Predominantly hallucinatory
.53 Predominantly polymorphic
.54 Predominantly depressive symptoms
.55 Predominantly manic symptoms
.56 Mixed
F1x.6 Amnesic syndrome
F1x.7 Residual and late-onset psychotic disorder
.70 Flashbacks
.71 Personality or behaviour disorder
.72 Residual affective disorder
.73 Dementia
.74 Other persisting cognitive impairment
.75 Late-onset psychotic disorder
F1x.8 Other mental and behavioural disorders
F1x.9 Unspecified mental and behavioural disorder
- 28 -
F20-F29
Schizophrenia, schizotypal and delusional disorders
F20 Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified
A fifth character may be used to classify course:
.x0 Continuous
.x1 Episodic with progressive deficit
.x2 Episodic with stable deficit
.x3 Episodic remittent
.x4 Incomplete remission
.x5 Complete remission
.x6 Other
.x9 Course uncertain, period of observation too short
F21 Schizotypal disorder
F22 Persistent delusional disorders
F22.0 Delusional disorder
F22.8 Other persistent delusional disorders
F22.9 Persistent delusional disorder, unspecified
F23 Acute and transient psychotic disorders
F23.0 Acute polymorphic psychotic disorder without symptoms
of
schizophrenia
F23.1 Acute polymorphic psychotic disorder with symptoms of
schizophrenia
F23.2 Acute schizophrenia-like psychotic disorder
F23.3 Other acute predominantly delusional psychotic disorders
F23.8 Other acute and transient psychotic disorders
F23.9 Acute and transient psychotic disorders unspecified
A fifth character may be used to identify the presence or absence of
associated acute stress:
.x0 Without associated acute stress
.x1 With associated acute stress
- 29 F24
Induced delusional disorder
F25 Schizoaffective disorders
F25.0 Schizoaffective disorder, manic type
F25.1 Schizoaffective disorder, depressive type
F25.2 Schizoaffective disorder, mixed type
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified
F28 Other nonorganic psychotic disorders
F29 Unspecified nonorganic psychosis
- 30 -
F30-F39
Mood [affective] disorders
Overview of this block
F30 Manic episode
F30.0 Hypomania
F30.1 Mania without psychotic symptoms
F30.2 Mania with psychotic symptoms
F30.8 Other manic episodes
F30.9 Manic episode, unspecified
F31 Bipolar affective disorder
F31.0 Bipolar affective disorder, current episode hypomanic
F31.1 Bipolar affective disorder, current episode manic without
psychotic
symptoms
F31.2 Bipolar affective disorder, current episode manic with
psychotic
symptoms
F31.3Bipolar affective disorder, current episode mild or moderate
depression
.30 Without somatic syndrome
.31 With somatic syndrome
F31.4 Bipolar affective disorder, current episode severe
depression without
psychotic symptoms
F31.5 Bipolar affective disorder, current episode severe
depression with
psychotic symptoms
F31.6 Bipolar affective disorder, current episode mixed
F31.7 Bipolar affective disorder, currently in remission
F31.8 Other bipolar affective disorders
F31.9 Bipolar affective disorder, unspecified
F32 Depressive episode
F32.0 Mild depressive episode
.00 Without somatic syndrome
.01 With somatic syndrome
F32.1 Moderate depressive episode
.10 Without somatic syndrome
.11 With somatic syndrome
F32.2 Severe depressive episode without psychotic symptoms
F32.3 Severe depressive episode with psychotic symptoms
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified
- 31 F33
Recurrent depressive disorder
F33.0 Recurrent depressive disorder, current episode mild
.00 Without somatic syndrome
.01 With somatic syndrome
F33.1 Recurrent depressive disorder, current episode moderate
.10 Without somatic syndrome
.11 With somatic syndrome
F33.2 Recurrent depressive disorder, current episode severe
without
psychotic symptoms
F33.3 Recurrent depressive disorder, current episode severe with
psychotic
symptoms
F33.4 Recurrent depressive disorder, currently in remission
F33.8 Other recurrent depressive disorders
F33.9 Recurrent depressive disorder, unspecified
F34 Persistent mood [affective] disorders
F34.0 Cyclothymia
F34.1 Dysthymia
F34.8 Other persistent mood [affective] disorders
F34.9 Persistent mood [affective] disorder, unspecified
F38 Other mood [affective] disorders
F38.0 Other single mood [affective] disorders
.00 Mixed affective episode
F38.1 Other recurrent mood [affective] disorders
.10 Recurrent brief depressive disorder
F38.8 Other specified mood [affective] disorders
F39 Unspecified mood [affective] disorder
- 32 -
F40-F48
Neurotic, stress-related and somatoform disorders
F40 Phobic anxiety disorders
F40.0 Agoraphobia
.00 Without panic disorder
.01 With panic disorder
F40.1 Social phobias
F40.2 Specific (isolated) phobias
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified
F41 Other anxiety disorders
F41.0 Panic disorder [episodic paroxysmal anxiety]
F41.1 Generalized anxiety disorder
F41.2 Mixed anxiety and depressive disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
F42 Obsessive - compulsive disorder
F42.0 Predominantly obsessional thoughts or ruminations
F42.1 Predominantly compulsive acts [obsessional rituals]
F42.2 Mixed obsessional thoughts and acts
F42.8 Other obsessive - compulsive disorders
F42.9 Obsessive - compulsive disorder, unspecified
F43 Reaction to severe stress, and adjustment disorders
F43.0 Acute stress reaction
F43.1 Post-traumatic stress disorder
F43.2 Adjustment disorders
.20 Brief depressive reaction
.21 Prolonged depressive reaction
.22 Mixed anxiety and depressive reaction
.23 With predominant disturbance of other emotions
.24 With predominant disturbance of conduct
.25 With mixed disturbance of emotions and conduct
.28 With other specified predominant symptoms
F43.8 Other reactions to severe stress
F43.9 Reaction to severe stress, unspecified
F44 Dissociative [conversion] disorders
F44.0 Dissociative amnesia
F44.1 Dissociative fugue
F44.2 Dissociative stupor
F44.3 Trance and possession disorders
F44.4 Dissociative motor disorders
- 33 F44.5
Dissociative convulsions
F44.6 Dissociative anaesthesia and sensory loss
F44.7 Mixed dissociative [conversion] disorders
F44.8 Other dissociative [conversion] disorders
.80 Ganser's syndrome
.81 Multiple personality disorder
.82 Transient dissociative [conversion] disorders occurring in
childhood
and adolescence
.88 Other specified dissociative [conversion] disorders
F44.9 Dissociative [conversion] disorder, unspecified
F45 Somatoform disorders
F45.0 Somatization disorder
F45.1 Undifferentiated somatoform disorder
F45.2 Hypochondriacal disorder
F45.3 Somatoform autonomic dysfunction
.30 Heart and cardiovascular system
.31 Upper gastrointestinal tract
.32 Lower gastrointestinal tract
.33 Respiratory system
.34 Genitourinary system
.38 Other organ or system
F45.4 Persistent somatoform pain disorder
F45.8 Other somatoform disorders
F45.9 Somatoform disorder, unspecified
F48 Other neurotic disorders
F48.0 Neurasthenia
F48.1 Depersonalization - derealization syndrome
F48.8 Other specified neurotic disorders
F48.9 Neurotic disorder, unspecified
- 34 -
F50-F59
Behavioural syndromes associated with physiological
disturbances and physical factors
F50 Eating disorders
F50.0 Anorexia nervosa
F50.1 Atypical anorexia nervosa
F50.2 Bulimia nervosa
F50.3 Atypical bulimia nervosa
F50.4 Overeating associated with other psychological
disturbances
F50.5 Vomiting associated with other psychological disturbances
F50.8 Other eating disorders
F50.9 Eating disorder, unspecified
F51 Nonorganic sleep disorders
F51.0 Nonorganic insomnia
F51.1 Nonorganic hypersomnia
F51.2 Nonorganic disorder of the sleep-wake schedule
F51.3 Sleepwalking [somnambulism]
F51.4 Sleep terrors [night terrors]
F51.5 Nightmares
F51.8 Other nonorganic sleep disorders
F51.9 Nonorganic sleep disorder, unspecified
F52 Sexual dysfunction, not caused by organic disorder or disease
F52.0 Lack or loss of sexual desire
F52.1 Sexual aversion and lack of sexual enjoyment
.10 Sexual aversion
.11 Lack of sexual enjoyment
F52.2 Failure of genital response
F52.3 Orgasmic dysfunction
F52.4 Premature ejaculation
F52.5 Nonorganic vaginismus
F52.6 Nonorganic dyspareunia
F52.7 Excessive sexual drive
F52.8 Other sexual dysfunction, not caused by organic disorders
or disease
F52.9 Unspecified sexual dysfunction, not caused by organic
disorder
or disease
F53Mental and behavioural disorders associated with the puerperium,
not elsewhere classified
F53.0 Mild mental and behavioural disorders associated with the
puerperium, not elsewhere classified
- 35 F53.1
Severe mental and behavioural disorders associated with
the
puerperium, not elsewhere classified
F53.8 Other mental and behavioural disorders associated with
the
puerperium, not elsewhere classified
F53.9 Puerperal mental disorder, unspecified
F54Psychological and behavioural factors associated with disorders
or diseases classified elsewhere
F55 Abuse of non-dependence-producing substances
F55.0 Antidepressants
F55.1 Laxatives
F55.2 Analgesics
F55.3 Antacids
F55.4 Vitamins
F55.5 Steroids or hormones
F55.6 Specific herbal or folk remedies
F55.8 Other substances that do not produce dependence
F55.9 Unspecified
F59Unspecified behavioural syndromes associated with physiological
disturbances and physical factors
- 36 -
F60-F69
Disorders of adult personality and behaviour
F60 Specific personality disorders
F60.0 Paranoid personality disorder
F60.1 Schizoid personality disorder
F60.2 Dissocial personality disorder
F60.3 Emotionally unstable personality disorder
.30 Impulsive type
.31 Borderline type
F60.4 Histrionic personality disorder
F60.5 Anankastic personality disorder
F60.6 Anxious [avoidant] personality disorder
F60.7 Dependent personality disorder
F60.8 Other specific personality disorders
F60.9 Personality disorder, unspecified
F61 Mixed and other personality disorders
F61.0 Mixed personality disorders
F61.1 Troublesome personality changes
F62 Enduring personality changes, not attributable to brain damage
and disease
F62.0 Enduring personality change after catastrophic experience
F62.1 Enduring personality change after psychiatric illness
F62.8 Other enduring personality changes
F62.9 Enduring personality change, unspecified
F63 Habit and impulse disorders
F63.0 Pathological gambling
F63.1 Pathological fire-setting [pyromania]
F63.2 Pathological stealing [kleptomania]
F63.3 Trichotillomania
F63.8 Other habit and impulse disorders
F63.9 Habit and impulse disorder, unspecified
F64 Gender identity disorders
F64.0 Transsexualism
F64.1 Dual-role transvestism
F64.2 Gender identity disorder of childhood
F64.8 Other gender identity disorders
F64.9 Gender identity disorder, unspecified
F65 Disorders of sexual preference
F65.0 Fetishism
F65.1 Fetishistic transvestism
F65.2 Exhibitionism
F65.3 Voyeurism
F65.4 Paedophilia
- 37 F65.5
Sadomasochism
F65.6 Multiple disorders of sexual preference
F65.8 Other disorders of sexual preference
F65.9 Disorder of sexual preference, unspecified
F66 Psychological and behavioural disorders associated with sexual
development and orientation
F66.0 Sexual maturation disorder
F66.1 Egodystonic sexual orientation
F66.2 Sexual relationship disorder
F66.8 Other psychosexual development disorders
F66.9 Psychosexual development disorder, unspecified
A fifth character may be used to indicate association with:
.x0 Heterosexuality
.x1 Homosexuality
.x2 Bisexuality
.x8 Other, including prepubertal
F68 Other disorders of adult personality and behaviour
F68.0 Elaboration of physical symptoms for psychological reasons
F68.1 Intentional production or feigning of symptoms or disabilities,
either physical or psychological [factitious disorder]
F68.8 Other specified disorders of adult personality and behaviour
F69 Unspecified disorder of adult personality and behaviour
- 38 -
F70-F79
Mental retardation
F70 Mild mental retardation
F71 Moderate mental retardation
F72 Severe mental retardation
F73 Profound mental retardation
F78 Other mental retardation
F79 Unspecified mental retardation
A fourth character may be used to specify the extent of associated behavioural
impairment:
F7x.0 No, or minimal, impairment of behaviour
F7x.1 Significant impairment of behaviour requiring
attention or treatment
F7x.8 Other impairments of behaviour
F7x.9 Without mention of impairment of behaviour
- 39 -
F80-F89
Disorders of psychological development
F80 Specific developmental disorders of speech and language
F80.0 Specific speech articulation disorder
F80.1 Expressive language disorder
F80.2 Receptive language disorder
F80.3 Acquired aphasia with epilepsy [Landau-Kleffner syndrome]
F80.8 Other developmental disorders of speech and language
F80.9 Developmental disorder of speech and language, unspecified
F81 Specific developmental disorders of scholastic skills
F81.0 Specific reading disorder
F81.1 Specific spelling disorder
F81.2 Specific disorder of arithmetical skills
F81.3 Mixed disorder of scholastic skills
F81.8 Other developmental disorders of scholastic skills
F81.9 Developmental disorder of scholastic skills, unspecified
F82 Specific developmental disorder of motor function
F83 Mixed specific developmental disorders
F84 Pervasive developmental disorders
F84.0 Childhood autism
F84.1 Atypical autism
F84.2 Rett's syndrome
F84.3 Other childhood disintegrative disorder
F84.4Overactive disorder associated with mental retardation and
stereotyped movements
F84.5 Asperger's syndrome
F84.8 Other pervasive developmental disorders
F84.9 Pervasive developmental disorder, unspecified
F88 Other disorders of psychological development
F89 Unspecified disorder of psychological development
- 40 -
F90-F98
Behavioural and emotional disorders with onset
usually occurring in childhood and adolescence
F90 Hyperkinetic disorders
F90.0 Disturbance of activity and attention
F90.1 Hyperkinetic conduct disorder
F90.8 Other hyperkinetic disorders
F90.9 Hyperkinetic disorder, unspecified
F91 Conduct disorders
F91.0 Conduct disorder confined to the family context
F91.1 Unsocialized conduct disorder
F91.2 Socialized conduct disorder
F91.3 Oppositional defiant disorder
F91.8 Other conduct disorders
F91.9 Conduct disorder, unspecified
F92 Mixed disorders of conduct and emotions
F92.0 Depressive conduct disorder
F92.8 Other mixed disorders of conduct and emotions
F92.9 Mixed disorder of conduct and emotions, unspecified
F93 Emotional disorders with onset specific to childhood
F93.0 Separation anxiety disorder of childhood
F93.1 Phobic anxiety disorder of childhood
F93.2 Social anxiety disorder of childhood
F93.3 Sibling rivalry disorder
F93.8 Other childhood emotional disorders
F93.9 Childhood emotional disorder, unspecified
F94 Disorders of social functioning with onset specific to childhood
and adolescence
F94.0 Elective mutism
F94.1 Reactive attachment disorder of childhood
F94.2 Disinhibited attachment disorder of childhood
F94.8 Other childhood disorders of social functioning
F94.9 Childhood disorder of social functioning, unspecified
F95 Tic disorders
F95.0 Transient tic disorder
F95.1 Chronic motor or vocal tic disorder
F95.2 Combined vocal and multiple motor tic disorder [de la Tourette's
syndrome]
F95.8 Other tic disorders
F95.9 Tic disorder, unspecified
- 41 F98
Other behavioural and emotional disorders with onset usually
occurring in childhood and adolescence
F98.0 Nonorganic enuresis
F98.1 Nonorganic encopresis
F98.2 Feeding disorder of infancy and childhood
F98.3 Pica of infancy and childhood
F98.4 Stereotyped movement disorders
F98.5 Stuttering [stammering]
F98.6 Cluttering
F98.8Other specified behavioural and emotional disorders with onset
usually occurring in childhood and adolescence
F98.9Unspecified behavioural and emotional disorders with onset usually
occurring in childhood and adolescence
F99
Unspecified mental disorder
F99 Mental disorder, not otherwise specified
- 42 Clinical
descriptions
and
diagnostic guidelines
- 43 -
F00-F09
Organic, including symptomatic, mental disorders
Overview of this block
F00 Dementia in Alzheimer's disease
F00.0Dementia in Alzheimer's disease with early onset
F00.1Dementia in Alzheimer's disease with late onset
F00.2Dementia in Alzheimer's disease, atypical or mixed type
F00.9Dementia in Alzheimer's disease, unspecified
F01Vascular dementia
F01.0Vascular dementia of acute onset
F01.1Multi-infarct dementia
F01.2Subcortical vascular dementia
F01.3Mixed cortical and subcortical vascular dementia
F01.8Other vascular dementia
F01.9Vascular dementia, unspecified
F02Dementia in other diseases classified elsewhere
F02.0Dementia in Pick's disease
F02.1Dementia in Creutzfeldt-Jakob disease
F02.2Dementia in Huntington's disease
F02.3Dementia in Parkinson's disease
F02.4Dementia in human immunodeficiency virus [HIV] disease
F02.8Dementia in other specified diseases classified elsewhere
F03Unspecified dementia
A fifth character may be added to specify dementia in F00-F03, as`follows:
.x0 Without additional symptoms
.x1 Other symptoms, predominantly delusional
.x2 Other symptoms, predominantly hallucinatory
.x3 Other symptoms, predominantly depressive
.x4 Other mixed symptoms
F04Organic amnesic syndrome, not induced by alcohol and other
psychoactive substances
F05Delirium, not induced by alcohol and other psychoactive substances
F05.0Delirium, not superimposed on dementia, so described
F05.1Delirium, superimposed on dementia
F05.8Other delirium
F05.9Delirium, unspecified
F06Other mental disorders due to brain damage and dysfunction and to physical
disease
F06.0Organic hallucinosis
F06.1Organic catatonic disorder
F06.2Organic delusional [schizophrenia-like] disorder
- 44 F06.3Organic
mood [affective] disorders
.30 Organic manic disorder
.31 Organic bipolar disorder
.32 Organic depressive disorder
.33 Organic mixed affective disorder
F06.4Organic anxiety disorder
F06.5Organic dissociative disorder
F06.6Organic emotionally labile [asthenic] disorder
F06.7Mild cognitive disorder
F06.8Other specified mental disorders due to brain damage and dysfunction and to
physical disease
F06.9Unspecified mental disorder due to brain damage and dysfunction and to
physical disease
F07Personality and behavioural disorders due to brain disease, damage and dysfunction
F07.0Organic personality disorder
F07.1Postencephalitic syndrome
F07.2Postconcussional syndrome
F07.8Other organic personality and behavioural disorder due to brain disease,
damage and dysfunction
F07.9 Unspecified organic personality and behavioural disorders due to brain
disease, damage and dysfunction
F09Unspecified organic or symptomatic mental disorder
- 45 -
Introduction
This block comprises`a range of mental disorders grouped together on the basis of
their common, demonstrable etiology in cerebral disease, brain injury, or other insult
leading to cerebral dysfunction. The dysfunction may be primary, as in diseases,
injuries, and insults that affect the brain directly or with predilection; or secondary, as
in systemic diseases and disorders that attack the brain only as one of the multiple
organs or systems of the body involved. Alcohol- and drug-caused brain disorders,
though logically belonging to this group, are classified under F10-F19 because of
practical advantages in keeping all disorders due to psychoactive substance use in a
single block.
Although the spectrum of psychopathological manifestations of the conditions
included here is broad, the essential features of the disorders form two main clusters.
On the one hand, there are syndromes in which the invariable and most prominent
features are either disturbances of cognitive functions, such as memory, intellect, and
learning, or disturbances of the sensorium, such as disorders of consciousness and
attention. On the other hand, there are syndromes of which the most conspicuous
manifestations are in the areas of perception (hallucinations), thought contents
(delusions), or mood and emotion (depression, elation, anxiety), or in the overall
pattern of personality and behaviour, while cognitive or sensory dysfunction is
minimal or difficult to ascertain. The latter group of disorders has less secure footing
in this block than the former because it contains many disorders that are
symptomatically similar to conditions classified in other blocks (F20-F29, F30-F39,
F40-F49, F60-F69) and are known to occur without gross cerebral pathological
change or dysfunction. However, the growing evidence that a variety of cerebral and
systemic diseases are causally related to the occurrence of such syndromes provides
sufficient justification for their inclusion here in a clinically oriented classification.
The majority of the disorders in this block can, at least theoretically, have their onset
at any age, except perhaps early childhood. In practice, most tend to start in adult life
or old age. While some of these disorders are seemingly irreversible and progressive,
others are transient or respond to currently available treatments.
Use of the term "organic" does not imply that conditions elsewhere in this
classification are "nonorganic" in the sense of having no cerebral substrate. In the
present context, the term "organic" means simply that the syndrome so classified can
be attributed to an independently diagnosable cerebral or systemic disease or disorder.
The term "symptomatic" is used for those organic mental disorders in which cerebral
involvement is secondary to a systemic extracerebral disease or disorder.
It follows from the foregoing that, in the majority of cases, the recording of a
diagnosis of any one of the disorders in this block will require the use of two codes:
one for the psychopathological syndrome and another for the underlying disorder. The
etiological code should be selected from the relevant chapter of the overall ICD-10
classification.
Dementia
- 46 A
general description of dementia is given here, to indicate the minimum requirement
for the diagnosis of dementia of any type, and is followed by the criteria that govern
the diagnosis of more specific types.
Dementia is a syndrome due to disease of the brain, usually of a chronic or
progressive nature, in which there is disturbance of multiple higher cortical functions,
including memory, thinking, orientation, comprehension, calculation, learning
capacity, language, and judgement. Consciousness is not clouded. Impairments of
cognitive function are commonly accompanied, and occasionally preceded, by
deterioration in emotional control, social behaviour, or motivation. This syndrome
occurs in Alzheimer's disease, in cerebrovascular disease, and in other conditions
primarily or secondarily affecting the brain.
In assessing the presence or absence of a dementia, special care should be taken to
avoid false-positive identification: motivational or emotional factors, particularly
depression, in addition to motor slowness and general physical frailty, rather than loss
of intellectual capacity, may account for failure to perform.
Dementia produces an appreciable decline in intellectual functioning, and usually
some interference with personal activities of daily living, such as washing, dressing,
eating, personal hygiene, excretory and toilet activities. How such a decline manifests
itself will depend largely on the social and cultural setting in which the patient lives.
Changes in role performance, such as lowered ability to keep or find a job, should not
be used as criteria of dementia because of the large cross-cultural differences that
exist in what is appropriate, and because there may be frequent, externally imposed
changes in the availability of work within a particular culture.
If depressive symptoms are present but the criteria for depressive episode (F32.0F32.3)
are not fulfilled, they can be recorded by means of a fifth character. The
presence of hallucinations or delusions may be treated similarly.
.x0 Without additional symptoms
.x1 Other symptoms, predominantly delusional
.x2 Other symptoms, predominantly hallucinatory
.x3 Other symptoms, predominantly depressive
.x4 Other mixed symptoms
Diagnostic guidelines
The primary requirement for diagnosis is evidence of a decline in both memory and
thinking which is sufficient to impair personal activities of daily living, as described
above. The impairment of memory typically affects the registration, storage, and
retrieval of new information, but previously learned and familiar material may also be
lost, particularly in the later stages. Dementia is more than dysmnesia: there is also
impairment of thinking and of reasoning capacity, and a reduction in the flow of
ideas. The processing of incoming information is impaired, in that the individual finds
it increasingly difficult to attend to more than one stimulus at a time, such as taking
part in a conversation with several persons, and to shift the focus of attention from one
topic to another. If dementia is the sole diagnosis, evidence of clear consciousness is
- 47 required.
However, a double diagnosis of delirium superimposed upon dementia is
common (F05.1). The above symptoms and impairments should have been evident for
at least 6 months for a confident clinical diagnosis of dementia to be made.
Differential diagnosis. Consider: a depressive disorder (F30-F39), which may exhibit
many of the features of an early dementia, especially memory impairment, slowed
thinking, and lack of spontaneity; delirium (F05); mild or moderate mental retardation
(F70-F71); states of subnormal cognitive functioning attributable to a severely
impoverished social environment and limited education; iatrogenic mental disorders
due to medication (F06.-).
Dementia may follow any other organic mental disorder classified in this block, or
coexist with some of them, notably delirium (see F05.1).
F00 Dementia in Alzheimer's disease
Alzheimer's disease is a primary degenerative cerebral disease of unknown etiology,
with characteristic neuropathological and neurochemical features. It is usually
insidious in onset and develops slowly but steadily over a period of years. This period
can be as short as 2 or 3 years, but can occasionally be considerably longer. The onset
can be in middle adult life or even earlier (Alzheimer's disease with early onset), but
the incidence is higher in later life (Alzheimer's disease with late onset). In cases with
onset before the age of 65-70, there is the likelihood of a family history of a similar
dementia, a more rapid course, and prominence of features of temporal and parietal
lobe damage, including dysphasia or dyspraxia. In cases with a later onset, the course
tends to be slower and to be characterized by more general impairment of higher
cortical functions. Patients with Down's syndrome are at high risk of developing
Alzheimer's disease.
There are characteristic changes in the brain: a marked reduction in the population of
neurons, particularly in the hippocampus, substantia innominata, locus ceruleus, and
temporoparietal and frontal cortex; appearance of neurofibrillary tangles made of
paired helical filaments; neuritic (argentophil) plaques, which consist largely of
amyloid and show a definite progression in their development (although plaques
without amyloid are also known to exist); and granulovacuolar bodies. Neurochemical
changes have also been found, including a marked reduction in the enzyme choline
acetyltransferase, in acetylcholine itself, and in other neurotransmitters and
neuromodulators.
As originally described, the clinical features are accompanied by the above brain
changes. However. it now appears that the two do not always progress in parallel: one
may be indisputably present with only minimal evidence of the other. Nevertheless,
the clinical features of Alzheimer's disease are such that it is often possible to make a
presumptive diagnosis on clinical grounds alone.
Dementia in Alzheimer's disease is at present irreversible.
Diagnostic guidelines
The following features are essential for a definite diagnosis:
- 48 (a)
Presence of a dementia as described above.
(b)Insidious onset with slow deterioration. While the onset usually seems difficult to
pinpoint in time, realization by others that the defects exist may come suddenly.
An apparent plateau may occur in the progression.
(c)Absence of clinical evidence, or findings from special investigations, to suggest
that the mental state may be due to other systemic or brain disease which can
induce a dementia (e.g. hypothyroidism, hypercalcaemia, vitamin B12
deficiency, niacin deficiency, neurosyphilis, normal pressure hydrocephalus, or
subdural haematoma).
(d)Absence of a sudden, apoplectic onset, or of neurological signs of focal damage
such as hemiparesis, sensory loss, visual field defects, and incoordination
occurring early in the illness (although these phenomena may be superimposed
later).
In a certain proportion of cases, the features of Alzheimer's disease and vascular
dementia may both be present. In such cases, double diagnosis (and coding) should be
made. When the vascular dementia precedes the Alzheimer's disease, it may be
impossible to diagnose the latter on clinical grounds.
Includes: primary degenerative dementia of the Alzheimer's type
Differential diagnosis. Consider: a depressive disorder (F30-F39); delirium (F05.-);
organic amnesic syndrome (F04); other primary dementias, such as in Pick's,
Creutzfeldt-Jakob or Huntington's disease (F02.-); secondary dementias associated
with a variety of physical diseases, toxic states, etc. (F02.8); mild, moderate or severe
mental retardation (F70-F72).
Dementia in Alzheimer's disease may coexist with vascular dementia (to be coded
F00.2), as when cerebrovascular episodes (multi-infarct phenomena) are
superimposed on a clinical picture and history suggesting Alzheimer's disease. Such
episodes may result in sudden exacerbations of the manifestations of dementia.
According to postmortem findings, both types may coexist in as many as 10-15% of
all dementia cases.
F00.0 Dementia in Alzheimer's disease with early onset
Dementia in Alzheimer's disease beginning before the age of 65. There is relatively
rapid deterioration, with marked multiple disorders of the higher cortical functions.
Aphasia, agraphia, alexia, and apraxia occur relatively early in the course of the
dementia in most cases.
Diagnostic guidelines
As for dementia, described above, with onset before the age of 65 years, and usually
with rapid progression of symptoms. Family history of Alzheimer's disease is a
contributory but not necessary factor for the diagnosis, as is a family history of
Down's syndrome or of lymphoma.
Includes: Alzheimer's disease, type 2
presenile dementia, Alzheimer's type
F00.1 Dementia in Alzheimer's disease with late onset
- 49 Dementia
in Alzheimer's disease where the clinically observable onset is after the age
of 65 years and usually in the late 70s or thereafter, with a slow progression, and
usually with memory impairment as the principal feature.
Diagnostic guidelines
As for dementia, described above, with attention to the presence or absence of
features differentiating the disorder from the early-onset subtype (F00.0).
Includes: Alzheimer's disease, type 1
senile dementia, Alzheimer's type
F00.2 Dementia in Alzheimer's disease, atypical or mixed type
Dementias that do not fit the descriptions and guidelines for either F00.0 or F00.1
should be classified here; mixed Alzheimer's and vascular dementias are also included
here.
F00.9 Dementia in Alzheimer's disease, unspecified
- 50 F01
Vascular dementia
Vascular (formerly arteriosclerotic) dementia, which includes multi-infarct dementia,
is distinguished from dementia in Alzheimer's disease by its history of onset, clinical
features, and subsequent course. Typically, there is a history of transient ischaemic
attacks with brief impairment of consciousness, fleeting pareses, or visual loss. The
dementia may also follow a succession of acute cerebrovascular accidents or, less
commonly, a single major stroke. Some impairment of memory and thinking then
becomes apparent. Onset, which is usually in later life, can be abrupt, following one
particular ischaemic episode, or there may be more gradual emergence. The dementia
is usually the result of infarction of the brain due to vascular diseases, including
hypertensive cerebrovascular disease. The infarcts are usually small but cumulative in
their effect.
Diagnostic guidelines
The diagnosis presupposes the presence of a dementia as described above.
Impairment of cognitive function is commonly uneven, so that there may be memory
loss, intellectual impairment, and focal neurological signs. Insight and judgement may
be relatively well preserved. An abrupt onset or a stepwise deterioration, as well as the
presence of focal neurological signs and symptoms, increases the probability of the
diagnosis; in some cases, confirmation can be provided only by computerized axial
tomography or, ultimately, neuropathological examination.
Associated features are: hypertension, carotid bruit, emotional lability with transient
depressive mood, weeping or explosive laughter, and transient episodes of clouded
consciousness or delirium, often provoked by further infarction. Personality is
believed to be relatively well preserved, but personality changes may be evident in a
proportion of cases with apathy, disinhibition, or accentuation of previous traits such
as egocentricity, paranoid attitudes, or irritability.
Includes: arteriosclerotic dementia
Differential diagnosis. Consider: delirium (F05.-); other dementia, particularly in
Alzheimer's disease (F00.-); mood [affective] disorders (F30-F39); mild or moderate
mental retardation (F70-F71); subdural haemorrhage (traumatic (S06.5), nontraumatic
(162.0)).
Vascular dementia may coexist with dementia in Alzheimer's disease (to be coded
F00.2), as when evidence of a vascular episode is superimposed on a clinical picture
and history suggesting Alzheimer's disease.
F01.0 Vascular dementia of acute onset
Usually develops rapidly after a succession of strokes from cerebrovascular
thrombosis, embolism, or haemorrhage, In rare cases, a single large infarction may be
the cause.
F01.1 Multi-infarct dementia
- 51 This
is more gradual in onset than the acute form, following a number of minor
ischaemic episodes which produce an accumulation of infarcts in the cerebral
parenchyma.
Includes: predominantly cortical dementia
F01.2 Subcortical vascular dementia
There may be a history of hypertension and foci of ischaemic destruction in the deep
white matter of the cerebral hemispheres, which can be suspected on clinical grounds
and demonstrated on computerized axial tomography scans. The cerebral cortex is
usually preserved and this contrasts with the clinical picture, which may closely
resemble that of dementia in Alzheimer's disease. (Where diffuse demyelination of
white matter can be demonstrated, the term "'Binswanger's encephalopathy" may be
used.)
F01.3 Mixed cortical and subcortical vascular dementia
Mixed cortical and subcortical components of the vascular dementia may be
suspected from the clinical features, the results of investigations (including autopsy),
or both.
F01.8 Other vascular dementia
F01.9 Vascular dementia, unspecified
F02Dementia in other diseases classified elsewhere
Cases of dementia due, or presumed to be due, to causes other than Alzheimer's
disease or cerebrovascular disease. Onset may be at any time in life, though rarely in
old age.
Diagnostic guidelines
Presence of a dementia as described above; presence of features characteristic of one
of the specified syndromes, as set out in the following categories.
F02.0 Dementia in Pick's disease
A progressive dementia, commencing in middle life (usually between 50 and 60
years), characterized by slowly progressing changes of character and social
deterioration, followed by impairment of intellect, memory, and language functions,
with apathy, euphoria, and (occasionally) extrapyramidal phenomena. The
neuropathological picture is one of selective atrophy of the frontal and temporal lobes,
but without the occurrence of neuritic plaques and neurofibrillary tangles in excess of
that seen in normal aging. Cases with early onset tend to exhibit a more malignant
course. The social and behavioural manifestations often precede frank memory
impairment.
Diagnostic guidelines
The following features are required for a definite diagnosis:
- 52 (a)
a progressive dementia;
(b)a predominance of frontal lobe features with euphoria, emotional blunting, and
coarsening of social behaviour, disinhibition, and either apathy or restlessness;
(c)behavioural manifestations, which commonly precede frank memory impairment.
Frontal lobe features are more marked than temporal and parietal, unlike Alzheimer's
disease.
Differential diagnosis. Consider: dementia in Alzheimer's disease (F00); vascular
dementia (F01); dementia secondary to other disorders such as neurosyphilis (F02.8);
normal pressure hydrocephalus (characterized by extreme psychomotor slowing, and
gait and sphincter disturbances) (G91.2); other neurological or metabolic disorders.
F02.1 Dementia in Creutzfeldt-Jakob disease
A progressive dementia with extensive neurological signs, due to specific
neuropathological changes (subacute spongiform encephalopathy) that are presumed
to be caused by a transmissible agent. Onset is usually in middle or later life, typically
in the fifth decade, but may be at any adult age. The course is subacute,leading to
death within 1-2 years.
Diagnostic guidelines
Creutzfeldt-Jakob disease should be suspected in all cases of a dementia that
progresses fairly rapidly over months to 1 or 2 years and that is accompanied or
followed by multiple neurological symptoms. In some cases, such as the so-called
amyotrophic form, the neurological signs may precede the onset of the dementia.
There is usually a progressive spastic paralysis of the limbs, accompanied by
extrapyramidal signs with tremor, rigidity, and choreoathetoid movements. Other
variants may include ataxia, visual failure, or muscle fibrillation and atrophy of the
upper motor neuron type. The triad consisting of
- rapidly progressing, devastating dementia,
- pyramidal and extrapyramidal disease with myoclonus, and
- a characteristic (triphasic) electroencephalogram
is thought to be highly suggestive of this disease.
Differential diagnosis. Consider: Alzheimer's disease (F00.-) or Pick's disease
(F02.0); Parkinson's disease (F02.3); postencephalitic parkinsonism (G21.3).
The rapid course and early motor involvement should suggest Creutzfeldt-Jakob
disease.
F02.2 Dementia in Huntington's disease
A dementia occurring as part of a widespread degeneration of the brain. Huntington's
disease is transmitted by a single autosomal dominant gene. Symptoms typically
emerge in the third and fourth decade, and the sex incidence is probably equal. In a
proportion of cases, the earliest symptoms may be depression, anxiety, or frank
paranoid illness, accompanied by a personality change. Progression is slow, leading to
death usually within 10 to 15 years.
- 53 Diagnostic
guidelines
The association of choreiform movement disorder, dementia, and family history of
Huntington's disease is highly suggestive of the diagnosis, though sporadic cases
undoubtedly occur.
Involuntary choreiform movements, typically of the face, hands, and shoulders, or in
the gait, are early manifestations. They usually precede the dementia and only rarely
remain absent until the dementia is very advanced. Other motor phenomena may
predominate when the onset is at an unusually young age (e.g. striatal rigidity) or at a
late age (e.g. intention tremor).
The dementia is characterized by the predominant involvement of frontal lobe
functions in the early stage, with relative preservation of memory until later.
Includes: dementia in Huntington's chorea
Differential diagnosis. Consider: other cases of choreic movements; Alzheimer's,
Pick's or Creutzfeldt-Jakob disease (F00.-, F02.0, F02.1).
F02.3 Dementia in Parkinson's disease
A dementia developing in the course of established Parkinson's disease (especially its
severe forms). No particular distinguishing clinical features have yet been
demonstrated. The dementia may be different from that in either Alzheimer's disease
or vascular dementia; however, there is also evidence that it may be the manifestation
of a co-occurrence of one of these conditions with Parkinson's disease. This justifies
the identification of cases of Parkinson's disease with dementia for research until the
issue is resolved.
Diagnostic guidelines
Dementia developing in an individual with advanced, usually severe, Parkinson's
disease.
Includes: dementia in paralysis agitans
dementia in parkinsonism
Differential diagnosis. Consider: other secondary dementias (F02.8); multi-infarct
dementia (F01.1) associated with hypertensive or diabetic vascular disease; brain
tumor (C70-C72); normal pressure hydrocephalus (G91.2).
F02.4 Dementia in human immunodeficiency virus [HIV] disease
A disorder characterized by cognitive deficits meeting the clinical diagnostic criteria
for dementia, in the absence of a concurrent illness or condition other than HIV
infection that could explain the findings.
HIV dementia typically presents with complaints of forgetfulness, slowness, poor
concentration, and difficulties with problem-solving and reading. Apathy, reduced
spontaneity, and social withdrawal are common, and in a significant minority of
- 54 affected
individuals the illness may present atypically as an affective disorder,
psychosis, or seizures. Physical examination often reveals tremor, impaired rapid
repetitive movements, imbalance, ataxia, hypertonia, generalized hyperreflexia,
positive frontal release signs, and impaired pursuit and saccadic eye movements.
Children also develop an HIV-associated neurodevelopmental disorder characterized
by developmental delay, hypertonia, microcephaly, and basal ganglia calcification.
The neurological involvement most often occurs in the absence of opportunistic
infections and neoplasms, which is not the case for adults.
HIV dementia generally, but not invariably, progresses quickly (over weeks or
months) to severe global dementia, mutism, and death.
Includes: AIDS-dementia complex
HIV encephalopathy or subacute encephalitis
F02.8 Dementia in other specified diseases classified elsewhere
Dementia can occur as a manifestation or consequence of a variety of cerebral and
somatic conditions. To specify the etiology, the ICD-10 code for the underlying
condition should be added.
Parkinsonism-dementia complex of Guam should also be coded here (identified by a
fifth character, if necessary). It is a rapidly progressing dementia followed by
extrapyramidal dysfunction and, in some cases, amyotrophic lateral sclerosis. The
disease was originally described on the island of Guam where it occurs with high
frequency in the indigenous population, affecting twice as many males as females; it
is now known to occur also in Papua New Guinea and Japan.
Includes: dementia in:
carbon monoxide poisoning (T58)
cerebral lipidosis (E75.-)
epilepsy (G40.-)
general paralysis of the insane (A52.1)
hepatolenticular degeneration (Wilson's disease) (E83.0)
hypercalcaemia (E83.5)
hypothyroidism, acquired (E00.-, E02)
intoxications (T36-T65)
multiple sclerosis (G35)
neurosyphilis (A52.1)
niacin deficiency [pellagra] (E52)
polyarteritis nodosa (M30.0)
systemic lupus erythematosus (M32.-)
trypanosomiasis (African B56.-, American B57.-)
vitamin B12 deficiency (E53.8)
F03 Unspecified dementia
- 55 This
category should be used when the general criteria for the diagnosis of dementia
are satisfied, but when it is not possible to identify one of the specific types (F00.0-
F02.9).
Includes: presenile or senile dementia NOS
presenile or senile psychosis NOS
primary degenerative dementia NOS
F04 Organic amnesic syndrome, not induced by alcohol
and other psychoactive substances
A syndrome of prominent impairment of recent and remote memory. While
immediate recall is preserved, the ability to learn new material is markedly reduced
and this results in anterograde amnesia and disorientation in time. Retrograde
amnesia of varying intensity is also present but its extent may lessen over time if
the underlying lesion or pathological process has a tendency to recover.
Confabulation may be a marked feature but is not invariably present. Perception
and other cognitive functions, including the intellect, are usually intact and provide
a background against which the memory disturbance appears as particularly
striking. The prognosis depends on the course of the underlying lesion (which
typically affects the hypothalamic-diencephalic system or the hippocampal region);
almost complete recovery is, in principle, possible.
Diagnostic guidelines
For a definitive diagnosis it is necessary to establish:
(a)presence of a memory impairment manifest in a defect of recent memory
(impaired learning of new material); anterograde and retrograde amnesia, and
a reduced ability to recall past experiences in reverse order of their
occurrence;
(b)history or objective evidence of an insult to, or a disease of, the brain (especially
with bilateral involvement of the diencephalic and medial temporal
structures);
(c)absence of a defect in immediate recall (as tested, for example, by the digit
span), of disturbances of attention and consciousness, and of global
intellectual impairment.
Confabulations, lack of insight and emotional changes (apathy, lack of initiative)
are additional, though not in every case necessary, pointers to the diagnosis.
Includes: Korsakov's syndrome or psychosis, nonalcoholic
Differential diagnosis. This disorder should be distinguished from other organic
syndromes in which memory impairment is prominent (e.g. dementia or delirium),
from dissociative amnesia (F44.0), from impaired memory function in depressive
disorders (F30-F39), and from malingering presenting with a complaint of memory
- 56 loss
(Z76.5). Korsakov's syndrome induced by alcohol or drugs should not be
coded here but in the appropriate section (F1x.6).
F05 Delirium, not induced by alcohol and other
psychoactive substances
An etiologically nonspecific syndrome characterized by concurrent disturbances of
consciousness and attention, perception, thinking, memory, psychomotor behaviour,
emotion, and the sleep-wake cycle. It may occur at any age but is most common after
the age of 60 years. The delirious state is transient and of fluctuating intensity; most
cases recover within 4 weeks or less. However, delirium lasting, with fluctuations, for
up to 6 months is not uncommon. especially when arising in the course of chronic
liver disease, carcinoma, or subacute bacterial endocarditis. The distinction that is
sometimes made between acute and subacute delirium is of little clinical relevance;
the condition should be seen as a unitary syndrome of variable duration and severity
ranging from mild to very severe. A delirious state may be superimposed on, or
progress into, dementia.
This category should not be used for states of delirium associated with the use of
psychoactive drugs specified in F10-F19. Delirious states due to prescribed
medication (such as acute confusional states in elderly patients due to antidepressants)
should be coded here. In such cases, the medication concerned should also be
recorded by means of an additional T code from Chapter XIX of ICD-10.
Diagnostic guidelines
For a definite diagnosis, symptoms, mild or severe, should be present in each one of
the following areas:
(a)impairment of consciousness and attention (on a continuum from clouding to
coma; reduced ability to direct, focus, sustain, and shift attention);
(b)global disturbance of cognition (perceptual distortions, illusions and hallucinations
- most often visual; impairment of abstract thinking and comprehension, with
or without transient delusions, but typically with some degree of incoherence;
impairment of immediate recall and of recent memory but with relatively intact
remote memory; disorientation for time as well as, in more severe cases, for
place and person);
(c)psychomotor disturbances (hypo- or hyperactivity and unpredictable shifts from
one to the other; increased reaction time; increased or decreased flow of speech;
enhanced startle reaction);
(d)disturbance of the sleep-wake cycle (insomnia or, in severe cases, total sleep loss
or reversal of the sleep-wake cycle; daytime drowsiness; nocturnal worsening
of symptoms; disturbing dreams or nightmares, which may continue as
hallucinations after awakening);
(e)emotional disturbances, e.g. depression, anxiety or fear, irritability, euphoria,
apathy,or wondering perplexity.
The onset is usually rapid, the course diurnally fluctuating, and the total duration of
the condition less than 6 months. The above clinical picture is so characteristic that a
- 57 fairly
confident diagnosis of delirium can be made even if the underlying cause is not
clearly established. In addition to a history of an underlying physical or brain disease,
evidence of cerebral dysfunction (e.g. an abnormal electroencephalogram, usually but
not invariably showing a slowing of the background activity) may be required if the
diagnosis is in doubt.
Includes: acute brain syndrome
acute confusional state (nonalcoholic)
acute infective psychosis
acute organic reaction
acute psycho-organic syndrome
Differential diagnosis. Delirium should be distinguished from other organic
syndromes, especially dementia (F00-F03), from acute and transient psychotic
disorders (F23.-), and from acute states in schizophrenia (F20.-) or mood [affective]
disorders (F30-F39) in which confusional features may be present. Delirium, induced
by alcohol and other psychoactive substances, should be coded in the appropriate
section (F1x.4).
F05.0 Delirium, not superimposed on dementia, so described
This code should be used for delirium that is not superimposed upon pre-existing
dementia.
F05.1 Delirium, superimposed on dementia
This code should be used for conditions meeting the above criteria but developing in
the course of a dementia (F00-F03).
F05.8 Other delirium
Includes: delirium of mixed origin
subacute confusional state or delirium
F05.9 Delirium, unspecified
- 58 F06
Other mental disorders due to brain damage
and dysfunction and to physical disease
This category includes miscellaneous conditions causally related to brain dysfunction
due to primary cerebral disease, to systemic disease affecting the brain secondarily, to
endocrine disorders such as Cushing's syndrome or other somatic illnesses, and to
some exogenous toxic substances (but excluding alcohol and drugs classified under
F10-F19) or hormones. These conditions have in common clinical features that do not
by themselves allow a presumptive diagnosis of an organic mental disorder, such as
dementia or delirium. Rather, the clinical manifestations resemble, or are identical
with, those of disorders not regarded as "organic" in the specific sense restricted to
this block of the classification. Their inclusion here is based on the hypothesis that
they are directly caused by cerebral disease or dysfunction rather than resulting from
either a fortuitous association with such disease or dysfunction, or a psychological
reaction to its symptoms, such as schizophrenia-like disorders associated with longstanding
epilepsy.
The decision to classify a clinical syndrome here is supported by the following:
(a)evidence of cerebral disease, damage or dysfunction or of systemic physical
disease, known to be associated with one of the listed syndromes;
(b)a temporal relationship (weeks or a few months) between the development of the
underlying disease and the onset of the mental syndrome;
(c)recovery from the mental disorder following removal or improvement of the
underlying presumed cause;
(d)absence of evidence to suggest an alternative cause of the mental syndrome (such
as a strong family history or precipitating stress).
Conditions (a) and (b) justify a provisional diagnosis; if all four are present, the
certainty of diagnostic classification is significantly increased.
The following are among the conditions known to increase the relative risk for the
syndromes classified here: epilepsy; limbic encephalitis; Huntington's disease; head
trauma; brain neoplasms; extracranial neoplasms with remote CNS effects (especially
carcinoma of the pancreas); vascular cerebral disease, lesions, or malformations;
lupus erythematosus and other collagen diseases; endocrine disease (especially hypoand
hyperthyroidism, Cushing's disease); metabolic disorders (e.g., hypoglycaemia,
porphyria, hypoxia); tropical infectious and parasitic diseases (e.g. trypanosomiasis);
toxic effects of nonpsychotropic drugs (propranolol, levodopa, methyldopa, steroids,
antihypertensives, antimalarials).
Excludes: mental disorders associated with delirium (F05.-)
mental disorders associated with dementia as classified in F00-F03
F06.0 Organic hallucinosis
A disorder of persistent or recurrent hallucinations, usually visual or auditory, that
occur in clear consciousness and may or may not be recognized by the subject as
such. Delusional elaboration of the hallucinations may occur, but insight is not
infrequently preserved.
- 59 Diagnostic
guidelines
In addition to the general criteria in the introduction to F06 above, there should be
evidence of persistent or recurrent hallucinations in any modality; no clouding of
consciousness; no significant intellectual decline; no predominant disturbance of
mood; and no predominance of delusions.
Includes: Dermatozoenwahn
organic hallucinatory state (nonalcoholic)
Excludes: alcoholic hallucinosis (F10.52)
schizophrenia (F20.-)
F06.1 Organic catatonic disorder
A disorder of diminished (stupor) or increased (excitement) psychomotor activity
associated with catatonic symptoms. The extremes of psychomotor disturbance may
alternate. It is not known whether the full range of catatonic disturbances described in
schizophrenia occurs in such organic states, nor has it been conclusively determined
whether an organic catatonic state may occur in clear consciousness or whether it is
always a manifestation of delirium, with subsequent partial or total amnesia. This
calls for caution in making this diagnosis and for a careful delimitation of the
condition from delirium. Encephalitis and carbon monoxide poisoning are presumed
to be associated with this syndrome more often than other organic causes.
Diagnostic guidelines
The general criteria for assuming organic etiology, laid down in the introduction to
F06, must be met. In addition, there should be one of the following:
(a)stupor (diminution or complete absence of spontaneous movement with partial or
complete mutism, negativism, and rigid posturing);
(b)excitement (gross hypermotility with or without a tendency to assaultiveness);
(c)both (shifting rapidly and unpredictably from hypo- to hyperactivity).
Other catatonic phenomena that increase confidence in the diagnosis are: stereotypies,
waxy flexibility, and impulsive acts.
Excludes: catatonic schizophrenia (20.2)
dissociative stupor (F44.2)
stupor NOS (R40.1)
F06.2 Organic delusional [schizophrenia-like] disorder
A disorder in which persistent or recurrent delusions dominate the clinical picture.
The delusions may be accompanied by hallucinations but are not confined to their
content. Features suggestive of schizophrenia, such as bizarre delusions,
hallucinations, or thought disorder, may also be present.
Diagnostic guidelines
- 60 The
general criteria for assuming an organic etiology, laid down in the introduction to
F06, must be met. In addition, there should be delusions (persecutory, of bodily
change, jealousy, disease, or death of the subject or another person). Hallucinations,
thought disorder, or isolated catatonic phenomena may be present. Consciousness and
memory must not be affected. This diagnosis should not be made if the presumed
evidence of organic causation is nonspecific or limited to findings such as enlarged
cerebral ventricles (visualized on computerized axial tomography) or "soft"
neurological signs.
Includes: paranoid and paranoid-hallucinatory organic states
schizophrenia-like psychosis in epilepsy
Excludes: acute and transient psychotic disorders (F23.-)
drug-induced psychotic disorders (F1x.5)
persistent delusional disorder (F22.-)
schizophrenia (F20.-)
F06.3 Organic mood [affective] disorders
Disorders characterized by a change in mood or affect, usually accompanied by a
change in the overall level of activity. The only criterion for inclusion of these
disorders in this block is their presumed direct causation by a cerebral or other
physical disorder whose presence must either be demonstrated independently (e.g. by
means of appropriate physical and laboratory investigations) or assumed on the basis
of adequate history information. The affective disorder must follow the presumed
organic factor and be judged not to represent an emotional response to the patient's
knowledge of having, or having the symptoms of, a concurrent brain disorder.
Postinfective depression (e.g. following influenza) is a common example and should
be coded here. Persistent mild euphoria not amounting to hypomania (which is
sometimes seen, for instance, in association with steroid therapy or antidepressants)
should not be coded here but under F06.8.
Diagnostic guidelines
In addition to the general criteria for assuming organic etiology, laid down in the
introduction to F06, the condition must meet the requirements for a diagnosis of one
of the disorders listed under F30-F33.
Excludes: mood [affective] disorders, nonorganic or unspecified (F30-
F39)
right hemispheric affective disorder (F07.8)
The following five-character codes might be used to specify the clinical disorder:
F06.30 Organic manic disorder
F06.31 Organic bipolar affective disorder
F06.32 Organic depressive disorder
F06.33 Organic mixed affective disorder
- 61 F06.4
Organic anxiety disorder
A disorder characterized by the essential descriptive features of a generalized anxiety
disorder (41.1), a panic disorder (F41.0), or a combination of both, but arising as a
consequence of an organic disorder capable of causing cerebral dysfunction (e.g.
temporal lobe epilepsy, thyrotoxicosis, or phaechromocytoma).
Excludes: anxiety disorders, nonorganic or unspecified (F41.-)
F06.5 Organic dissociative disorder
A disorder that meets the requirements for one of the disorders in F44.- (dissociative
[conversion] disorder) and for which the general criteria for organic etiology are also
fulfilled (as described in the introduction to this block).
Excludes: dissociative [conversion] disorders, nonorganic or unspecified
(F44.-)
F06.6 Organic emotionally labile [asthenic] disorder
A disorder characterized by marked and persistent emotional incontinence or lability,
fatiguability, or a variety of unpleasant physical sensations (e.g. dizziness) and pains
regarded as being due to the presence of an organic disorder. This disorder is thought
to occur in association with cerebrovascular disease or hypertension more often than
with other causes.
Excludes: somatoform disorders, nonorganic or unspecified (F45.-)
F06.7 Mild cognitive disorder
This disorder may precede, accompany, or follow a wide variety of infections and
physical disorders, both cerebral and systemic (including HIV infection). Direct
neurological evidence of cerebral involvement is not necessarily present, but there
may nevertheless be distress and interference with usual activities. The boundaries of
this category are still to be firmly established. When associated with a physical
disorder from which the patient recovers, mild cognitive disorder does not last for
more than a few additional weeks. This diagnosis should not be made if the condition
is clearly attributable to a mental or behavioural disorder classified in any of the
remaining blocks in this book.
Diagnostic guidelines
The main feature is a decline in cognitive performance. This may include memory
impairment, learning or concentration difficulties. Objective tests usually indicate
abnormality. The symptoms are such that a diagnosis of dementia (F00-F03), organic
amnesic syndrome (F04) or delirium (F05.-) cannot be made.
Differential diagnosis. The disorder can be differentiated from postencephalitic
syndrome (F07.1) and postconcussional syndrome (F07.2) by its different etiology,
more restricted range of generally milder symptoms, and usually shorter duration.
F06.8 Other specified mental disorders due to brain damage and
dysfunction and to physical disease
- 62 Examples
are abnormal mood states occurring during treatment with steroids or
antidepressants.
Includes: epileptic psychosis NOS
F06.9 Unspecified mental disorder due to brain damage and dysfunc- tion and to physical
disease
F07Personality and behavioural disorders due to brain disease, damage and dysfunction
Alteration of personality and behaviour can be a residual or concomitant disorder of
brain disease, damage, or dysfunction. In some instances, differences in the
manifestation of such residual or concomitant personality and behavioural syndromes
may be suggestive of the type and/or localization of the intracerebral problem, but the
reliability of this kind of diagnostic inference should not be overestimated. Thus the
underlying etiology should always be sought by independent means and, if known,
recorded.
F07.0 Organic personality disorder
This disorder is characterized by a significant alteration of the habitual patterns of
premorbid behaviour. The expression of emotions, needs, and impulses is particularly
affected. Cognitive functions may be defective mainly or even exclusively in the areas
of planning and anticipating the likely personal and social consequences, as in the socalled
frontal lobe syndrome. However, it is now known that this syndrome occurs not
only with frontal lobe lesions but also with lesions to other circumscribed areas of the
brain.
Diagnostic guidelines
In addition to an established history or other evidence of brain disease, damage, or
dysfunction, a definitive diagnosis requires the presence of two or more of the
following features:
(a)consistently reduced ability to persevere with goal-directed activities, especially
those involving longer periods of time and postponed gratification;
(b)altered emotional behaviour, characterized by emotional lability, shallow and
unwarranted cheerfulness (euphoria, inappropriate jocularity), and easy change
to irritability or short-lived outbursts of anger and aggression; in some instances
apathy may be a more prominent feature;
(c)expression of needs and impulses without consideration of consequences or social
convention (the patient may engage in dissocial acts, such as stealing,
inappropriate sexual advances, or voracious eating, or may exhibit disregard for
personal hygiene);
(d)cognitive disturbances, in the form of suspiciousness or paranoid ideation, and/or
excessive preoccupation with a single, usually abstract, theme (e.g. religion,
"right" and "wrong");
(e)marked alteration of the rate and flow of language production, with features such as
circumstantiality, over-inclusiveness, viscosity, and hypergraphia;
(f)altered sexual behaviour (hyposexuality or change of sexual preference).
- 63 Includes:
frontal lobe syndrome
limbic epilepsy personality syndrome
lobotomy syndrome
organic pseudopsychopathic personality
organic pseudoretarded personality
postleucotomy syndrome
Excludes: enduring personality change after catastrophic experience
(F62.0)
enduring personality change after psychiatric illness (F62.1)
postconcussional syndrome (F07.2)
postencephalitic syndrome (F07.1)
specific personality disorder (F60.-)
F07.1 Postencephalitic syndrome
The syndrome includes residual behavioural change following recovery from either
viral or bacterial encephalitis. Symptoms are nonspecific and vary from individual to
individual, from one infectious agent to another, and, most consistently, with the age
of the individual at the time of infection. The principal difference between this
disorder and the organic personality disorders is that it is often reversible.
Diagnostic guidelines
The manifestations may include general malaise, apathy or irritability, some lowering
of cognitive functioning (learning difficulties), altered sleep and eating patterns, and
changes in sexuality and in social judgement. There may be a variety of residual
neurological dysfunctions such as paralysis, deafness, aphasia, constructional apraxia,
and acalculia.
Excludes: organic personality disorder (F07.0)
F07.2 Postconcussional syndrome
The syndrome occurs following head trauma (usually sufficiently severe to result in
loss of consciousness) and includes a number of disparate symptoms such as
headache, dizziness (usually lacking the features of true vertigo), fatigue, irritability,
difficulty in concentrating and performing mental tasks, impairment of memory,
insomnia, and reduced tolerance to stress, emotional excitement, or alcohol. These
symptoms may be accompanied by feelings of depression or anxiety, resulting from
some loss of self-esteem and fear of permanent brain damage. Such feelings enhance
the original symptoms and a vicious circle results. Some patients become
hypochondriacal, embark on a search for diagnosis and cure, and may adopt a
permanent sick role. The etiology of these symptoms is not always clear, and both
organic and psychological factors have been proposed to account for them. The
nosological status of this condition is thus somewhat uncertain. There is little doubt,
however, that this syndrome is common and distressing to the patient.
- 64 Diagnostic
guidelines
At least three of the features described above should be present for a definite
diagnosis. Careful evaluation with laboratory techniques (electroencephalography,
brain stem evoked potentials, brain imaging, oculonystagmography) may yield
objective evidence to substantiate the symptoms but results are often negative. The
complaints are not necessarily associated with compensation motives.
Includes: postcontusional syndrome (encephalopathy)
post-traumatic brain syndrome, nonpsychotic
F07.8 Other organic personality and behavioural disorders due to brain disease, damage
and dysfunction
Brain disease, damage , or dysfunction may produce a variety of cognitive, emotional,
personality, and behavioural disorders, not all of which are classifiable under the
preceding rubrics. However, since the nosological status of the tentative syndromes in
this area is uncertain, they should be coded as "other". A fifth character may be added,
if necessary, to identify presumptive individual entities such as:
Right hemispheric organic affective disorder (changes in the ability to express or
comprehend emotion in individuals with right hemisphere disorder). Although the
patient may superficially appear to be depressed, depression is not usually present: it
is the expression of emotion that is restricted.
Also coded here:
(a)any other specified but presumptive syndromes of personality or behavioural
change due to brain disease, damage, or dysfunction other than those listed
under F07.0-F07.2; and
(b)conditions with mild degrees of cognitive impairment not yet amounting to
dementia in progressive mental disorders such as Alzheimer's disease,
Parkinson's disease, etc. The diagnosis should be changed when the criteria for
dementia are fulfilled.
Excludes: delirium (F05.-)
F07.9 Unspecified organic personality and behavioural disorder
due to brain disease, damage and dysfunction
Includes: organic psychosyndrome
F09Unspecified organic or symptomatic mental disorder
This category should only be used for recording mental disorders of known
organic etiology.
Includes: organic psychosis NOS
symptomatic psychosis NOS
Excludes: psychosis NOS (F29)
- 65 -
F10-F19
Mental and behavioural disorders due to psychoactive
substance use
Overview of this block
F10.-Mental and behavioural disorders due to use of alcohol
F11.-Mental and behavioural disorders due to use of opioids
F12.-Mental and behavioural disorders due to use of cannabinoids
F13.-Mental and behavioural disorders due to use of sedatives or hypnotics
F14.-Mental and behavioural disorders due to use of cocaine
F15.-Mental and behavioural disorders due to use of other stimulants, including
caffeine
F16.-Mental and behavioural disorders due to use of hallucinogens
F17.-Mental and behavioural disorders due to use of tobacco
F18.-Mental and behavioural disorders due to use of volatile solvents
F19.-Mental and behavioural disorders due to multiple drug use and use of other
psychoactive substances
Four- and five-character codes may be used to specify the clinical conditions, as follows:
F1x.0 Acute intoxication
.00 Uncomplicated
.01 With trauma or other bodily injury
.02 With other medical complications
.03 With delirium
.04 With perceptual distortions
.05 With coma
.06 With convulsions
.07 Pathological intoxication
F1x.1 Harmful use
F1x.2 Dependence syndrome
.20 Currently abstinent
.21 Currently abstinent, but in a protected environment
.22 Currently on a clinically supervised maintenance or replacement
regime [controlled dependence]
.23 Currently abstinent, but receiving treatment with
aversive or blocking drugs
.24 Currently using the substance [active dependence]
.25 Continuous use
.26 Episodic use [dipsomania]
F1x.3 Withdrawal state
.30 Uncomplicated
.31 With convulsions
- 66 F1x.4
Withdrawal state with delirium
.40 Without convulsions
.41 With convulsions
F1x.5 Psychotic disorder
.50 Schizophrenia-like
.51 Predominantly delusional
.52 Predominantly hallucinatory
.53 Predominantly polymorphic
.54 Predominantly depressive symptoms
.55 Predominantly manic symptoms
.56 Mixed
F1x.6 Amnesic syndrome
F1x.7 Residual and late-onset psychotic disorder
.70 Flashbacks
.71 Personality or behaviour disorder
.72 Residual affective disorder
.73 Dementia
.74 Other persisting cognitive impairment
.75 Late-onset psychotic disorder
F1x.8 Other mental and behavioural disorders
F1x.9 Unspecified mental and behavioural disorder
- 67 -
Introduction
This block contains a wide variety of disorders that differ in severity (from
uncomplicated intoxication and harmful use to obvious psychotic disorders and
dementia), but that are all attributable to the use of one or more psychoactive
substances (which may or may not have been medically prescribed).
The substance involved is indicated by means of the second and third characters (i.e.
the first two digits after the letter F), and the fourth and fifth characters specify the
clinical states. To save space, all the psychoactive substances are listed first, followed
by the four-character codes; these should be used, as required, for each substance
specified, but it should be noted that not all four-character codes are applicable to all
substances.
Diagnostic guidelines
Identification of the psychoactive substance used may be made on the basis of
self-report data, objective analysis of specimens of urine, blood, etc., or other
evidence (presence of drug samples in the patient's possession, clinical signs and
symptoms, or reports from informed third parties). It is always advisable to seek
corroboration from more than one source of evidence relating to substance use.
Objective analyses provide the most compelling evidence of present or recent use,
though these data have limitations with regard to past use and current levels of use.
Many drug users take more than one type of drug, but the diagnosis of the disorder
should be classified, whenever possible, according to the most important single
substance (or class of substances) used. This may usually be done with regard to the
particular drug, or type of drug, causing the presenting disorder. When in doubt, code
the drug or type of drug most frequently misused, particularly in those cases involving
continuous or daily use.
Only in cases in which patterns of psychoactive substance taking are chaotic and
indiscriminate, or in which the contributions of different drugs are inextricably mixed,
should code F19.- be used (disorders resulting from multiple drug use).
Misuse of other than psychoactive substances, such as laxatives or aspirin, should be
coded by means of F55.- (abuse of non-dependence-producing substances), with a
fourth character to specify the type of substance involved.
Cases in which mental disorders (particularly delirium in the elderly) are due to
psychoactive substances, but without the presence of one of the disorders in this block
(e.g. harmful use or dependence syndrome), should be coded in F00-F09. Where a
state of delirium is superimposed upon such a disorder in this block, it should be
coded by means of F1x.3 or F1x.4.
The level of alcohol involvement can be indicated by means of a supplementary code
from Chapter XX of ICD-10: Y90.- (evidence of alcohol involvement determined by
blood alcohol content) or Y91.- (evidence of alcohol involvement determined by level
of intoxication).
- 68 F1x.0Acute
intoxication
A transient condition following the administration of alcohol or other psychoactive
substance, resulting in disturbances in level of consciousness, cognition,
perception, affect or behaviour, or other psychophysiological functions and
responses.
This should be a main diagnosis only in cases where intoxication occurs without more
persistent alcohol- or drug-related problems being concomitantly present.
Where there are such problems, precedence should be given to diagnoses
of harmful use (F1x.1), dependence syndrome (F1x.2), or psychotic
disorder (F1x.5).
Diagnostic guidelines
Acute intoxication is usually closely related to dose levels (see ICD-10, Chapter XX).
Exceptions to this may occur in individuals with certain underlying organic
conditions (e.g. renal or hepatic insufficiency) in whom small doses of a
substance may produce a disproportionately severe intoxicating effect.
Disinhibition due to social context should also be taken into account (e.g.
behavioural disinhibition at parties or carnivals). Acute intoxication is a
transient phenomenon. Intensity of intoxication lessens with time, and
effects eventually disappear in the absence of further use of the substance.
Recovery is therefore complete except where tissue damage or another
complication has arisen.
Symptoms of intoxication need not always reflect primary actions of the substance:
for instance, depressant drugs may lead to symptoms of agitation or
hyperactivity, and stimulant drugs may lead to socially withdrawn and
introverted behaviour. Effects of substances such as cannabis and
hallucinogens may be particularly unpredictable. Moreover, many
psychoactive substances are capable of producing different types of effect
at different dose levels. For example, alcohol may have apparently stimulant
effects on behaviour at lower dose levels, lead to agitation and
aggression with increasing dose levels, and produce clear sedation at very
high levels.
Includes: acute drunkenness in alcoholism
"bad trips" (due to hallucinogenic drugs)
drunkenness NOS
Differential diagnosis. Consider acute head injury and hypoglycaemia. Consider also
the possibilities of intoxication as the result of mixed substance use.
The following five-character codes may be used to indicate whether the acute
intoxication was associated with any complications:
F1x.00 Uncomplicated
Symptoms of varying severity, usually dose-dependent, particularly at high dose
levels.
- 69 F1x.01
With trauma or other bodily injury
F1x.02 With other medical complications
Complications such as haematemesis, inhalation of vomitus.
F1x.03 With delirium
F1x.04 With perceptual distortions
F1x.05 With coma
F1x.06 With convulsions
F1x.07 Pathological intoxication
Applies only to alcohol. Sudden onset of aggression and often violent behaviour that
is not typical of the individual when sober, very soon after drinking
amounts of alcohol that would not produce intoxication in most people.
F1x.1Harmful use
A pattern of psychoactive substance use that is causing damage to health. The damage
may be physical (as in cases of hepatitis from the self-administration of
injected drugs) or mental (e.g. episodes of depressive disorder secondary to
heavy consumption of alcohol).
Diagnostic guidelines
The diagnosis requires that actual damage should have been caused to the mental or
physical health of the user.
Harmful patterns of use are often criticized by others and frequently associated with
adverse social consequences of various kinds. The fact that a pattern of use
or a particular substance is disapproved of by another person or by the
culture, or may have led to socially negative consequences such as arrest or
marital arguments is not in itself evidence of harmful use.
Acute intoxication (see F1x.0), or "hangover" is not in itself sufficient evidence of the
damage to health required for coding harmful use.
Harmful use should not be diagnosed if dependence syndrome (F1x.2), a psychotic
disorder (F1x.5), or another specific form of drug- or alcohol-related
disorder is present.
F1x.2Dependence syndrome
A cluster of physiological, behavioural, and cognitive phenomena in which the use of
a substance or a class of substances takes on a much higher priority for a
given individual than other behaviours that once had greater value. A
central descriptive characteristic of the dependence syndrome is the desire
(often strong, sometimes overpowering) to take psychoactive drugs (which
may or may not have been medically prescribed), alcohol, or tobacco.
- 70 There
may be evidence that return to substance use after a period of
abstinence leads to a more rapid reappearance of other features of the
syndrome than occurs with nondependent individuals.
Diagnostic guidelines
A definite diagnosis of dependence should usually be made only if three or more of
the following have been present together at some time during the previous
year:
(a)a strong desire or sense of compulsion to take the substance;
(b)difficulties in controlling substance-taking behaviour in terms of its onset,
termination, or levels of use;
(c)a physiological withdrawal state (see F1x.3 and F1x.4) when substance use has
ceased or been reduced, as evidenced by: the characteristic
withdrawal syndrome for the substance; or use of the same (or a
closely related) substance with the intention of relieving or
avoiding withdrawal symptoms;
(d)evidence of tolerance, such that increased doses of the psychoactive substance are
required in order to achieve effects originally produced by lower
doses (clear examples of this are found in alcohol- and
opiate-dependent individuals who may take daily doses sufficient
to incapacitate or kill nontolerant users);
(e)progressive neglect of alternative pleasures or interests because of psychoactive
substance use, increased amount of time necessary to obtain or
take the substance or to recover from its effects;
(f)persisting with substance use despite clear evidence of overtly harmful
consequences, such as harm to the liver through excessive
drinking, depressive mood states consequent to periods of heavy
substance use, or drug-related impairment of cognitive
functioning; efforts should be made to determine that the user was
actually, or could be expected to be, aware of the nature and extent
of the harm.
Narrowing of the personal repertoire of patterns of psychoactive substance use has
also been described as a characteristic feature (e.g. a tendency to drink
alcoholic drinks in the same way on weekdays and weekends, regardless of
social constraints that determine appropriate drinking behaviour).
It is an essential characteristic of the dependence syndrome that either psychoactive
substance taking or a desire to take a particular substance should be
present; the subjective awareness of compulsion to use drugs is most
commonly seen during attempts to stop or control substance use. This
diagnostic requirement would exclude, for instance, surgical patients given
opioid drugs for the relief of pain, who may show signs of an opioid
withdrawal state when drugs are not given but who have no desire to
continue taking drugs.
The dependence syndrome may be present for a specific substance (e.g. tobacco or
diazepam), for a class of substances (e.g. opioid drugs), or for a wider
- 71 range
of different substances (as for those individuals who feel a sense of
compulsion regularly to use whatever drugs are available and who show
distress, agitation, and/or physical signs of a withdrawal state upon
abstinence).
Includes: chronic alcoholism
dipsomania
drug addiction
The diagnosis of the dependence syndrome may be further specified by the following
five-character codes:
F1x.20 Currently abstinent
F1x.21 Currently abstinent, but in a protected environment
(e.g. in hospital, in a therapeutic community, in prison, etc.)
F1x.22 Currently on a clinically supervised maintenance or replacement regime
[controlled dependence]
(e.g. with methadone; nicotine gum or nicotine patch)
F1x.23 Currently abstinent, but receiving treatment with aversive or blocking
drugs
(e.g. naltrexone or disulfiram)
F1x.24 Currently using the substance [active dependence]
F1x.25 Continuous use
F1x.26 Episodic use [dipsomania]
F1.3 Withdrawal state
A group of symptoms of variable clustering and severity occurring on absolute or
relative withdrawal of a substance after repeated, and usually prolonged
and/or high-dose, use of that substance. Onset and course of the
withdrawal state are time-limited and are related to the type of substance
and the dose being used immediately before abstinence. The withdrawal
state may be complicated by convulsions.
Diagnostic guidelines
Withdrawal state is one of the indicators of dependence syndrome (see F1x.2) and this
latter diagnosis should also be considered.
Withdrawal state should be coded as the main diagnosis if it is the reason for referral
and sufficiently severe to require medical attention in its own right.
Physical symptoms vary according to the substance being used. Psychological
disturbances (e.g. anxiety, depression, and sleep disorders) are also
- 72 common
features of withdrawal. Typically, the patient is likely to report
that withdrawal symptoms are relieved by further substance use.
It should be remembered that withdrawal symptoms can be induced by
conditioned/learned stimuli in the absence of immediately preceding
substance use. In such cases a diagnosis of withdrawal state should be
made only if it is warranted in terms of severity.
Differential diagnosis. Many symptoms present in drug withdrawal state may also be
caused by other psychiatric conditions, e.g. anxiety states and depressive
disorders. Simple "hangover" or tremor due to other conditions should not
be confused with the symptoms of a withdrawal state.
The diagnosis of withdrawal state may be further specified by using the following
five-character codes:
F1x.30 Uncomplicated
F1x.31 With convulsions
F1x.4 Withdrawal state with delirium
A condition in which the withdrawal state (see F1x.3) is complicated by delirium (see
criteria for F05.-).
Alcohol-induced delirium tremens should be coded here. Delirium tremens is a
short-lived, but occasionally life-threatening, toxic-confusional state with
accompanying somatic disturbances. It is usually a consequence of
absolute or relative withdrawal of alcohol in severely dependent users with
a long history of use. Onset usually occurs after withdrawal of alcohol. In
some cases the disorder appears during an episode of heavy drinking, in
which case it should be coded here.
Prodromal symptoms typically include insomnia, tremulousness, and fear. Onset may
also be preceded by withdrawal convulsions. The classical triad of
symptoms includes clouding of consciousness and confusion, vivid
hallucinations and illusions affecting any sensory modality, and marked
tremor. Delusions, agitation, insomnia or sleep-cycle reversal, and
autonomic overactivity are usually also present.
Excludes: delirium, not induced by drugs and alcohol (F05.-)
The diagnosis of withdrawal state with delirium may be further specified by using the
following five-character codes:
F1x.40 Without convulsions
F1x.41 With convulsions
F1x.5 Psychotic disorder
- 73 A
cluster of psychotic phenomena that occur during or immediately after
psychoactive substance use and are characterized by vivid hallucinations
(typically auditory, but often in more than one sensory modality),
misidentifications, delusions and/or ideas of reference (often of a paranoid
or persecutory nature), psychomotor disturbances (excitement or stupor),
and an abnormal affect, which may range from intense fear to ecstasy. The
sensorium is usually clear but some degree of clouding of consciousness,
though not severe confusion, may be present. The disorder typically
resolves at least partially within 1 month and fully within 6 months.
Diagnostic guidelines
A psychotic disorder occurring during or immediately after drug use (usually within
48 hours) should be recorded here provided that it is not a manifestation of
drug withdrawal state with delirium (see F1x.4) or of late onset. Late-onset
psychotic disorders (with onset more than 2 weeks after substance use)
may occur, but should be coded as F1x.75.
Psychoactive substance-induced psychotic disorders may present with varying
patterns of symptoms. These variations will be influenced by the type of
substance involved and the personality of the user. For stimulant drugs
such as cocaine and amfetamines, drug-induced psychotic disorders are
generally closely related to high dose levels and/or prolonged use of the
substance.
A diagnosis of a psychotic disorder should not be made merely on the basis of
perceptual distortions or hallucinatory experiences when substances
having primary hallucinogenic effects (e.g. lysergide (LSD), mescaline,
cannabis at high doses) have been taken. In such cases, and also for
confusional states, a possible diagnosis of acute intoxication (F1x.0)
should be considered.
Particular care should also be taken to avoid mistakenly diagnosing a more serious
condition (e.g. schizophrenia) when a diagnosis of psychoactive
substance-induced psychosis is appropriate. Many psychoactive
substance-induced psychotic states are of short duration provided that no
further amounts of the drug are taken (as in the case of amfetamine and
cocaine psychoses). False diagnosis in such cases may have distressing
and costly implications for the patient and for the health services.
Includes: alcoholic hallucinosis
alcoholic jealousy
alcoholic paranoia
alcoholic psychosis NOS
Differential diagnosis. Consider the possibility of another mental disorder being
aggravated or precipitated by psychoactive substance use (e.g.
schizophrenia (F20.-); mood [affective] disorder (F30-F39); paranoid or
schizoid personality disorder (F60.0, F60.1)). In such cases, a diagnosis of
psychoactive substance-induced psychotic state may be inappropriate.
- 74 The
diagnosis of psychotic state may be further specified by the following
five-character codes:
F1x.50 Schizophrenia-like
F1x.51 Predominantly delusional
F1x.52 Predominantly hallucinatory
(includes alcoholic hallucinosis)
F1x.53 Predominantly polymorphic
F1x.54 Predominantly depressive symptoms
F1x.55 Predominantly manic symptoms
F1x.56 Mixed
F1x.6 Amnesic syndrome
A syndrome associated with chronic prominent impairment of recent memory; remote
memory is sometimes impaired, while immediate recall is preserved.
Disturbances of time sense and ordering of events are usually evident, as
are difficulties in learning new material. Confabulation may be marked but
is not invariably present. Other cognitive functions are usually relatively
well preserved and amnesic defects are out of proportion to other
disturbances.
Diagnostic guidelines
Amnesic syndrome induced by alcohol or other psychoactive substances coded here
should meet the general criteria for organic amnesic syndrome (see F04).
The primary requirements for this diagnosis are:
(a)memory impairment as shown in impairment of recent memory (learning of new
material); disturbances of time sense (rearrangements of
chronological sequence, telescoping of repeated events into one,
etc.);
(b)absence of defect in immediate recall, of impairment of consciousness, and of
generalized cognitive impairment;
(c)history or objective evidence of chronic (and particularly high-dose) use of alcohol
or drugs.
Personality changes, often with apparent apathy and loss of initiative, and a tendency
towards self-neglect may also be present, but should not be regarded as
necessary conditions for diagnosis.
Although confabulation may be marked it should not be regarded as a necessary
prerequisite for diagnosis.
- 75 Includes:
Korsakov's psychosis or syndrome, alcohol- or other
psychoactive substance-induced
Differential diagnosis. Consider: organic amnesic syndrome (nonalcoholic) (see F04);
other organic syndromes involving marked impairment of memory (e.g.
dementia or delirium) (F00-F03; F05.-); a depressive disorder (F31-F33).
F1x.7Residual and late-onset psychotic disorder
A disorder in which alcohol- or psychoactive substance-induced changes of cognition,
affect, personality, or behaviour persist beyond the period during which a
direct psychoactive substance-related effect might reasonably be assumed
to be operating.
Diagnostic guidelines
Onset of the disorder should be directly related to the use of alcohol or a psychoactive
substance. Cases in which initial onset occurs later than episode(s) of
substance use should be coded here only where clear and strong evidence
is available to attribute the state to the residual effect of the substance. The
disorder should represent a change from or marked exaggeration of prior
and normal state of functioning.
The disorder should persist beyond any period of time during which direct effects of
the psychoactive substance might be assumed to be operative (see F1x.0,
acute intoxication). Alcohol- or psychoactive substance-induced dementia
is not always irreversible; after an extended period of total abstinence,
intellectual functions and memory may improve.
The disorder should be carefully distinguished from withdrawal-related conditions
(see F1x.3 and F1x.4). It should be remembered that, under certain
conditions and for certain substances, withdrawal state phenomena may be
present for a period of many days or weeks after discontinuation of the
substance.
Conditions induced by a psychoactive substance, persisting after its use, and meeting
the criteria for diagnosis of psychotic disorder should not be diagnosed
here (use F1x.5, psychotic disorder). Patients who show the chronic
end-state of Korsakov's syndrome should be coded under F1x.6.
Differential diagnosis. Consider: pre-existing mental disorder masked by substance
use and re-emerging as psychoactive substance-related effects fade (for
example, phobic anxiety, a depressive disorder, schizophrenia, or
schizotypal disorder). In the case of flashbacks, consider acute and
transient psychotic disorders (F23.-). Consider also organic injury and
mild or moderate mental retardation (F70-F71), which may coexist with
psychoactive substance misuse.
This diagnostic rubric may be further subdivided by using the following
five-character codes:
- 76 F1x.70
Flashbacks
May be distinguished from psychotic disorders partly by their episodic nature,
frequently of very short duration (seconds or minutes) and by their
duplication (sometimes exact) of previous drug-related experiences.
F1x.71 Personality or behaviour disorder
Meeting the criteria for organic personality disorder (F07.0).
F1x.72 Residual affective disorder
Meeting the criteria for organic mood [affective] disorders (F06.3).
F1x.73 Dementia
Meeting the general criteria for dementia as outlined in the introduction to F00-F09.
F1x.74 Other persisting cognitive impairment
A residual category for disorders with persisting cognitive impairment, which do not
meet the criteria for psychoactive substance-induced amnesic syndrome
(F1x.6) or dementia (F1x.73).
F1x.75 Late-onset psychotic disorder
F1x.8Other mental and behavioural disorders
Code here any other disorder in which the use of a substance can be identified as
contributing directly to the condition, but which does not meet the criteria
for inclusion in any of the above disorders.
F1x.9Unspecified mental and behavioural disorder
F20-F29
Schizophrenia, schizotypal and delusional disorders
Overview of this block
F20 Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified
A fifth character may be used to classify course:
F20.x0 Continuous
F20.x1 Episodic with progressive deficit
F20.x2 Episodic with stable deficit
F20.x3 Episodic remittent
F20.x4 Incomplete remission
F20.x5 Complete remission
F20.x8 Other
- 77 F20.x9
Course uncertain, period of observation too short
F21 Schizotypal disorder
F22 Persistent delusional disorders
F22.0 Delusional disorder
F22.8 Other persistent delusional disorders
F22.9 Persistent delusional disorder, unspecified
F23 Acute and transient psychotic disorders
F23.0Acute polymorphic psychotic disorder without symptoms of schizophrenia
F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia
F23.2 Acute schizophrenia-like psychotic disorder
F23.3 Other acute predominantly delusional psychotic disorder
F23.8 Other acute and transient psychotic disorders
F23.9 Acute and transient psychotic disorder, unspecified
A fifth character may be used to identify the presence or absence of associated acute
stress:
F23.x0 Without associated acute stress
F23.x1 With associated acute stress
F24 Induced delusional disorder
F25 Schizoaffective disorders
F25.0 Schizoaffective disorder, manic type
F25.1 Schizoaffective disorder, depressive type
F25.2 Schizoaffective disorder, mixed type
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified
F28 Other nonorganic psychotic disorders
F29 Unspecified nonorganic psychosis
- 78 -
Introduction
Schizophrenia is the commonest and most important disorder of this group. Schizotypal disorder
possesses many of the characteristic features of schizophrenic disorders and is probably genetically
related to them; however, the hallucinations, delusions, and gross behavioural disturbances of
schizophrenia itself are absent and so this disorder does not always come to medical attention. Most of
the delusional disorders are probably unrelated to schizophrenia, although they may be difficult to
distinguish clinically, particularly in their early stages. They form a heterogeneous and poorly
understood collection of disorders, which can conveniently be divided according to their typical
duration into a group of persistent delusional disorders and a larger group of acute and transient
psychotic disorders. The latter appear to be particularly common in developing countries. The
subdivisions listed here should be regarded as provisional. Schizoaffective disorders have been
retained in this section in spite of their controversial nature.
F20 Schizophrenia
The schizophrenic disorders are characterized in general by fundamental and characteristic
distortions of thinking and perception, and by inappropriate or blunted affect. Clear
consciousness and intellectual capacity are usually maintained, although certain cognitive
deficits may evolve in the course of time. The disturbance involves the most basic functions
that give the normal person a feeling of individuality, uniqueness, and self-direction. The
most intimate thoughts, feelings, and acts are often felt to be known to or shared by others,
and explanatory delusions may develop, to the effect that natural or supernatural forces are at
work to influence the afflicted individual's thoughts and actions in ways that are often bizarre.
The individual may see himself or herself as the pivot of all that happens. Hallucinations,
especially auditory, are common and may comment on the individual's behaviour or
thoughts. Perception is frequently disturbed in other ways: colours or sounds may seem
unduly vivid or altered in quality, and irrelevant features of ordinary things may appear more
important than the whole object or situation. Perplexity is also common early on and
frequently leads to a belief that everyday situations possess a special, usually sinister, meaning
intended uniquely for the individual. In the characteristic schizo- phrenic disturbance of
thinking, peripheral and irrelevant features of a total concept, which are inhibited in normal
directed mental activity, are brought to the fore and utilized in place of those that are relevant
and appropriate to the situation. Thus thinking becomes vague, elliptical, and obscure, and
its expression in speech sometimes incomprehensible. Breaks and interpolations in the train
of thought are frequent, and thoughts may seem to be withdrawn by some outside agency.
Mood is characteristically shallow, capricious, or incongruous. Ambivalence and disturbance
of volition may appear as inertia, negativism, or stupor. Catatonia may be present. The onset
may be acute, with seriously disturbed behaviour, or insidious, with a gradual development
of odd ideas and conduct. The course of the disorder shows equally great variation and is by
no means inevitably chronic or deteriorating (the course is specified by five-character
categories). In a proportion of cases, which may vary in different cultures and populations,
the outcome is complete, or nearly complete, recovery. The sexes are approximately equally
affected but the onset tends to be later in women.
Although no strictly pathognomonic symptoms can be identified, for practical purposes it is
useful to divide the above symptoms into groups that have special importance for the
diagnosis and often occur together, such as:
(a) thought echo, thought insertion or withdrawal, and thought broadcasting;
(b)delusions of control, influence, or passivity, clearly referred to body or limb movements or
specific thoughts, actions, or sensations; delusional perception;
(c)hallucinatory voices giving a running commentary on the patient's behaviour, or
discussing the patient among themselves, or other types of hallucinatory voices
coming from some part of the body;
(d)persistent delusions of other kinds that are culturally inappropriate and completely
impossible, such as religious or political identity, or superhuman powers and
- 79 abilities
(e.g. being able to control the weather, or being in communication
with aliens from another world);
(e)persistent hallucinations in any modality, when accompanied either by fleeting or
half-formed delusions without clear affective content, or by persistent
over-valued ideas, or when occurring every day for weeks or months on end;
(f)breaks or interpolations in the train of thought, resulting in incoherence or irrelevant
speech, or neologisms;
(g)catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism,
mutism, and stupor;
(h)"negative" symptoms such as marked apathy, paucity of speech, and blunting or
incongruity of emotional responses, usually resulting in social withdrawal and
lowering of social performance; it must be clear that these are not due to
depression or to neuroleptic medication;
(i)a significant and consistent change in the overall quality of some aspects of personal
behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed
attitude, and social withdrawal.
Diagnostic guidelines
The normal requirement for a diagnosis of schizophrenia is that a minimum of one very clear
symptom (and usually two or more if less clear-cut) belonging to any one of the groups listed
as (a) to (d) above, or symptoms from at least two of the groups referred to as (e) to (h), should
have been clearly present for most of the time during a period of 1 month or more.
Conditions meeting such symptomatic requirements but of duration less than 1 month
(whether treated or not) should be diagnosed in the first instance as acute schizophrenia-like
psychotic disorder (F23.2) and reclassified as schizophrenia if the symptoms persist for longer
periods. Symptom (i) in the above list applies only to the diagnosis of Simple Schizophrenia
(F20.6), and a duration of at least one year is required.
Viewed retrospectively, it may be clear that a prodromal phase in which symptoms and
behaviour, such as loss of interest in work, social activities, and personal appearance and
hygiene, together with generalized anxiety and mild degrees of depression and
preoccupation, preceded the onset of psychotic symptoms by weeks or even months.
Because of the difficulty in timing onset, the 1-month duration criterion applies only to the
specific symptoms listed above and not to any prodromal nonpsychotic phase.
The diagnosis of schizophrenia should not be made in the presence of extensive depressive or
manic symptoms unless it is clear that schizophrenic symptoms antedated the affective
disturbance. If both schizophrenic and affective symptoms develop together and are evenly
balanced, the diagnosis of schizoaffective disorder (F25.-) should be made, even if the
schizophrenic symptoms by themselves would have justified the diagnosis of schizophrenia.
Schizophrenia should not be diagnosed in the presence of overt brain disease or during states
of drug intoxication or withdrawal. Similar disorders developing in the presence of epilepsy
or other brain disease should be coded under F06.2 and those induced by drugs under F1x.5.
Pattern of course
The course of schizophrenic disorders can be classified by using the following five-character
codes:
F20.x0 Continuous
F20.x1 Episodic with progressive deficit
F20.x2 Episodic with stable deficit
F20.x3 Episodic remittent
F20.x4 Incomplete remission
F20.x5 Complete remission
F20.x8 Other
F20.x9 Course uncertain, period of observation too short
- 80 F20.0
Paranoid schizophrenia
This is the commonest type of schizophrenia in most parts of the world. The clinical picture
is dominated by relatively stable, often paranoid, delusions, usually accompanied by
hallucinations, particularly of the auditory variety, and perceptual disturbances.
Disturbances of affect, volition, and speech, and catatonic symptoms, are not prominent.
Examples of the most common paranoid symptoms are:
(a)delusions of persecution, reference, exalted birth, special mission, bodily change, or
jealousy;
(b)hallucinatory voices that threaten the patient or give commands, or auditory hallucinations
without verbal form, such as whistling, humming, or laughing;
(c)hallucinations of smell or taste, or of sexual or other bodily sensations; visual hallucinations
may occur but are rarely predominant.
Thought disorder may be obvious in acute states, but if so it does not prevent the typical
delusions or hallucinations from being described clearly. Affect is usually less blunted than in
other varieties of schizophrenia, but a minor degree of incongruity is common, as are mood
disturbances such as irritability, sudden anger, fearfulness, and suspicion. "Negative"
symptoms such as blunting of affect and impaired volition are often present but do not
dominate the clinical picture.
The course of paranoid schizophrenia may be episodic, with partial or complete remissions,
or chronic. In chronic cases, the florid symptoms persist over years and it is difficult to
distinguish discrete episodes. The onset tends to be later than in the hebephrenic and
catatonic forms.
Diagnostic guidelines
The general criteria for a diagnosis of schizophrenia (see introduction to F20 above) must be
satisfied. In addition, hallucinations and/or delusions must be prominent, and disturbances
of affect, volition and speech, and catatonic symptoms must be relatively inconspicuous. The
hallucinations will usually be of the kind described in (b) and (c) above. Delusions can be of
almost any kind but delusions of control, influence, or passivity, and persecutory beliefs of
various kinds are the most characteristic.
Includes: paraphrenic schizophrenia
Differential diagnosis. It is important to exclude epileptic and drug-induced psychoses, and
to remember that persecutory delusions might carry little diagnostic weight in people from
certain countries or cultures.
Excludes: involutional paranoid state (F22.8)
paranoia (F22.0)
F20.1 Hebephrenic schizophrenia
A form of schizophrenia in which affective changes are prominent, delusions and
hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and
mannerisms common. The mood is shallow and inappropriate and often accompanied by
giggling or self-satisfied, self-absorbed smiling, or by a lofty manner, grimaces, mannerisms,
pranks, hypochondriacal complaints, and reiterated phrases. Thought is disorganized and
speech rambling and incoherent. There is a tendency to remain solitary, and behaviour
seems empty of purpose and feeling. This form of schizophrenia usually starts between the
ages of 15 and 25 years and tends to have a poor prognosis because of the rapid development
of "negative" symptoms, particularly flattening of affect and loss of volition.
- 81 In
addition, disturbances of affect and volition, and thought disorder are usually prominent.
Hallucinations and delusions may be present but are not usually prominent. Drive and
determination are lost and goals abandoned, so that the patient's behaviour becomes
characteristically aimless and empty of purpose. A superficial and manneristic preoccupation
with religion, philosophy, and other abstract themes may add to the listener's difficulty in
following the train of thought.
Diagnostic guidelines
The general criteria for a diagnosis of schizophrenia (see introduction to F20 above) must be
satisfied. Hebephrenia should normally be diagnosed for the first time only in adolescents or
young adults. The premorbid personality is characteristically, but not necessarily, rather shy
and solitary. For a confident diagnosis of hebephrenia, a period of 2 or 3 months of
continuous observation is usually necessary, in order to ensure that the characteristic
behaviours described above are sustained.
Includes: disorganized schizophrenia
hebephrenia
F20.2 Catatonic schizophrenia
Prominent psychomotor disturbances are essential and dominant features and may alternate
between extremes such as hyperkinesis and stupor, or automatic obedience and negativism.
Constrained attitudes and postures may be maintained for long periods. Episodes of violent
excitement may be a striking feature of the condition.
For reasons that are poorly understood, catatonic schizophrenia is now rarely seen in
industrial countries, though it remains common elsewhere. These catatonic phenomena may
be combined with a dream-like (oneiroid) state with vivid scenic hallucinations.
Diagnostic guidelines
The general criteria for a diagnosis of schizophrenia (see introduction to F20 above) must be
satisfied. Transitory and isolated catatonic symptoms may occur in the context of any other
subtype of schizophrenia, but for a diagnosis of catatonic schizophrenia one or more of the
following behaviours should dominate the clinical picture:
(a)stupor (marked decrease in reactivity to the environment and in spontaneous movements
and activity) or mutism;
(b)excitement (apparently purposeless motor activity, not influenced by external stimuli);
(c)posturing (voluntary assumption and maintenance of inappropriate or bizarre postures);
(d)negativism (an apparently motiveless resistance to all instructions or attempts to be moved,
or movement in the opposite direction);
(e)rigidity (maintenance of a rigid posture against efforts to be moved);
(f)waxy flexibility (maintenance of limbs and body in externally imposed positions); and
(g)other symptoms such as command automatism (automatic compliance with instructions),
and perseveration of words and phrases.
In uncommunicative patients with behavioural manifestations of catatonic disorder, the
diagnosis of schizophrenia may have to be provisional until adequate evidence of the presence
of other symptoms is obtained. It is also vital to appreciate that catatonic symptoms are not
diagnostic of schizophrenia. A catatonic symptom or symptoms may also be provoked by
brain disease, metabolic disturbances, or alcohol and drugs, and may also occur in mood
disorders.
Includes: catatonic stupor
schizophrenic catalepsy
schizophrenic catatonia
schizophrenic flexibilitas cerea
- 82 F20.3
Undifferentiated schizophrenia
Conditions meeting the general diagnostic criteria for schizophrenia (see introduction to F20
above) but not conforming to any of the above subtypes (F20.0-F20.2), or exhibiting the
features of more than one of them without a clear predominance of a particular set of
diagnostic characteristics. This rubric should be used only for psychotic conditions (i.e.
residual schizophrenia, F20.5, and post-schizophrenic depression, F20.4, are excluded) and
after an attempt has been made to classify the condition into one of the three preceding
categories.
Diagnostic guidelines
This category should be reserved for disorders that:
(a)meet the general criteria for schizophrenia;
(b)either without sufficient symptoms to meet the criteria for only one of the subtypes F20.0,
F20.1, F20.2, F20.4, or F20.5, or with so many symptoms that the criteria for
more than one of the paranoid (F20.0), hebephrenic (F20.1), or catatonic
(F20.2) subtypes are met.
Includes: atypical schizophrenia
F20.4 Post-schizophrenic depression
A depressive episode, which may be prolonged, arising in the aftermath of a schizophrenic
illness. Some schizophrenic symptoms must still be present but no longer dominate the
clinical picture. These persisting schizophrenic symptoms may be "positive" or "negative",
though the latter are more common. It is uncertain, and immaterial to the diagnosis, to what
extent the depressive symptoms have merely been uncovered by the resolution of earlier
psychotic symptoms (rather than being a new development) or are an intrinsic part of
schizophrenia rather than a psychological reaction to it. They are rarely sufficiently severe or
extensive to meet criteria for a severe depressive episode (F32.2 and F32.3), and it is often
difficult to decide which of the patient's symptoms are due to depression and which to
neuroleptic medication or to the impaired volition and affective flattening of schizophrenia
itself. This depressive disorder is associated with an increased risk of suicide.
Diagnostic guidelines
The diagnosis should be made only if:
(a)the patient has had a schizophrenic illness meeting the general criteria for schizophrenia
(see introduction to F20 above) within the past 12 months;
(b)some schizophrenic symptoms are still present; and
(c)the depressive symptoms are prominent and distressing, fulfilling at least the criteria for a
depressive episode (F32.-), and have been present for at least 2 weeks.
If the patient no longer has any schizophrenic symptoms, a depressive episode should be
diagnosed (F32.-). If schizophrenic symptoms are still florid and prominent, the diagnosis
should remain that of the appropriate schizophrenic subtype (F20.0, F20.1, F20.2, or F20.3).
F20.5 Residual schizophrenia
A chronic stage in the development of a schizophrenic disorder in which there has been a
clear progression from an early stage (comprising one or more episodes with psychotic
symptoms meeting the general criteria for schizophrenia described above) to a later stage
characterized by long-term, though not necessarily irreversible, "negative" symptoms.
Diagnostic guidelines
- 83 For
a confident diagnosis, the following requirements should be met:
(a)prominent "negative" schizophrenic symptoms, i.e. psychomotor slowing, underactivity,
blunting of affect, passivity and lack of initiative, poverty of quantity or content
of speech, poor nonverbal communication by facial expression, eye contact,
voice modulation, and posture, poor self-care and social performance;
(b)evidence in the past of at least one clear-cut psychotic episode meeting the diagnostic
criteria for schizophrenia;
(c)a period of at least 1 year during which the intensity and frequency of florid symptoms
such as delusions and hallucinations have been minimal or substantially
reduced and the "negative" schizophrenic syndrome has been present;
(d)absence of dementia or other organic brain disease or disorder, and of chronic depression
or institutionalism sufficient to explain the negative impairments.
If adequate information about the patient's previous history cannot be obtained, and it
therefore cannot be established that criteria for schizophrenia have been met at some time in
the past, it may be necessary to make a provisional diagnosis of residual schizophrenia.
Includes: chronic undifferentiated schizophrenia
"Restzustand"
schizophrenic residual state
F20.6 Simple schizophrenia
An uncommon disorder in which there is an insidious but progressive development of
oddities of conduct, inability to meet the demands of society, and decline in total
performance. Delusions and hallucinations are not evident, and the disorder is less obviously
psychotic than the hebephrenic, paranoid, and catatonic subtypes of schizophrenia. The
characteristic "negative" features of residual schizophrenia (e.g. blunting of affect, loss of
volition) develop without being preceded by any overt psychotic symptoms. With increasing
social impoverishment, vagrancy may ensue and the individual may then become
self-absorbed, idle, and aimless.
Diagnostic guidelines
Simple schizophrenia is a difficult diagnosis to make with any confidence because it depends
on establishing the slowly progressive development of the characteristic "negative" symptoms
of residual schizophrenia (see F20.5 above) without any history of hallucinations, delusions,
or other manifestations of an earlier psychotic episode, and with significant changes in
personal behaviour, manifest as a marked loss of interest, idleness, and social withdrawal over
a period of at least one year.
Includes: schizophrenia simplex
F20.8 Other schizophrenia
Includes: cenesthopathic schizophrenia
schizophreniform disorder NOS
Excludes: acute schizophrenia-like disorder (F23.2)
cyclic schizophrenia (F25.2)
latent schizophrenia (F23.2)
F20.9 Schizophrenia, unspecified
F21 Schizotypal disorder
- 84 A
disorder characterized by eccentric behaviour and anomalies of thinking and affect which
resemble those seen in schizophrenia, though no definite and characteristic schizophrenic
anomalies have occurred at any stage. There is no dominant or typical disturbance, but any
of the following may be present:
(a)inappropriate or constricted affect (the individual appears cold and aloof);
(b)behaviour or appearance that is odd, eccentric, or peculiar;
(c)poor rapport with others and a tendency to social withdrawal;
(d)odd beliefs or magical thinking, influencing behaviour and inconsistent with subcultural
norms;
(e)suspiciousness or paranoid ideas;
(f)obsessive ruminations without inner resistance, often with dysmorphophobic, sexual or
aggressive contents;
(g)unusual perceptual experiences including somatosensory (bodily) or other illusions,
depersonalization or derealization;
(h)vague, circumstantial, metaphorical, overelaborate, or stereotyped thinking, manifested by
odd speech or in other ways, without gross incoherence;
(i)occasional transient quasi-psychotic episodes with intense illusions, auditory or other
hallucinations, and delusion-like ideas, usually occurring without external
provocation.
The disorder runs a chronic course with fluctuations of intensity. Occasionally it evolves into
overt schizophrenia. There is no definite onset and its evolution and course are usually those
of a personality disorder. It is more common in individuals related to schizophrenics and is
believed to be part of the genetic "spectrum" of schizophrenia.
Diagnostic guidelines
This diagnostic rubric is not recommended for general use because it is not clearly
demarcated either from simple schizophrenia or from schizoid or paranoid personality
disorders. If the term is used, three or four of the typical features listed above should have
been present, continuously or episodically, for at least 2 years. The individual must never
have met criteria for schizophrenia itself. A history of schizophrenia in a first-degree relative
gives additional weight to the diagnosis but is not a prerequisite.
Includes: borderline schizophrenia
latent schizophrenia
latent schizophrenic reaction
prepsychotic schizophrenia
prodromal schizophrenia
pseudoneurotic schizophrenia
pseudopsychopathic schizophrenia
schizotypal personality disorder
Excludes: Asperger's syndrome (F84.5)
schizoid personality disorder (F60.1)
F22 Persistent delusional disorders
This group includes a variety of disorders in which long-standing delusions constitute the
only, or the most conspicuous, clinical characteristic and which cannot be classified as
organic, schizophrenic, or affective. They are probably heterogeneous, and have uncertain
relationships to schizophrenia. The relative importance of genetic factors, personality
characteristics, and life circumstances in their genesis is uncertain and probably variable.
F22.0 Delusional disorder
This group of disorders is characterized by the development either of a single delusion or of a
set of related delusions which are usually persistent and sometimes lifelong. The delusions
- 85 are
highly variable in content. Often they are persecutory, hypochondriacal, or grandiose,
but they may be concerned with litigation or jealousy, or express a conviction that the
individual's body is misshapen, or that others think that he or she smells or is homosexual.
Other psychopathology is characteristically absent, but depressive symptoms may be present
intermittently, and olfactory and tactile hallucinations may develop in some cases. Clear and
persistent auditory hallucinations (voices), schizophrenic symptoms such as delusions of
control and marked blunting of affect, and definite evidence of brain disease are all
incompatible with this diagnosis. However, occasional or transitory auditory hallucinations,
particularly in elderly patients, do not rule out this diagnosis, provided that they are not
typically schizophrenic and form only a small part of the overall clinical picture. Onset is
commonly in middle age but sometimes, particularly in the case of beliefs about having a
misshapen body, in early adult life. The content of the delusion, and the timing of its
emergence, can often be related to the individual's life situation, e.g. persecutory delusions in
members of minorities. Apart from actions and attitudes directly related to the delusion or
delusional system, affect, speech, and behaviour are normal.
Diagnostic guidelines
Delusions constitute the most conspicuous or the only clinical characteristic. They must be
present for at least 3 months and be clearly personal rather than subcultural. Depressive
symptoms or even a full-blown depressive episode (F32.-) may be present intermittently,
provided that the delusions persist at times when there is no disturbance of mood. There
must be no evidence of brain disease, no or only occasional auditory hallucinations, and no
history of schizophrenic symptoms (delusions of control, thought broadcasting, etc.).
Includes: paranoia
paranoid psychosis
paranoid state
paraphrenia (late)
sensitiver Beziehungswahn
Excludes: paranoid personality disorder (F60.0)
psychogenic paranoid psychosis (F23.3)
paranoid reaction (F23.3)
paranoid schizophrenia (F20.0)
F22.8 Other persistent delusional disorders
This is a residual category for persistent delusional disorders that do not meet the criteria for
delusional disorder (F22.0). Disorders in which delusions are accompanied by persistent
hallucinatory voices or by schizophrenic symptoms that are insufficient to meet criteria for
schizophrenia (F20.-) should be coded here. Delusional disorders that have lasted for less
than 3 months should, however, be coded, at least temporarily, under F23.-.
Includes: delusional dysmorphophobia
involutional paranoid state
paranoia querulans
F22.9 Persistent delusional disorder, unspecified
F23 Acute and transient psychotic disorders
Systematic clinical information that would provide definitive guidance on the classification of
acute psychotic disorders is not yet available, and the limited data and clinical tradition that
must therefore be used instead do not give rise to concepts that can be clearly defined and
separated from each other. In the absence of a tried and tested multiaxial system, the method
used here to avoid diagnostic con- fusion is to construct a diagnostic sequence that reflects the
- 86 order
of priority given to selected key features of the disorder. The order of priority used here
is:
(a)an acute onset (within 2 weeks) as the defining feature of the whole group;
(b)the presence of typical syndromes;
(c)the presence of associated acute stress.
The classification is nevertheless arranged so that those who do not agree with this order of
priority can still identify acute psychotic disorders with each of these specified features.
It is also recommended that whenever possible a further subdivision of onset be used, if
applicable, for all the disorders of this group. Acute onset is defined as a change from a state
without psychotic features to a clearly abnormal psychotic state, within a period of 2 weeks or
less. There is some evidence that acute onset is associated with a good outcome, and it may
be that the more abrupt the onset, the better the outcome. It is therefore recommended that,
whenever appropriate, abrupt onset (within 48 hours or less) be specified.
The typical syndromes that have been selected are first, the rapidly changing and variable
state, called here "polymorphic", that has been given prominence in acute psychotic states in
several countries, and second, the presence of typical schizophrenic symptoms.
Associated acute stress can also be specified, with a fifth character if desired, in view of its
traditional linkage with acute psychosis. The limited evidence available, however, indicates
that a substantial proportion of acute psychotic disorders arise without associated stress, and
provision has therefore been made for the presence or the absence of stress to be recorded.
Associated acute stress is taken to mean that the first psychotic symptoms occur within about
2 weeks of one or more events that would be regarded as stressful to most people in similar
circumstances, within the culture of the person concerned. Typical events would be
bereavement, unexpected loss of partner or job, marriage, or the psychological trauma of
combat, terrorism, and torture. Long-standing difficulties or problems should not be
included as a source of stress in this context.
Complete recovery usually occurs within 2 to 3 months, often within a few weeks or even
days, and only a small proportion of patients with these disorders develop persistent and
disabling states. Unfortunately, the present state of knowledge does not allow the early
prediction of that small proportion of patients who will not recover rapidly.
These clinical descriptions and diagnostic guidelines are written on the assumption that they
will be used by clinicians who may need to make a diagnosis when having to assess and treat
patients within a few days or weeks of the onset of the disorder, not knowing how long the
disorder will last. A number of reminders about the time limits and transition from one
disorder to another have therefore been included, so as to alert those recording the diagnosis
to the need to keep them up to date.
The nomenclature of these acute disorders is as uncertain as their nosological status, but an
attempt has been made to use simple and familiar terms. "Psychotic disorder" is used as a
term of convenience for all the members of this group (psychotic is defined in the general
introduction, page 3) with an additional qualifying term indicating the major defining feature
of each separate type as it appears in the sequence noted above.
Diagnostic guidelines
None of the disorders in the group satisfies the criteria for either manic (F30.-) or depressive
(F32.-) episodes, although emotional changes and individual affective symptoms may be
prominent from time to time.
- 87 These
disorders are also defined by the absence of organic causation, such as states of
concussion, delirium, or dementia. Perplexity, preoccupation, and inattention to the
immediate conversation are often present, but if they are so marked or persistent as to suggest
delirium or dementia of organic cause, the diagnosis should be delayed until investigation or
observation has clarified this point. Similarly, disorders in F23.- should not be diagnosed in
the presence of obvious intoxication by drugs or alcohol. However, a recent minor increase
in the consumption of, for instance, alcohol or marijuana, with no evidence of severe
intoxication or disorientation, should not rule out the diagnosis of one of these acute
psychotic disorders.
It is important to note that the 48-hour and the 2-week criteria are not put forward as the
times of maximum severity and disturbance, but as times by which the psychotic symptoms
have become obvious and disruptive of at least some aspects of daily life and work. The peak
disturbance may be reached later in both instances; the symptoms and disturbance have only
to be obvious by the stated times, in the sense that they will usually have brought the patient
into contact with some form of helping or medical agency. Prodromal periods of anxiety,
depression, social withdrawal, or mildly abnormal behaviour do not qualify for inclusion in
these periods of time.
A fifth character may be used to indicate whether or nor the acute psychotic disorder is
associated with acute stress:
F23.x0 Without associated acute stress
F23.x1 With associated acute stress
F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
An acute psychotic disorder in which hallucinations, delusions, and perceptual disturbances
are obvious but markedly variable, changing from day to day or even from hour to hour.
Emotional turmoil, with intense transient feelings of happiness and ecstasy or anxieties and
irritability, is also frequently present. This polymorphic and unstable, changing clinical
picture is characteristic, and even though individual affective or psychotic symptoms may at
times be present, the criteria for manic episode (F30.-), depressive episode (F32.-), or
schizophrenia (F20.-) are not fulfilled. This disorder is particularly likely to have an abrupt
onset (within 48 hours) and a rapid resolution of symptoms; in a large proportion of cases
there is no obvious precipitating stress.
If the symptoms persist for more than 3 months, the diagnosis should be changed.
(Persistent delusional disorder (F22.-) or other nonorganic psychotic disorder (F28) is likely
to be the most appropriate.)
Diagnostic guidelines
For a definite diagnosis:
(a)the onset must be acute (from a nonpsychotic state to a clearly psychotic state within 2
weeks or less);
(b)there must be several types of hallucination or delusion, changing in both type and
intensity from day to day or within the same day;
(c)there should be a similarly varying emotional state; and
(d)in spite of the variety of symptoms, none should be present with sufficient consistency to
fulfil the criteria for schizophrenia (F20.-) or for manic or depressive episode
(F30.- or F32.-).
Includes: bouffée délirante without symptoms of schizophrenia or unspecified
cycloid psychosis without symptoms of schizophrenia or
unspecified
- 88 F23.1
Acute polymorphic psychotic disorder with symptoms of schizophrenia
An acute psychotic disorder which meets the descriptive criteria for acute polymorphic
psychotic disorder (F23.0) but in which typically schizophrenic symptoms are also
consistently present.
Diagnostic guidelines
For a definite diagnosis, criteria (a), (b), and (c) specified for acute polymorphic psychotic
disorder (F23.0) must be fulfilled; in addition, symptoms that fulfil the criteria for
schizophrenia (F20.-) must have been present for the majority of the time since the
establishment of an obviously psychotic clinical picture.
If the schizophrenic symptoms persist for more than 1 month, the diagnosis should be
changed to schizophrenia (F20.-).
Includes: bouffée délirante with symptoms of schizophrenia
cycloid psychosis with symptoms of schizophrenia
F23.2 Acute schizophrenia-like psychotic disorder
An acute psychotic disorder in which the psychotic symptoms are comparatively stable and
fulfil the criteria for schizophrenia (F20.-) but have lasted for less than 1 month. Some degree
of emotional variability or instability may be present, but not to the extent described in acute
polymorphic psychotic disorder (F23.0).
Diagnostic guidelines
For a definite diagnosis:
(a)the onset of psychotic symptoms must be acute (2 weeks or less from a nonpsychotic to a
clearly psychotic state);
(b)symptoms that fulfil the criteria for schizophrenia (F20.-) must have been present for the
majority of the time since the establishment of an obviously psychotic clinical
picture;
(c)the criteria for acute polymorphic psychotic disorder are not fulfilled.
If the schizophrenic symptoms last for more than 1 month, the diagnosis should be changed
to schizophrenia (F20.-).
Includes: acute (undifferentiated) schizophrenia
brief schizophreniform disorder
brief schizophreniform psychosis
oneirophrenia
schizophrenic reaction
Excludes: organic delusional [schizophrenia-like] disorder (F06.2)
schizophreniform disorder NOS (F20.8)
F23.3 Other acute predominantly delusional psychotic disorders
Acute psychotic disorders in which comparatively stable delusions or hallucinations are the
main clinical features, but do not fulfil the criteria for schizophrenia (F20.-). Delusions of
persecution or reference are common, and hallucinations are usually auditory (voices talking
directly to the patient).
Diagnostic guidelines
For a definite diagnosis:
- 89 (a)the
onset of psychotic symptoms must be acute (2 weeks or less from a nonpsychotic to a
clearly psychotic state);
(b)delusions or hallucinations must have been present for the majority of the time since the
establishment of an obviously psychotic state; and
(c)the criteria for neither schizophrenia (F20.-) nor acute polymorphic psychotic disorder
(F23.0) are fulfilled.
If delusions persist for more than 3 months, the diagnosis should be changed to persistent
delusional disorder (F22.-). If only hallucinations persist for more than 3 months, the
diagnosis should be changed to other nonorganic psychotic disorder (F28).
Includes: paranoid reaction
psychogenic paranoid psychosis
F23.8 Other acute and transient psychotic disorders
Any other acute psychotic disorders that are unclassifiable under any other category in F23
(such as acute psychotic states in which definite delusions or hallucinations occur but persist
for only small proportions of the time) should be coded here. States of undifferentiated
excitement should also be coded here if more detailed information about the patient's mental
state is not available, provided that there is no evidence of an organic cause.
F23.9 Acute and transient psychotic disorder, unspecified
Includes: (brief) reactive psychosis NOS
F24 Induced delusional disorder
A delusional disorder shared by two or more people with close emotional links. Only one of
the people suffers from a genuine psychotic disorder; the delusions are induced in the other(s)
and usually disappear when the people are separated.
Includes: folie à deux
induced paranoid or psychotic disorder
F25 Schizoaffective disorders
These are episodic disorders in which both affective and schizophrenic symptoms are
prominent within the same episode of illness, preferably simultaneously, but at least within a
few days of each other. Their relationship to typical mood [affective] disorders (F30-F39)
and to schizophrenic disorders (F20-F24) is uncertain. They are given a separate category
because they are too common to be ignored. Other conditions in which affective symptoms
are superimposed upon or form part of a pre-existing schizophrenic illness, or in which they
coexist or alternate with other types of persistent delusional disorders, are classified under the
appropriate category in F20-F29. Mood-incongruent delusions or hallucinations in affective
disorders (F30.2, F31.2, F31.5, F32.3, or F33.3) do not by themselves justify a diagnosis of
schizoaffective disorder.
Patients who suffer from recurrent schizoaffective episodes, particularly those whose
symptoms are of the manic rather than the depressive type, usually make a full recovery and
only rarely develop a defect state.
Diagnostic guidelines
- 90 A
diagnosis of schizoaffective disorder should be made only when both definite schizophrenic
and definite affective symptoms are prominent simultaneously, or within a few days of each
other, within the same episode of illness, and when, as a consequence of this, the episode of
illness does not meet criteria for either schizophrenia or a depressive or manic episode. The
term should not be applied to patients who exhibit schizophrenic symptoms and affective
symptoms only in different episodes of illness. It is common, for example, for a schizophrenic
patient to present with depressive symptoms in the aftermath of a psychotic episode (see
post-schizophrenic depression (F20.4)). Some patients have recurrent schizoaffective
episodes, which may be of the manic or depressive type or a mixture of the two. Others have
one or two schizoaffective episodes interspersed between typical episodes of mania or
depression. In the former case, schizoaffective disorder is the appropriate diagnosis. In the
latter, the occurrence of an occasional schizoaffective episode does not invalidate a diagnosis
of bipolar affective disorder or recurrent depressive disorder if the clinical picture is typical in
other respects.
F25.0 Schizoaffective disorder, manic type
A disorder in which schizophrenic and manic symptoms are both prominent in the same
episode of illness. The abnormality of mood usually takes the form of elation, accompanied
by increased self-esteem and grandiose ideas, but sometimes excitement or irritability are
more obvious and accompanied by aggressive behaviour and persecutory ideas. In both cases
there is increased energy, overactivity, impaired concentration, and a loss of normal social
inhibition. Delusions of reference, grandeur, or persecution may be present, but other more
typically schizophrenic symptoms are required to establish the diagnosis. People may insist,
for example, that their thoughts are being broadcast or interfered with, or that alien forces are
trying to control them, or they may report hearing voices of varied kinds or express bizarre
delusional ideas that are not merely grandiose or persecutory. Careful questioning is often
required to establish that an individual really is experiencing these morbid phenomena, and
not merely joking or talking in metaphors. Schizoaffective disorders, manic type, are usually
florid psychoses with an acute onset; although behaviour is often grossly disturbed, full
recovery generally occurs within a few weeks.
Diagnostic guidelines
There must be a prominent elevation of mood, or a less obvious elevation of mood combined
with increased irritability or excitement. Within the same episode, at least one and preferably
two typically schizophrenic symptoms (as specified for schizophrenia (F20.-), diagnostic
guidelines (a)-(d)) should be clearly present.
This category should be used both for a single schizoaffective episode of the manic type and
for a recurrent disorder in which the majority of episodes are schizoaffective, manic type.
Includes: schizoaffective psychosis, manic type
schizophreniform psychosis, manic type
F25.1 Schizoaffective disorder, depressive type
A disorder in which schizophrenic and depressive symptoms are both prominent in the same
episode of illness. Depression of mood is usually accompanied by several characteristic
depressive symptoms or behavioural abnormalities such as retardation, insomnia, loss of
energy, appetite or weight, reduction of normal interests, impairment of concentration, guilt,
feelings of hopelessness, and suicidal thoughts. At the same time, or within the same episode,
other more typically schizophrenic symptoms are present; patients may insist, for example,
that their thoughts are being broadcast or interfered with, or that alien forces are trying to
control them. They may be convinced that they are being spied upon or plotted against and
this is not justified by their own behaviour. Voices may be heard that are not merely
disparaging or condemnatory but that talk of killing the patient or discuss this behaviour
between themselves. Schizoaffective episodes of the depressive type are usually less florid
and alarming than schizoaffective episodes of the manic type, but they tend to last longer and
- 91 the
prognosis is less favourable. Although the majority of patients recover completely, some
eventually develop a schizophrenic defect.
Diagnostic guidelines
There must be prominent depression, accompanied by at least two characteristic depressive
symptoms or associated behavioural abnormalities as listed for depressive episode (F32.-);
within the same episode, at least one and preferably two typically schizophrenic symptoms
(as specified for schizophrenia (F20.-), diagnostic guidelines (a)-(d)) should be clearly present.
This category should be used both for a single schizoaffective episode, depressive type, and
for a recurrent disorder in which the majority of episodes are schizoaffective, depressive type.
Includes: schizoaffective psychosis, depressive type
schizophreniform psychosis, depressive type
F25.2 Schizoaffective disorder, mixed type
Disorders in which symptoms of schizophrenia (F20.-) coexist with those of a mixed bipolar
affective disorder (F31.6) should be coded here.
Includes: cyclic schizophrenia
mixed schizophrenic and affective psychosis
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified
Includes: schizoaffective psychosis NOS
F28 Other nonorganic psychotic disorders
Psychotic disorders that do not meet the criteria for schizophrenia (F20.-) or for psychotic
types of mood [affective] disorders (F30-F39), and psychotic disorders that do not meet the
symptomatic criteria for persistent delusional disorder (F22.-) should be coded here.
Includes: chronic hallucinatory psychosis NOS
F29 Unspecified nonorganic psychosis
This category should also be used for psychosis of unknown etiology.
Includes: psychosis NOS
Excludes: mental disorder NOS (F99)
organic or symptomatic psychosis NOS (F09)
F30-F39
Mood [affective] disorders
Overview of this block
F30 Manic Episode
F30.0 Hypomania
- 92 F30.1
Mania without psychotic symptoms
F30.2 Mania with psychotic symptoms
F30.8 Other manic episodes
F30.9 Manic episode, unspecified
F31 Bipolar affective disorder
F31.0 Bipolar affective disorder, current episode hypomanic
F31.1Bipolar affective disorder, current episode manic without psychotic symptoms
F31.2Bipolar affective disorder, current episode manic with psychotic symptoms
F31.3Bipolar affctive disorder, current episode mild or moderate depression
.30 Without somatic syndrome
.31 With somatic syndrome
F31.4Bipolar affective disorder, current episode severe depression without psychotic
symptoms
F31.5Bipolar affective disorder, current episode severe depression with psychotic
symptoms
F31.6Bipolar affective disorder, current episode mixed
F31.7Bipolar affective disorder, currently in remission
F31.8Other bipolar affective disorders
F31.9Bipolar affective disorder, unspecified
F32 Depressive episode
F32.0Mild depressive episode
.00 Without somatic syndrome
.01 With somatic syndrome
F32.1 Moderate depressive episode
.10 Without somatic syndrome
.11 With somatic syndrome
F32.2 Severe depressive episode without psychotic symptoms
F32.3 Severe depressive episode with psychotic symptoms
F32.8 Other depressive episodes
F32.9 Depressive episode, unspecified
- 93 F33
Recurrent depressive disorder
F33.0 Recurrent depressive disorder, current episode mild
.00 Without somatic syndrome
.01 With somatic syndrome
F33.1 Recurrent depressive disorder, current episode moderate
.10 Without somatic syndrome
.11 With somatic syndrome
F33.2Recurrent depressive disorder, current episode severe without psychotic symptoms
F33.3Recurrent depressive disorder, current episode severe with psychotic symptoms
F33.4Recurrent depressive disorder, currently in remission
F33.8Other recurrent depressive disorders
F33.9Recurrent depressive disorder, unspecified
F34 Persistent mood [affective] disorders
F34.0 Cyclothymia
F34.1 Dysthymia
F34.8 Other persistent mood [affective] disorders
F34.9 Persistent mood [affective] disorder, unspecified
F38 Other mood [affective] disorders
F38.0 Other single mood [affective] disorders
.00 Mixed affective episode
F38.1 Other recurrent mood [affective] disorders
.10 Recurrent brief depressive disorder
F38.8 Other specified mood [affective] disorders
F39 Unspecified mood [affective] disorder
- 94 -
Introduction
The relationship between etiology, symptoms, underlying biochemical processes, response
to treatment, and outcome of mood [affective] disorders is not yet sufficiently well
understood to allow their classification in a way that is likely to meet with universal
approval. Nevertheless, a classification must be attempted, and that presented here is put
forward in the hope that it will at least be acceptable, since it is the result of widespread
consultation.
In these disorders, the fundamental disturbance is a change in mood or affect, usually to
depression (with or without associated anxiety) or to elation. This mood change is normally
accompanied by a change in the overall level of activity, and most other symptoms are
either secondary to, or easily understood in the context of, such changes. Most of these
disorders tend to be recurrent, and the onset of individual episodes is often related to
stressful events or situations. This block deals with mood disorders in all age groups; those
arising in childhood and adolescence should therefore be coded here.
The main criteria by which the affective disorders have been classified have been chosen for
practical reasons, in that they allow common clinical disorders to be easily identified. Single
episodes have been distinguished from bipolar and other multiple episode disorders because
substantial proportions of patients have only one episode of illness, and severity is given
prominence because of implications for treatment and for provision of different levels of
service. It is acknowledged that the symptoms referred to here as "somatic" could also have
been called "melancholic", "vital", "biological", or "endogenomorphic", and that the
scientific status of this syndrome is in any case somewhat questionable. It is to be hoped
that the result of its inclusion here will be widespread critical appraisal of the usefulness of
its separate identification. The classification is arranged so that this somatic syndrome can
be recorded by those who so wish, but can also be ignored without loss of any other
information.
Distinguishing between different grades of severity remains a problem; the three grades of
mild, moderate, and severe have been specified here because many clinicians wish to have
them available.
The terms "mania" and "severe depression" are used in this classification to denote the
opposite ends of the affective spectrum; "hypomania" is used to denote an intermediate state
without delusions, hallucinations, or complete disruption of normal activities, which is often
(but not exclusively) seen as patients develop or recover from mania.
F30 Manic episode
Three degrees of severity are specified here, sharing the common underlying characteristics
of elevated mood, and an increase in the quantity and speed of physical and mental
activity. All the subdivisions of this category should be used only for a single manic
episode. If previous or subsequent affective episodes (depressive, manic, or
hypomanic), the disorder should be coded under bipolar affective disorder (F31.-).
Includes: bipolar disorder, single manic episode
- 95 F30.0
Hypomania
Hypomania is a lesser degree of mania (F30.1), in which abnormalities of mood and
behaviour are too persistent and marked to be included under cyclothymia (F34.0)
but are not accompanied by hallucinations or delusions. There is a persistent mild
elevation of mood (for at least several days on end), increased energy and activity,
and usually marked feelings of well-being and both physical and mental efficiency.
Increased sociability, talkativeness, overfamiliarity, increased sexual energy, and a
decreased need for sleep are often present but not to the extent that they lead to
severe disruption of work or result in social rejection. Irritability, conceit, and
boorish behaviour may take the place of the more usual euphoric sociability.
Concentration and attention may be impaired, thus diminishing the ability to settle down to
work or to relaxation and leisure, but this may not prevent the appearance of
interests in quite new ventures and activities, or mild over-spending.
Diagnostic guidelines
Several of the features mentioned above, consistent with elevated or changed mood and
increased activity, should be present for at least several days on end, to a degree and
with a persistence greater than described for cyclothymia (F34.0). Considerable
interference with work or social activity is consistent with a diagnosis of hypomania,
but if disruption of these is severe or complete, mania (F30.1 or F30.2) should be
diagnosed.
Differential diagnosis. Hypomania covers the range of disorders of mood and level of
activities between cyclothymia (F34.0) and mania (F30.1 and F30.2). The increased
activity and restlessness (and often weight loss) must be distinguished from the same
symptoms occurring in hyperthyroidism and anorexia nervosa; early states of
"agitated depression", particularly in late middle age, may bear a superficial
resemblance to hypomania of the irritable variety. Patients with severe obsessional
symptoms may be active part of the night completing their domestic cleaning
rituals, but their affect will usually be the opposite of that described here.
When a short period of hypomania occurs as a prelude to or aftermath of mania (F30.1 and
F30.2), it is usually not worth specifying the hypomania separately.
F30.1 Mania without psychotic symptoms
Mood is elevated out of keeping with the individual's circumstances and may vary from
carefree joviality to almost uncontrollable excitement. Elation is accompanied by
increased energy, resulting in overactivity, pressure of speech, and a decreased need
for sleep. Normal social inhibitions are lost, attention cannot be sustained, and there
is often marked distractability. Self-esteem is inflated, and grandiose or
over-optimistic ideas are freely expressed.
Perceptual disorders may occur, such as the appreciation of colours as especially vivid (and
usually beautiful), a preoccupation with fine details of surfaces or textures, and
subjective hyperacusis. The individual may embark on extravagant and impractical
schemes, spend money recklessly, or become aggressive, amorous, or facetious in
- 96 inappropriate
circumstances. In some manic episodes the mood is irritable and
suspicious rather than elated. The first attack occurs most commonly between the
ages of 15 and 30 years, but may occur at any age from late childhood to the seventh
or eighth decade.
Diagnostic guidelines
The episode should last for at least 1 week and should be severe enough to disrupt ordinary
work and social activities more or less completely. The mood change should be
accompanied by increased energy and several of the symptoms referred to above
(particularly pressure of speech, decreased need for sleep, grandiosity, and excessive
optimism).
F30.2 Mania with psychotic symptoms
The clinical picture is that of a more severe form of mania as described in F30.1.Inflated
self-esteem and grandiose ideas may develop into delusions, and irritability and
suspiciousness into delusions of persecution. In severe cases, grandiose or religious
delusions of identity or role may be prominent, and flight of ideas and pressure of
speech may result in the individual becoming incomprehensible. Severe and
sustained physical activity and excitement may result in aggression or violence, and
neglect of eating, drinking, and personal hygiene may result in dangerous states of
dehydration and self-neglect. If required, delusions or hallucinations can be
specified as congruent or incongruent with the mood. "Incongruent" should be
taken as including affectively neutral delusions and hallucinations; for example,
delusions of reference with no guilty or accusatory content, or voices speaking to the
individual about events that have no special emotional significance.
Differential diagnosis. One of the commonest problems is differentiation of this disorder
from schizophrenia, particularly if the stages of development through hypomania
have been missed and the patient is seen only at the height of the illness when
widespread delusions, incomprehensible speech, and violent excitement may
obscure the basic disturbance of affect. Patients with mania that is responding to
neuroleptic medication may present a similar diagnostic problem at the stage when
they have returned to normal levels of physical and mental activity but still have
delusions or hallucinations. Occasional hallucinations or delusions as specified for
schizophrenia (F20.-) may also be classed as mood-incongruent, but if these
symptoms are prominent and persistent, the diagnosis of schizoaffective disorder
(F25.-) is more likely to be appropriate (see also page ??).
Includes: manic stupor
F30.8 Other manic episodes
F30.9 Manic episode, unspecified
Includes: mania NOS
- 97 F31
Bipolar affective disorder
This disorder is characterized by repeated (i.e. at least two) episodes in which the patient's
mood and activity levels are significantly disturbed, this disturbance consisting on
some occasions of an elevation of mood and increased energy and activity (mania or
hypomania), and on others of a lowering of mood and decreased energy and activity
(depression). Characteristically, recovery is usually complete between episodes, and
the incidence in the two sexes is more nearly equal than in other mood disorders. As
patients who suffer only from repeated episodes of mania are comparatively rare, and
resemble (in their family history, premorbid personality, age of onset, and long-term
prognosis) those who also have at least occasional episodes of depression, such
patients are classified as bipolar (F31.8).
Manic episodes usually begin abruptly and last for between 2 weeks and 4-5 months
(median duration about 4 months). Depressions tend to last longer (median length
about 6 months), though rarely for more than a year, except in the elderly. Episodes
of both kinds often follow stressful life events or other mental trauma, but the
presence of such stress is not essential for the diagnosis. The first episode may occur
at any age from childhood to old age. The frequency of episodes and the pattern of
remissions and relapses are both very variable, though remissions tend to get shorter
as time goes on and depressions to become commoner and longer lasting after
middle age.
Although the original concept of "manic-depressive psychosis" also included patients who
suffered only from depression, the term "manic-depressive disorder or psychosis" is
now used mainly as a synonym for bipolar disorder.
Includes: manic-depressive illness, psychosis or reaction
Excludes:bipolar disorder, single manic episode (F30.-)
cyclothymia (F34.0)
F31.0 Bipolar affective disorder, current episode hypomanic
Diagnostic guidelines
For a definite diagnosis:
(a)the current episode must fulfil the criteria for hypomania (F30.0); and
(b)there must have been at least one other affective episode (hypomanic, manic, depressive,
or mixed) in the past.
F31.1 Bipolar affective disorder, current episode manic without psychotic symptoms
Diagnostic guidelines
For a definite diagnosis:
- 98 (a)the
current episode must fulfil the criteria for mania without psychotic symptoms
(F30.1); and
(b)there must have been at least one other affective episode (hypomanic, manic, depressive,
or mixed) in the past.
F31.2Bipolar affective disorder, current episode manic with psychotic symptoms
Diagnostic guidelines
For a definite diagnosis:
(a)the current episode must fulfil the criteria for mania with psychotic symptoms (F30.2);
and
(b)there must have been at least one other affective episode (hypomanic, manic, depressive,
or mixed) in the past.
If required, delusions or hallucinations may be specified as congruent or incongruent with
mood (see F30.2).
F31.3Bipolar affective disorder, current episode mild or moderate depression
Diagnostic guidelines
For a definite diagnosis:
(a)the current episode must fulfil the criteria for a depressive episode of either mild (F32.0)
or moderate (F32.1) severity; and
(b)there must have been at least one hypomanic, manic, or mixed affective episode in the
past.
A fifth character may be used to specify the presence or absence of the somatic syndrome in
the current episode of depression:
F31.30 Without somatic syndrome
F31.31 With somatic syndrome
F31.4Bipolar affective disorder, current episode severe depression without psychotic symptoms
Diagnostic guidelines
For a definite diagnosis:
(a)the current episode must fulfil the criteria for a severe depressive episode without
psychotic symptoms (F32.2); and
(b)there must have been at least one hypomanic, manic, or mixed affective episode in the
past.
F31.5Bipolar affective disorder, current episode severe depression with psychotic symptoms
- 99 Diagnostic
guidelines
For a definite diagnosis:
(a)the current episode must fulfil the criteria for a severe depressive episode with psychotic
symptoms (F32.3); and
(b)there must have been at least one hypomanic, manic, or mixed affective episode in the
past.
If required, delusions or hallucinations may be specified as congruent or incongruent with
mood (see F30.2).
F31.6Bipolar affective disorder, current episode mixed
The patient has had at least one manic, hypomanic, or mixed affective episode in the past
and currently exhibits either a mixture or a rapid alternation of manic, hypomanic,
and depressive symptoms.
Diagnostic guidelines
Although the most typical form of bipolar disorder consists of alternating manic and
depressive episodes separated by periods of normal mood, it is not uncommon for
depressive mood to be accompanied for days or weeks on end by overactivity and
pressure of speech, or for a manic mood and grandiosity to be accompanied by
agitation and loss of energy and libido. Depressive symptoms and symptoms of
hypomania or mania may also alternate rapidly, from day to day or even from hour
to hour. A diagnosis of mixed bipolar affective disorder should be made only if the
two sets of symptoms are both prominent for the greater part of the current episode
of illness, and if that episode has lasted for at least 2 weeks.
Excludes: single mixed affective episode (F38.0)
F31.7 Bipolar affective disorder, currently in remission
The patient has had at least one manic, hypomanic, or mixed affective episode in the past
and in addition at least one other affective episode of hypomanic, manic, depressive,
or mixed type, but is not currently suffering from any significant mood disturbance,
and has not done so for several months. The patient may, however, be receiving
treatment to reduce the risk of future episodes.
F31.8 Other bipolar affective disorders
Includes: bipolar II disorder
recurrent manic episodes
F31.9 Bipolar affective disorder, unspecified
F32 Depressive episode
- 100 In
typical depressive episodes of all three varieties described below (mild (F32.0), moderate
(F32.1), and severe (F32.2 and F32.3)), the individual usually suffers from depressed
mood, loss of interest and enjoyment, and reduced energy leading to increased
fatiguability and diminished activity. Marked tiredness after only slight effort is
common. Other common symptoms are:
(a)reduced concentration and attention;
(b)reduced self-esteem and self-confidence;
(c)ideas of guilt and unworthiness (even in a mild type of episode);
(d)bleak and pessimistic views of the future;
(e)ideas or acts of self-harm or suicide;
(f)disturbed sleep
(g)diminished appetite.
The lowered mood varies little from day to day, and is often unresponsive to circumstances,
yet may show a characteristic diurnal variation as the day goes on. As with manic
episodes, the clinical presentation shows marked individual variations, and atypical
presentations are particularly common in adolescence. In some cases, anxiety,
distress, and motor agitation may be more prominent at times than the depression,
and the mood change may also be masked by added features such as irritability,
excessive consumption of alcohol, histrionic behaviour, and exacerbation of
pre-existing phobic or obsessional symptoms, or by hypochondriacal
preoccupations. For depressive episodes of all three grades of severity, a duration of
at least 2 weeks is usually required for diagnosis, but shorter periods may be
reasonable if symptoms are unusually severe and of rapid onset.
Some of the above symptoms may be marked and develop characteristic features that are
widely regarded as having special clinical significance. The most typical examples of
these "somatic" symptoms (see introduction to this block, page 112 [of Blue Book])
are: loss of interest or pleasure in activities that are normally enjoyable; lack of
emotional reactivity to normally pleasurable surroundings and events; waking in the
morning 2 hours or more before the usual time; depression worse in the morning;
objective evidence of definite psychomotor retardation or agitation (remarked on or
reported by other people); marked loss of appetite; weight loss (often defined as 5%
or more of body weight in the past month); marked loss of libido. Usually, this
somatic syndrome is not regarded as present unless about four of these symptoms
are definitely present.
The categories of mild (F32.0), moderate (F32.1) and severe (F32.2 and F32.3) depressive
episodes described in more detail below should be used only for a single (first)
depressive episode. Further depressive episodes should be classified under one of
the subdivisions of recurrent depressive disorder (F33.-).
These grades of severity are specified to cover a wide range of clinical states that are
encountered in different types of psychiatric practice. Individuals with mild
depressive episodes are common in primary care and general medical settings,
whereas psychiatric inpatient units deal largely with patients suffering from the
severe grades.
- 101 Acts
of self-harm associated with mood [affective] disorders, most commonly self-poisoning
by prescribed medication, should be recorded by means of an additional code from
Chapter XX of ICD-10 (X60-X84). These codes do not involve differentiation
between attempted suicide and "parasuicide", since both are included in the general
category of self-harm.
Differentiation between mild, moderate, and severe depressive episodes rests upon a
complicated clinical judgement that involves the number, type, and severity of
symptoms present. The extent of ordinary social and work activities is often a useful
general guide to the likely degree of severity of the episode, but individual, social,
and cultural influences that disrupt a smooth relationship between severity of
symptoms and social performance are sufficiently common and powerful to make it
unwise to include social performance amongst the essential criteria of severity.
The presence of dementia (F00-F03) or mental retardation (F70-F79) does not rule out the
diagnosis of a treatable depressive episode, but communication difficulties are likely
to make it necessary to rely more than usual for the diagnosis upon objectively
observed somatic symptoms, such as psychomotor retardation, loss of appetite and
weight, and sleep disturbance.
Includes: single episodes of depressive reaction, major depression (without psychotic
symptoms), psychogenic depression or reactive depression (F32.0, F32.1
or F32.2)
F32.0 Mild depressive episode
Diagnostic guidelines
Depressed mood, loss of interest and enjoyment, and increased fatiguability are usually
regarded as the most typical symptoms of depression, and at least two of these, plus
at least two of the other symptoms described on page 119 (for F32.-) should usually
be present for a definite diagnosis. None of the symptoms should be present to an
intense degree. Minimum duration of the whole episode is about 2 weeks.
An individual with a mild depressive episode is usually distressed by the symptoms and has
some difficulty in continuing with ordinary work and social activities, but will
probably not cease to function completely.
A fifth character may be used to specify the presence of the somatic syndrome:
F32.00 Without somatic syndrome
The criteria for mild depressive episode are fulfilled, and there are few or none of the
somatic symptoms present.
F32.01 With somatic syndrome
The criteria for mild depressive episode are fulfilled, and four or more of the somatic
symptoms are also present. (If only two or three somatic symptoms are present but
they are unusually severe, use of this category may be justified.)
- 102 F32.1
Moderate depressive episode
Diagnostic guidelines
At least two of the three most typical symptoms noted for mild depressive episode (F32.0)
should be present, plus at least three (and preferably four) of the other symptoms.
Several symptoms are likely to be present to a marked degree, but this is not
essential if a particularly wide variety of symptoms is present overall. Minimum
duration of the whole episode is about 2 weeks.
An individual with a moderately severe depressive episode will usually have considerable
difficulty in continuing with social, work or domestic activities.
A fifth character may be used to specify the occurrence of the somatic syndrome:
F32.10 Without somatic syndrome
The criteria for moderate depressive episode are fulfilled, and few if any of the somatic
symptoms are present.
F32.11 With somatic syndrome
The criteria for moderate depressive episode are fulfilled, and four or more or the somatic
symptoms are present. (If only two or three somatic symptoms are present but they
are unusually severe, use of this category may be justified.)
F32.2 Severe depressive episode without psychotic symptoms
In a severe depressive episode, the sufferer usually shows considerable distress or agitation,
unless retardation is a marked feature. Loss of self-esteem or feelings of uselessness
or guilt are likely to be prominent, and suicide is a distinct danger in particularly
severe cases. It is presumed here that the somatic syndrome will almost always be
present in a severe depressive episode.
Diagnostic guidelines
All three of the typical symptoms noted for mild and moderate depressive episodes (F32.0,
F32.1) should be present, plus at least four other symptoms, some of which should
be of severe intensity. However, if important symptoms such as agitation or
retardation are marked, the patient may be unwilling or unable to describe many
symptoms in detail. An overall grading of severe episode may still be justified in
such instances. The depressive episode should usually last at least 2 weeks, but if the
symptoms are particularly severe and of very rapid onset, it may be justified to make
this diagnosis after less than 2 weeks.
During a severe depressive episode it is very unlikely that the sufferer will be able to
continue with social, work, or domestic activities, except to a very limited extent.
This category should be used only for single episodes of severe depression without psychotic
symptoms; for further episodes, a subcategory of recurrent depressive disorder
(F33.-) should be used.
- 103 Includes:
single episodes of agitated depression
melancholia or vital depression without psychotic symptoms
F32.3 Severe depressive episode with psychotic symptoms
Diagnostic guidelines
A severe depressive episode which meets the criteria given for F32.2 above and in which
delusions, hallucinations, or depressive stupor are present. The delusions usually
involve ideas of sin, poverty, or imminent disasters, responsibility for which may be
assumed by the patient. Auditory or olfactory hallucinations are usually of
defamatory or accusatory voices or of rotting filth or decomposing flesh. Severe
psychomotor retardation may progress to stupor. If required, delusions or
hallucinations may be specified as mood-congruent or mood-incongruent (see
F30.2).
Differential diagnosis. Depressive stupor must be differentiated from catatonic
schizophrenia (F20.2), from dissociative stupor (F44.2), and from organic forms of
stupor. This category should be used only for single episodes of severe depression
with psychotic symptoms; for further episodes a subcategory of recurrent depressive
disorder (F33.-) should be used.
Includes: single episodes of major depression with psychotic symptoms, psychotic
depression, psychogenic depressive psychosis, reactive depressive
psychosis
F32.8 Other depressive episodes
Episodes should be included here which do not fit the descriptions given for depressive
episodes described in F32.0-F32.3, but for which the overall diagnostic impression
indicates that they are depressive in nature. Examples include fluctuating mixtures
of depressive symptoms (particularly the somatic variety) with non-diagnostic
symptoms such as tension, worry, and distress, and mixtures of somatic depressive
symptoms with persistent pain or fatigue not due to organic causes (as sometimes
seen in general hospital services).
Includes: atypical depression
single episodes of "masked" depression NOS
F32.9 Depressive episode, unspecified
Includes: depression NOS
depressive disorder NOS
F33 Recurrent depressive disorder
The disorder is characterized by repeated episodes of depression as specified in depressive
episode (mild (F32.0), moderate (F32.1), or severe (F32.2 and F32.3)), without any
history of independent episodes of mood elevation and overactivity that fulfil the
criteria of mania (F30.1 and F30.2). However, the category should still be used if
- 104 there
is evidence of brief episodes of mild mood elevation and overactivity which
fulfil the criteria of hypomania (F30.0) immediately after a depressive episode
(sometimes apparently precipitated by treatment of a depression). The age of onset
and the severity, duration, and frequency of the episodes of depression are all highly
variable. In general, the first episode occurs later than in bipolar disorder, with a
mean age of onset in the fifth decade. Individual episodes also last between 3 and 12
months (median duration about 6 months) but recur less frequently. Recovery is
usually complete between episodes, but a minority of patients may develop a
persistent depression, mainly in old age (for which this category should still be used).
Individual episodes of any severity are often precipitated by stressful life events; in
many cultures, both individual episodes and persistent depression are twice as
common in women as in men.
The risk that a patient with recurrent depressive disorder will have an episode of mania
never disappears completely, however many depressive episodes he or she has
experienced. If a manic episode does occur, the diagnosis should change to bipolar
affective disorder.
Recurrent depressive episode may be subdivided, as below, by specifying first the type of
the current episode and then (if sufficient information is available) the type that
predominates in all the episodes.
Includes: recurrent episodes of depressive reaction, psychogenic depression,
reactive depression, seasonal affective disorder (F33.0 or F33.2)
recurrent episodes of endogenous depression, major depression, manic
depressive psychosis (depressed type), psychogenic or reactive
depressive psychosis, psychotic depression, vital depression (F33.2 or
F33.3)
Excludes:recurrent brief depressive episodes (F38.1)
F33.0 Recurrent depressive disorder, current episode mild
Diagnostic guidelines
For a definite diagnosis:
(a)the criteria for recurrent depressive disorder (F33.-) should be fulfilled, and the current
episode should fulfil the criteria for depressive episode, mild severity (F32.0); and
(b)at least two episodes should have lasted a minimum of 2 weeks and should have been
separated by several months without significant mood disturbance.
Otherwise, the diagnosis should be other recurrent mood [affective] disorder (F38.1).
A fifth character may be used to specify the presence of the somatic syndrome in the current
episode:
F33.00 Without somatic syndrome
(See F32.00)
- 105 F33.01
With somatic syndrome
(See F32.01)
If required, the predominant type of previous episodes (mild or moderate, severe, uncertain)
may be specified.
F33.2Recurrent depressive disorder, current episode moderate
Diagnostic guidelines
For a definite diagnosis:
(a)the criteria for recurrent depressive disorder (F33.-) should be fulfilled, and the current
episode should fulfil the criteria for depressive episode, moderate severity
(F32.1); and
(b)at least two episodes should have lasted a minimum of 2 weeks and should have been
separated by several months without significant mood disturbance.
Otherwise the diagnosis should be other recurrent mood [affective] disorder (F38.1).
A fifth character may be used to specify the presence of the somatic syndrome in the current
episode:
F33.10 Without somatic syndrome
(see F32.10)
F33.11 With somatic syndrome
(see F32.11)
If required, the predominant type of previous episodes (mild, moderate, severe, uncertain)
may be specified.
F33.3Recurrent depressive disorder, current episode severe with psychotic symptoms
Diagnostic guidelines
For a definite diagnosis:
(a)the criteria for recurrent depressive disorder (F33.-) should be fulfilled, and the current
episode should fulfil the criteria for severe depressive episode with psychotic
symptoms (F32.3); and
(b)at least two episodes should have lasted a minimum of 2 weeks and should have been
separated by several months without significant mood disturbance.
Otherwise the diagnosis should be other recurrent mood [affective] disorder (F38.1).
If required, delusions or hallucinations may be specified as mood-congruent or moodincongruent
(see F30.2).
- 106 If
required, the predominant type of previous episodes (mild, moderate, severe, uncertain)
may be specified.
F33.4 Recurrent depressive disorder, currently in remission
Diagnostic guidelines
For a definite diagnosis:
(a)the criteria for recurrent depressive disorder (F33.-) should have been fulfilled in the past,
but the current state should not fulfil the criteria for depressive episode of any
degree of severity or for any other disorder in F30 - F39; and
(b)at least two episodes should have lasted a minimum of 2 weeks and should have been
separated by several months without significant mood disturbance.
Otherwise the diagnosis should be other recurrent mood [affective] disorder (F38.1).
This category can still be used if the patient is receiving treatment to reduce the risk of
further episodes.
F33.8 Other recurrent depressive disorders
F33.9 Recurrent depressive disorder, unspecified
Includes: monopolar depression NOS
F34 Persistent mood [affective] disorders
These are persistent and usually fluctuating disorders of mood in which individual episodes
are rarely if ever sufficiently severe to warrant being described as hypomanic or even
mild depressive episodes. Because they last for years at a time, and sometimes for the
greater part of the individual's adult life, they involve considerable subjective distress
and disability. In some instances, however, recurrent or single episodes of manic
disorder, or mild or severe depressive disorder, may become superimposed on a
persistent affective disorder. The persistent affective disorders are classified here
rather than with the personality disorders because of evidence from family studies
that they are genetically related to the mood disorders, and because they are
sometimes amenable to the same treatments as mood disorders. Both early- and lateonset
varieties of cyclothymia and dysthymia are described, and should be specified
as such if required.
F34.0 Cyclothymia
A persistent instability of mood, involving numerous periods of mild depression and mild
elation. This instability usually develops early in adult life and pursues a chronic
course, although at times the mood may be normal and stable for months at a time.
The mood swings are usually perceived by the individual as being unrelated to life
events. The diagnosis is difficult to establish without a prolonged period of
- 107 observation
or an unusually good account of the individual's past behaviour.
Because the mood swings are relatively mild and the periods of mood elevation may
be enjoyable, cyclothymia frequently fails to come to medical attention. In some
cases this may be because the mood change, although present, is less prominent than
cyclical changes in activity, self-confidence, sociability, or appetitive behaviour. If
required, age of onset may be specified as early (in late teenage or the twenties) or
late.
Diagnostic guidelines
The essential feature is a persistent instability of mood, involving numerous periods of mild
depression and mild elation, none of which has been sufficiently severe or prolonged
to fulfil the criteria for bipolar affective disorder (F31.-) or recurrent depressive
disorder (F33.-). This implies that individual episodes of mood swings do not fulfil
the criteria for any of the categories described under manic episode (F30.-) or
depressive episode (F32.-).
Includes:affective personality disorder
cycloid personality
cyclothymic personality
Differential diagnosis. This disorder is common in the relatives of patients with bipolar
affective disorder (F31.-) and some individuals with cyclothymia eventually develop
bipolar affective disorder themselves. It may persist throughout adult life, cease
temporarily or permanently, or develop into more severe mood swings meeting the
criteria for bipolar affective disorder (F31.-) or recurrent depressive disorder (F33.-)
F34.1 Dysthymia
A chronic depression of mood which does not currently fulfil the criteria for recurrent
depressive disorder, mild or moderate severity (F33.0 of F33.1), in terms of either
severity or duration of individual episodes, although the criteria for mild depressive
episode may have been fulfilled in the past, particularly at the onset of the disorder.
The balance between individual phases of mild depression and intervening periods
of comparative normality is very variable. Sufferers usually have periods of days or
weeks when they describe themselves as well, but most of the time (often for months
at a time) they feel tired and depressed; everything is an effort and nothing is
enjoyed. They brood and complain, sleep badly and feel inadequate, but are usually
able to cope with the basic demands of everyday life. Dysthymia therefore has much
in common with the concepts of depressive neurosis and neurotic depression. If
required, age of onset may be specified as early (in late teenage or the twenties) or
late.
Diagnostic guidelines
The essential feature is a very long-standing depression of mood which is never, or only
very rarely, severe enough to fulfil the criteria for recurrent depressive disorder, mild
or moderate severity (F33.0 or F33.1). It usually begins early in adult life and lasts for
at least several years, sometimes indefinitely. When the onset is later in life, the
- 108 disorder
is often the aftermath of a discrete depressive episode (F32.-) and associated
with bereavement or other obvious stress.
Includes: depressive neurosis
depressive personality disorder
neurotic depression (with more than 2 years' duration)
persistent anxiety depression
Excludes: anxiety depression (mild or not persistent) (F41.2)
bereavement reaction, lasting less than 2 years (F43.21, prolonged depressive
reaction)
residual schizophrenia (F20.5)
F34.8 Other persistent mood [affective] disorders
A residual category for persistent affective disorders that are not sufficiently severe or longlasting
to fulfil the criteria for cyclothymia (F34.0) or dysthymia (F34.1) but that are
nevertheless clinically significant. Some types of depression previously called
"neurotic" are included here, provided that they do not meet the criteria for either
cyclothymia (F34.0) or dysthymia (F34.1) or for depressive episode of mild (F32.0)
or moderate (F32.1) severity.
F34.9 Persistent mood [affective] disorder, unspecified
F38 Other mood [affective] disorders
F38.0 Other single mood [affective] disorders
F38.00 Mixed affective episode
An affective episode lasting for at least 2 weeks, characterized by either a mixture or a rapid
alternation (usually within a few hours) of hypomanic, manic, and depressive
symptoms.
F38.1 Other recurrent mood [affective] disorders
F38.10 Recurrent brief depressive disorder
Recurrent brief depressive episodes, occurring about once a month over the past year. The
individual depressive episodes all last less than 2 weeks (typically 2-3 days, with
complete recovery) but fulfil the symptomatic criteria for mild, moderate, or severe
depressive episode (F32.0, F32.1, F32.2).
Differential diagnosis. In contrast to those with dysthymia (F34.1), patients are not
depressed for the majority of the time. If the depressive episodes occur only in
relation to the menstrual cycle, F38.8 should be used with a second code for the
underlying cause (N94.8, other specified conditions associated with female genital
organs and menstrual cycle).
F38.8 Other specified mood [affective] disorders
This is a residual category for affective disorders that do not meet the criteria for any other
categories F30 - F38.1 above.
- 109 F39
Unspecified mood [affective] disorder
To be used only as a last resort, when no other term can be used.
Includes: affective psychosis NOS
Excludes: mental disorder NOS (F99)
- 110 -
F40-F48
Neurotic, stress-related and somatoform disorders
Overview of this block
F40 Phobic anxiety disorders
F40.0 Agoraphobia
.00 Without panic disorder
.01 With panic disorder
F40.1 Social phobias
F40.2 Specific (isolated) phobias
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified
F41 Other anxiety disorders
F41.0 Panic disorder [episodic paroxysmal anxiety]
F41.1 Generalized anxiety disorder
F41.2 Mixed anxiety and depressive disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
F42 Obsessive-compulsive disorder
F42.0 Predominantly obsessional thoughts or ruminations
F42.1 Predominantly compulsive acts [obsessional rituals]
F42.2 Mixed obsessional thoughts and acts
F42.8 Other obsessive-compulsive disorders
F42.9 Obsessive-compulsive disorder, unspecified
F43 Reaction to severe stress, and adjustment disorders
F43.0 Acute stress reaction
F43.1 Post-traumatic stress disorder
F43.2 Adjustment disorders
.20 Brief depressive reaction
.21 Prolonged depressive reaction
.22 Mixed anxiety and depressive reaction
.23 With predominant disturbance of other emotions
.24 With predominant disturbance of conduct
.25 With mixed disturbance of emotions and conduct
.28 With other specified predominant symptoms
F43.8 Other reactions to severe stress
F43.9 Reaction to severe stress, unspecified
- 111 F44
Dissociative [conversion] disorders
F44.0 Dissociative amnesia
F44.1 Dissociative fugue
F44.2 Dissociative stupor
F44.3 Trance and possession disorders
F44.4 Dissociative motor disorders
F44.5 Dissociative convulsions
F44.6 Dissociative anaesthesia and sensory loss
F44.7 Mixed dissociative [conversion] disorders
F44.8 Other dissociative [conversion] disorders
.80 Ganser's syndrome
.81 Multiple personality disorder
.82 Transient dissociative [conversion] disorders occurring in childhood and
adolescence
.88 Other specified dissociative [conversion] disorders
F44.9 Dissociative [conversion] disorder, unspecified
F45 Somatoform disorders
F45.0 Somatization disorder
F45.1 Undifferentiated somatoform disorder
F45.2 Hypochondriacal disorder
F45.3 Somatoform autonomic dysfunction
.30 Heart and cardiovascular system
.31 Upper gastrointestinal tract
.32 Lower gastrointestinal tract
.33 Respiratory system
.34 Genitourinary system
.38 Other organ or system
F45.4 Persistent somatoform pain disorder
F45.8 Other somatoform disorders
F45.9 Somatoform disorder, unspecified
F48 Other neurotic disorders
F48.0 Neurasthenia
F48.1 Depersonalization-derealization syndrome
F48.8 Other specified neurotic disorders
F48.9 Neurotic disorder, unspecified
- 112 -
Introduction
Neurotic, stress-related, and somatoform disorders have been brought together in one large overall
group because of their historical association with the concept of neurosis and the association of a
substantial (though uncertain)proportion of these disorders with psychological causation. As noted in
the general introduction to this classification, the concept of neurosis has not been retained as a major
organizing principle, but care has been taken to allow the easy identification of disorders that some
users still might wish to regard as neurotic in their own usage of the term (see note on neurosis in the
general introduction (page 3).
Mixtures of symptoms are common (coexistent depression and anxiety being by far the most
frequent), particularly in the less severe varieties of these disorders often seen in primary care.
Although efforts should be made to decide which is the predominant syndrome, a category is
provided for those cases of mixed depression and anxiety in which it would be artificial to force a
decision (F41.2).
F40 Phobic anxiety disorders
In this group of disorders, anxiety is evoked only, or predominantly, by certain well-defined situations
or objects (external to the individual) which are not currently dangerous. As a result, these
situations or objects are characteristically avoided or endured with dread. Phobic anxiety is
indistinguishable subjectively, physiologically, and behaviourally from other types of anxiety
and may vary in severity from mild unease to terror. The individual's concern may focus on
individual symptoms such as palpitations or feeling faint and is often associated with
secondary fears of dying, losing control, or going mad. The anxiety is not relieved by the
knowledge that other people do not regard the situation in question as dangerous or
threatening. Mere contemplation of entry to the phobic situation usually generates
anticipatory anxiety.
The adoption of the criterion that the phobic object or situation is external to the subject implies that
many of the fears relating to the presence of disease (nosophobia) and disfigurement
(dysmorphobia) are now classified under F45.2 (hypochondriacal disorder). However, if the
fear of disease arises predominantly and repeatedly from possible exposure to infection or
contamination, or is simply a fear of medical procedures (injections, operations, etc.) or
medical establishments (dentists' surgeries, hospitals, etc.), a category from F40.- will be
appropriate (usually F40.2, specific phobia).
Phobic anxiety often coexists with depression. Pre-existing phobic anxiety almost invariably gets
worse during an intercurrent depressive episode. Some depressive episodes are accompanied
by temporary phobic anxiety and a depressive mood often accompanies some phobias,
particularly agoraphobia. Whether two diagnoses, phobic anxiety and depressive episode, are
needed or only one is determined by whether one disorder developed clearly before the other
and by whether one is clearly predominant at the time of diagnosis. If the criteria for
depressive disorder were met before the phobic symptoms first appeared, the former should
be given diagnostic precedence (see note in Introduction, pages 6 and 7).
Most phobic disorders other than social phobias are more common in women than in men.
In this classification, a panic attack (F41.0) occurring in an established phobic situation is regarded as
an expression of the severity of the phobia, which should be given diagnostic precedence.
Panic disorder as a main diagnosis should be diagnosed only in the absence of any of the
phobias listed in F40.-.
F40.0 Agoraphobia
The term "agoraphobia" is used here with a wider meaning than it had when originally introduced
and as it is still used in some countries. It is now taken to include fears not only of open
- 113 spaces
but also of related aspects such as the presence of crowds and the difficulty of
immediate easy escape to a safe place (usually home). The term therefore refers to an
interrelated and often overlapping cluster of phobias embracing fears of leaving home: fear of
entering shops, crowds, and public places, or of travelling alone in trains, buses, or planes.
Although the severity of the anxiety and the extent of avoidance behaviour are variable, this is
the most incapacitating of the phobic disorders and some sufferers become completely
housebound; many are terrified by the thought of collapsing and being left helpless in public.
The lack of an immediately available exit is one of the key features of many of these
agoraphobic situations. Most sufferers are women and the onset is usually early in adult life.
Depressive and obsessional symptoms and social phobias may also be present but do not
dominate the clinical picture. In the absence of effective treatment, agoraphobia often
becomes chronic, though usually fluctuating.
Diagnostic guidelines
All of the following criteria should be fulfilled for a definite diagnosis:
(a)the psychological or autonomic symptoms must be primarily manifestations of anxiety and not
secondary to other symptoms, such as delusions or obsessional thoughts;
(b)the anxiety must be restricted to (or occur mainly in) at least two of the following situations:
crowds, public places, travelling away from home, and travelling alone; and
(c)avoidance of the phobic situation must be, or have been, a prominent feature.
Differential diagnosis. It must be remembered that some agoraphobics experience little anxiety
because they are consistently able to avoid their phobic situations. The presence of other
symptoms such as depression, depersonalization, obsessional symptoms, and social phobias
does not invalidate the diagnosis, provided that these symptoms do not dominate the clinical
picture. However, if the patient was already significantly depressed when the phobic
symptoms first appeared, depressive episode may be a more appropriate main diagnosis; this
is more common in late-onset cases.
The presence or absence of panic disorder (F41.0) in the agoraphobic situation on a majority of
occasions may be recorded by means of a fifth character:
F40.00 Without panic disorder
F40.01 With panic disorder
Includes: panic disorder with agoraphobia
F40.1 Social phobias
Social phobias often start in adolescence and are centred around a fear of scrutiny by other people in
comparatively small groups (as opposed to crowds), usually leading to avoidance of social
situations. Unlike most other phobias, social phobias are equally common in men and
women. They may be discrete (i.e. restricted to eating in public, to public speaking, or to
encounters with the opposite sex) or diffuse, involving almost all social situations outside the
family circle. A fear of vomiting in public may be important. Direct eye-to-eye
confrontation may be particularly stressful in some cultures. Social phobias are usually
associated with low self-esteem and fear of criticism. They may present as a complaint of
blushing, hand tremor, nausea, or urgency of micturition, the individual sometimes being
convinced that one of these secondary manifestations of anxiety is the primary problem;
symptoms may progress to panic attacks. Avoidance is often marked, and in extreme cases
may result in almost complete social isolation.
Diagnostic guidelines
All of the following criteria should be fulfilled for a definite diagnosis:
- 114 (a)the
psychological, behavioural, or autonomic symptoms must be primarily manifestations of
anxiety and not secondary to other symptoms such as delusions or obsessional
thoughts;
(b)the anxiety must be restricted to or predominate in particular social situations; and
(c)the phobic situation is avoided whenever possible.
Includes: anthropophobia
social neurosis
Differential diagnosis. Agoraphobia and depressive disorders are often prominent, and may both
contribute to sufferers becoming "housebound". If the distinction between social phobia and
agoraphobia is very difficult, precedence should be given to agoraphobia; a depressive
diagnosis should not be made unless a full depressive syndrome can be identified clearly.
F40.2 Specific (isolated) phobias
These are phobias restricted to highly specific situations such as proximity to particular animals,
heights, thunder, darkness, flying, closed spaces, urinating or defecating in public toilets,
eating certain foods, dentistry, the sight of blood or injury, and the fear of exposure to specific
diseases. Although the triggering situation is discrete, contact with it can evoke panic as in
agoraphobia or social phobias. Specific phobias usually arise in childhood or early adult life
and can persist for decades if they remain untreated. The seriousness of the resulting
handicap depends on how easy it is for the sufferer to avoid the phobic situation. Fear of the
phobic situation tends not to fluctuate, in contrast to agoraphobia. Radiation sickness and
venereal infections and, more recently, AIDS are common subjects of disease phobias.
Diagnostic guidelines
All of the following should be fulfilled for a definite diagnosis:
(a)the psychological or autonomic symptoms must be primary manifestations of anxiety, and not
secondary to other symptoms such as delusion or obsessional thought;
(b)the anxiety must be restricted to the presence of the particular phobic object or situation; and
(c)the phobic situation is avoided whenever possible.
Includes: acrophobia
animal phobias
claustrophobia
examination phobia
simple phobia
Differential diagnosis. It is usual for there to be no other psychiatric symptoms, in contrast to
agoraphobia and social phobias. Blood-injury phobias differ from others in leading to
bradycardia and sometimes syncope, rather than tachycardia. Fears of specific diseases such
as cancer, heart disease, or venereal infection should be classified under hypochondriacal
disorder (F45.2), unless they relate to specific situations where the disease might be acquired.
If the conviction of disease reaches delusional intensity, the diagnosis should be delusional
disorder (F22.0). Individuals who are convinced that they have an abnormality or
disfigurement of a specific bodily (often facial) part, which is not objectively noticed by others
(sometimes termed dysmorphophobia), should be classified under hypochondriacal disorder
(F45.2) or delusional disorder (F22.0), depending upon the strength and persistence of their
conviction.
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified
Includes: phobia NOS
phobic states NOS
- 115 F41
Other anxiety disorders
Manifestations of anxiety are the major symptoms of these disorders and are not restricted to any
particular environmental situation. Depressive and obsessional symptoms, and even some
elements of phobic anxiety, may also be present, provided that they are clearly secondary or
less severe.
F41.0 Panic disorder [episodic paroxysmal anxiety]
The essential features are recurrent attacks of severe anxiety (panic) which are not restricted to any
particular situation or set of circumstances, and which are therefore unpredictable. As in
other anxiety disorders, the dominant symptoms vary from person to person, but sudden
onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality
(depersonalization or derealization) are common. There is also, almost invariably, a
secondary fear of dying, losing control, or going mad. Individual attacks usually last for
minutes only, though sometimes longer; their frequency and the course of the disorder are
both rather variable. An individual in a panic attack often experiences a crescendo of fear and
autonomic symptoms which results in an exit, usually hurried, from wherever he or she may
be. If this occurs in a specific situation, such as on a bus or in a crowd, the patient may
subsequently avoid that situation. Similarly, frequent and unpredictable panic attacks
produce fear of being alone or going into public places. A panic attack is often followed by a
persistent fear of having another attack.
Diagnostic guidelines
In this classification, a panic attack that occurs in an established phobic situation is regarded as an
expression of the severity of the phobia, which should be given diagnostic precedence. Panic
disorder should be the main diagnosis only in the absence of any of the phobias in F40.-.
For a definite diagnosis, several severe attacks of autonomic anxiety should have occurred within a
period of about 1 month:
(a)in circumstances where there is no objective danger;
(b)without being confined to known or predictable situations; and
(c)with comparative freedom from anxiety symptoms between attacks (although anticipatory anxiety
is common).
Includes: panic attack
panic state
Differential diagnosis. Panic disorder must be distinguished from panic attacks occurring as part of
established phobic disorders as already noted. Panic attacks may be secondary to depressive
disorders, particularly in men, and if the criteria for a depressive disorder are fulfilled at the
same time, the panic disorder should not be given as the main diagnosis.
F41.1 Generalized anxiety disorder
The essential feature is anxiety, which is generalized and persistent but not restricted to, or even
strongly predominating in, any particular environmental circumstances (i.e. it is
"free-floating"). As in other anxiety disorders the dominant symptoms are highly variable,
but complaints of continuous feelings of nervousness, trembling, muscular tension, sweating,
lightheadedness, palpitations, dizziness, and epigastric discomfort are common. Fears that
the sufferer or a relative will shortly become ill or have an accident are often expressed,
together with a variety of other worries and forebodings. This disorder is more common in
women, and often related to chronic environmental stress. Its course is variable but tends to
be fluctuating and chronic.
- 116 Diagnostic
guidelines
The sufferer must have primary symptoms of anxiety most days for at least several weeks at a time,
and usually for several months. These symptoms should usually involve elements of:
(a)apprehension (worries about future misfortunes, feeling "on edge", difficulty in concentrating, etc.);
(b)motor tension (restless fidgeting, tension headaches, trembling, inability to relax); and
(c)autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnoea, epigastric
discomfort, dizziness, dry mouth, etc.).
In children, frequent need for reassurance and recurrent somatic complaints may be prominent.
The transient appearance (for a few days at a time) of other symptoms, particularly depression, does
not rule out generalized anxiety disorder as a main diagnosis, but the sufferer must not meet
the full criteria for depressive episode (F32.-), phobic anxiety disorder (F40.-), panic disorder
(F41.0), or obsessive-compulsive disorder (F42.-)
Includes: anxiety neurosis
anxiety reaction
anxiety state
Excludes: neurasthenia (F48.0)
F41.2 Mixed anxiety and depressive disorder
This mixed category should be used when symptoms of both anxiety and depression are present, but
neither set of symptoms, considered separately, is sufficiently severe to justify a diagnosis. If
severe anxiety is present with a lesser degree of depression, one of the other categories for
anxiety or phobic disorders should be used. When both depressive and anxiety syndromes
are present and severe enough to justify individual diagnoses, both disorders should be
recorded and this category should not be used; if, for practical reasons of recording, only one
diagnosis can be made, depression should be given precedence. Some autonomic symptoms
(tremor, palpitations, dry mouth, stomach churning, etc.) must be present, even if only
intermittently; if only worry or over-concern is present, without autonomic symptoms, this
category should not be used. If symptoms that fulfil the criteria for this disorder occur in
close association with significant life changes or stressful life events, category F43.2,
adjustment disorders, should be used.
Individuals with this mixture of comparatively mild symptoms are frequently seen in primary care,
but many more cases exist among the population at large which never come to medical or
psychiatric attention.
Includes: anxiety depression (mild or not persistent)
Excludes: persistent anxiety depression (dysthymia) (F34.1)
F41.3 Other mixed anxiety disorders
This category should be used for disorders that meet the criteria for generalized anxiety disorder
(F41.1) and that also have prominent (although often short-lasting) features of other disorders
in F40-F48, although the full criteria for these additional disorders are not met. The
commonest examples are obsessive-compulsive disorder (F42.-), dissociative disorders
(F44.-), somatization disorder (F45.0), undifferentiated somatoform disorder (F45.1), and
hypochondriacal disorder (F45.2). If symptoms that fulfil the criteria for this disorder occur
in close association with significant life changes or stressful life events, category F43.2,
adjustment disorders, should be used.
F41.8 Other specified anxiety disorders
- 117 Includes:
anxiety hysteria
F41.9 Anxiety disorder, unspecified
Includes: anxiety NOS
F42 Obsessive-compulsive disorder
The essential feature of this disorder is recurrent obsessional thoughts or compulsive acts. (For
brevity, "obsessional" will be used subsequently in place of "obsessive-compulsive" when
referring to symptoms.) Obsessional thoughts are ideas, images or impulses that enter the
individual's mind again and again in a stereotyped form. They are almost invariably
distressing (because they are violent or obscene, or simply because they are perceived as
senseless) and the sufferer often tries, unsuccessfully, to resist them. They are, however,
recognized as the individual's own thoughts, even though they are involuntary and often
repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and
again. They are not inherently enjoyable, nor do they result in the completion of inherently
useful tasks. The individual often views them as preventing some objectively unlikely event,
often involving harm to or caused by himself or herself. Usually, though not invariably, this
behaviour is recognized by the individual as pointless or ineffectual and repeated attempts are
made to resist it; in very long-standing cases, resistance may be minimal. Autonomic anxiety
symptoms are often present, but distressing feelings of internal or psychic tension without
obvious autonomic arousal are also common. There is a close relationship between
obsessional symptoms, particularly obsessional thoughts, and depression. Individuals with
obsessive-compulsive disorder often have depressive symptoms, and patients suffering from
recurrent depressive disorder (F33.-) may develop obsessional thoughts during their episodes
of depression. In either situation, increases or decreases in the severity of the depressive
symptoms are generally accompanied by parallel changes in the severity of the obsessional
symptoms.
Obsessive-compulsive disorder is equally common in men and women, and there are often prominent
anankastic features in the underlying personality. Onset is usually in childhood or early adult
life. The course is variable and more likely to be chronic in the absence of significant
depressive symptoms.
Diagnostic guidelines
For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most
days for at least 2 successive weeks and be a source of distress or interference with activities.
The obsessional symptoms should have the following characteristics:
(a)they must be recognized as the individual's own thoughts or impulses;
(b)there must be at least one thought or act that is still resisted unsuccessfully, even though others
may be present which the sufferer no longer resists;
(c)the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or
anxiety is not regarded as pleasure in this sense);
(d)the thoughts, images, or impulses must be unpleasantly repetitive.
Includes: anankastic neurosis
obsessional neurosis
obsessive-compulsive neurosis
Differential diagnosis. Differentiating between obsessive-compulsive disorder and a depressive
disorder may be difficult because these two types of symptoms so frequently occur together.
In an acute episode of disorder, precedence should be given to the symptoms that developed
- 118 first;
when both types are present but neither predominates, it is usually best to regard the
depression as primary. In chronic disorders the symptoms that most frequently persist in the
absence of the other should be given priority.
Occasional panic attacks or mild phobic symptoms are no bar to the diagnosis. However, obsessional
symptoms developing in the presence of schizophrenia, Tourette's syndrome, or organic
mental disorder should be regarded as part of these conditions.
Although obsessional thoughts and compulsive acts commonly coexist, it is useful to be able to specify
one set of symptoms as predominant in some individuals, since they may respond to different
treatments.
F42.0 Predominantly obsessional thoughts or ruminations
These may take the form of ideas, mental images, or impulses to act. They are very variable in content
but nearly always distressing to the individual. A woman may be tormented, for example, by
a fear that she might eventually be unable to resist an impulse to kill the child she loves, or by
the obscene or blasphemous and ego-alien quality of a recurrent mental image. Sometimes
the ideas are merely futile, involving an endless and quasi-philosophical consideration of
imponderable alternatives. This indecisive consideration of alternatives is an important
element in many other obsessional ruminations and is often associated with an inability to
make trivial but necessary decisions in day-to-day living.
The relationship between obsessional ruminations and depression is particularly close: a diagnosis of
obsessive-compulsive disorder should be preferred only if ruminations arise or persist in the
absence of a depressive disorder.
F42.1 Predominantly compulsive acts [obsessional rituals]
The majority of compulsive acts are concerned with cleaning (particularly hand-washing), repeated
checking to ensure that a potentially dangerous situation has not been allowed to develop, or
orderliness and tidiness. Underlying the overt behaviour is a fear, usually of danger either to
or caused by the patient, and the ritual act is an ineffectual or symbolic attempt to avert that
danger. Compulsive ritual acts may occupy many hours every day and are sometimes
associated with marked indecisiveness and slowness. Overall, they are equally common in
the two sexes but hand-washing rituals are more common in women and slowness without
repetition is more common in men.
Compulsive ritual acts are less closely associated with depression than obsessional thoughts and are
more readily amenable to behavioural therapies.
F42.2 Mixed obsessional thoughts and acts
Most obsessive-compulsive individuals have elements of both obsessional thinking and compulsive
behaviour. This subcategory should be used if the two are equally prominent, as is often the
case, but it is useful to specify only one if it is clearly predominant, since thoughts and acts
may respond to different treatments.
F42.8 Other obsessive-compulsive disorders
F42.9 Obsessive-compulsive disorder, unspecified
F43 Reaction to severe stress, and adjustment disorders
This category differs from others in that it includes disorders identifiable not only on grounds of
symptomatology and course but also on the basis of one or other of two causative influences an
exceptionally stressful life event producing an acute stress reaction, or a significant life
change leading to continued unpleasant circumstances that result in an adjustment disorder.
Less severe psychosocial stress ("life events") may precipitate the onset or contribute to the
- 119 presentation
of a very wide range of disorders classified elsewhere in this work, but the
etiological importance of such stress is not always clear and in each case will be found to
depend on individual, often idiosyncratic, vulnerability. In other words, the stress is neither
necessary nor sufficient to explain the occurrence and form of the disorder. In contrast, the
disorders brought together in this category are thought to arise always as a direct
consequence of the acute severe stress or continued trauma. The stressful event or the
continuing unpleasantness of circumstances is the primary and overriding causal factor, and
the disorder would not have occurred without its impact. Reactions to severe stress and
adjustment disorders in all age groups, including children and adolescents, are included in
this category.
Although each individual symptom of which both the acute stress reaction and the adjustment
disorder are composed may occur in other disorders, there are some special features in the
way the symptoms are manifest that justify the inclusion of these states as a clinical entity.
The third condition in this section - post-traumatic stress disorder - has relatively specific and
characteristic clinical features.
These disorders can thus be regarded as maladaptive responses to severe or continued stress, in that
they interfere with successful coping mechanisms and thus lead to problems in social
functioning.
Acts of self-harm, most commonly self-poisoning by prescribed medication, that are associated closely
in time with the onset of either a stress reaction or an adjustment disorder should be recorded
by means of an additional X code from ICD-10, Chapter XX. These codes do not allow
differentiation between attempted suicide and "parasuicide", both being included in the
general category of self-harm.
F43.0 Acute stress reaction
A transient disorder of significant severity which develops in an individual without any other apparent
mental disorder in response to exceptional physical and/or mental stress and which usually
subsides within hours or days. The stressor may be an overwhelming traumatic experience
involving serious threat to the security or physical integrity of the individual or of a loved
person(s) (e.g. natural catastrophe, accident, battle, criminal assault, rape), or an unusually
sudden and threatening change in the social position and/or network of the individual, such
as multiple bereavement or domestic fire. The risk of this disorder developing is increased if
physical exhaustion or organic factors (e.g. in the elderly) are also present.
Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress
reactions, as evidenced by the fact that not all people exposed to exceptional stress develop the
disorder. The symptoms show great variation but typically they include an initial state of
"daze", with some constriction of the field of consciousness and narrowing of attention,
inability to comprehend stimuli, and disorientation. This state may be followed either by
further withdrawal from the surrounding situation (to the extent of a dissociative stupor - see
F44.2), or by agitation and over-activity (flight reaction or fugue). Autonomic signs of panic
anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually
appear within minutes of the impact of the stressful stimulus or event, and disappear within
2-3 days (often within hours). Partial or complete amnesia (see F44.0) for the episode may be
present.
Diagnostic guidelines
There must be an immediate and clear temporal connection between the impact of an exceptional
stressor and the onset of symptoms; onset is usually within a few minutes, if not immediate.
In addition, the symptoms:
- 120 (a)show
a mixed and usually changing picture; in addition to the initial state of "daze", depression,
anxiety, anger, despair, overactivity, and withdrawal may all be seen, but no one
type of symptom predominates for long;
(b)resolve rapidly (within a few hours at the most) in those cases where removal from the stressful
environment is possible; in cases where the stress continues or cannot by its nature
be reversed, the symptoms usually begin to diminish after 24-48 hours and are
usually minimal after about 3 days.
This diagnosis should not be used to cover sudden exacerbations of symptoms in individuals already
showing symptoms that fulfil the criteria of any other psychiatric disorder, except for those in
F60.- (personality disorders). However, a history of previous psychiatric disorder does not
invalidate the use of this diagnosis.
Includes: acute crisis reaction
combat fatigue
crisis state
psychic shock
F43.1 Post-traumatic stress disorder
This arises as a delayed and/or protracted response to a stressful event or situation (either short- or
long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause
pervasive distress in almost anyone (e.g. natural or man-made disaster, combat, serious
accident, witnessing the violent death of others, or being the victim of torture, terrorism, rape,
or other crime). Predisposing factors such as personality traits (e.g. compulsive, asthenic) or
previous history of neurotic illness may lower the threshold for the development of the
syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its
occurrence.
Typical symptoms include episodes of repeated reliving of the trauma in intrusive memories
("flashbacks") or dreams, occurring against the persisting background of a sense of
"numbness" and emotional blunting, detachment from other people, unresponsiveness to
surroundings, anhedonia, and avoidance of activities and situations reminiscent of the
trauma. Commonly there is fear and avoidance of cues that remind the sufferer of the
original trauma. Rarely, there may be dramatic, acute bursts of fear, panic or aggression,
triggered by stimuli arousing a sudden recollection and/or re-enactment of the trauma or of
the original reaction to it.
There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction,
and insomnia. Anxiety and depression are commonly associated with the above symptoms
and signs, and suicidal ideation is not infrequent. Excessive use of alcohol or drugs may be a
complicating factor.
The onset follows the trauma with a latency period which may range from a few weeks to months
(but rarely exceeds 6 months). The course is fluctuating but recovery can be expected in the
majority of cases. In a small proportion of patients the condition may show a chronic course
over many years and a transition to an enduring personality change (see F62.0).
Diagnostic guidelines
This disorder should not generally be diagnosed unless there is evidence that it arose within 6 months
of a traumatic event of exceptional severity. A "probable" diagnosis might still be possible if
the delay between the event and the onset was longer than 6 months, provided that the
clinical manifestations are typical and no alternative identification of the disorder (e.g. as an
anxiety or obsessive-compulsive disorder or depressive episode) is plausible. In addition to
evidence of trauma, there must be a repetitive, intrusive recollection or re-enactment of the
event in memories, daytime imagery, or dreams. Conspicuous emotional detachment,
numbing of feeling, and avoidance of stimuli that might arouse recollection of the trauma are
- 121 often
present but are not essential for the diagnosis. The autonomic disturbances, mood
disorder, and behavioural abnormalities all contribute to the diagnosis but are not of prime
importance.
The late chronic sequelae of devastating stress, i.e. those manifest decades after the stressful
experience, should be classified under F62.0.
Includes: traumatic neurosis
F43.2 Adjustment disorders
States of subjective distress and emotional disturbance, usually interfering with social functioning and
performance, and arising in the period of adaptation to a significant life change or to the
consequences of a stressful life event (including the presence or possibility of serious physical
illness). The stressor may have affected the integrity of an individual's social network
(through bereavement or separation experiences) or the wider system of social supports and
values (migration or refugee status). The stressor may involve only the individual or also his
or her group or community.
Individual predisposition or vulnerability plays a greater role in the risk of occurrence and the shaping
of the manifestations of adjustment disorders than it does in the other conditions in F43.-, but
it is nevertheless assumed that the condition would not have arisen without the stressor. The
manifestations vary, and include depressed mood, anxiety, worry (or a mixture of these), a
feeling of inability to cope, plan ahead, or continue in the present situation, and some degree
of disability in the performance of daily routine. The individual may feel liable to dramatic
behaviour or outbursts of violence, but these rarely occur. However, conduct disorders (e.g.
aggressive or dissocial behaviour) may be an associated feature, particularly in adolescents.
None of the symptoms is of sufficient severity or prominence in its own right to justify a more
specific diagnosis. In children, regressive phenomena such as return to bed-wetting, babyish
speech, or thumb-sucking are frequently part of the symptom pattern. If these features
predominate, F43.23 should be used.
The onset is usually within 1 month of the occurrence of the stressful event or life change, and the
duration of symptoms does not usually exceed 6 months, except in the case of prolonged
depressive reaction (F43.21). If the symptoms persist beyond this period, the diagnosis
should be changed according to the clinical picture present, and any continuing stress can be
coded by means of one of the Z codes in Chapter XXI of ICD-10.
Contacts with medical and psychiatric services because of normal bereavement reactions, appropriate
to the culture of the individual concerned and not usually exceeding 6 months in duration,
should not be recorded by means of the codes in this book but by a code from Chapter XXI
of ICD-10 such as Z63.4 (disappearance or death of family member) plus for example Z71.9
(counselling) or Z73.3 (stress not elsewhere classified). Grief reactions of any duration,
considered to be abnormal because of their form or content, should be coded as F43.22,
F43.23, F43.24 or F43.25, and those that are still intense and last longer than 6 months as
F43.21 (prolonged depressive reaction).
Diagnostic guidelines
Diagnosis depends on a careful evaluation of the relationship between:
(a)form, content, and severity of symptoms;
(b)previous history and personality; and
(c)stressful event, situation, or life crisis.
The presence of this third factor should be clearly established and there should be strong, though
perhaps presumptive, evidence that the disorder would not have arisen without it. If the
stressor is relatively minor, or if a temporal connection (less than 3 months) cannot be
- 122 demonstrated,
the disorder should be classified elsewhere, according to its presenting
features.
Includes: culture shock
grief reaction
hospitalism in children
Excludes: separation anxiety disorder of childhood (F93.0)
If the criteria for adjustment disorder are satisfied, the clinical form or predominant features can be
specified by a fifth character:
F43.20 Brief depressive reaction
A transient, mild depressive state of duration not exceeding 1 month.
F43.21 Prolonged depressive reaction
A mild depressive state occurring in response to a prolonged exposure to a stressful situation but of
duration not exceeding 2 years.
F43.22 Mixed anxiety and depressive reaction
Both anxiety and depressive symptoms are prominent, but at levels no greater than specified in mixed
anxiety and depressive disorder (F41.2) or other mixed anxiety disorder (F41.3).
F43.23 With predominant disturbance of other emotions
The symptoms are usually of several types of emotion, such as anxiety, depression, worry, tensions,
and anger. Symptoms of anxiety and depression may fulfil the criteria for mixed anxiety and
depressive disorder (F41.2) or other mixed anxiety disorder (F41.3), but they are not so
predominant that other more specific depressive or anxiety disorders can be diagnosed. This
category should also be used for reactions in children in which regressive behaviour such as
bed-wetting or thumb-sucking are also present.
F43.24 With predominant disturbance of conduct
The main disturbance is one involving conduct, e.g. an adolescent grief reaction resulting in aggressive
or dissocial behaviour.
F43.25 With mixed disturbance of emotions and conduct
Both emotional symptoms and disturbance of conduct are prominent features.
F43.28 With other specified predominant symptoms
F43.8 Other reactions to severe stress
F43.9 Reaction to severe stress, unspecified
F44 Dissociative [conversion] disorders
The common theme shared by dissociative (or conversion) disorders is a partial or complete loss of the
normal integration between memories of the past, awareness of identity, immediate
sensations, and control of bodily movements. There is normally a considerable degree of
conscious control over the memories and sensations that can be selected for immediate
attention, and the movements that are to be carried out. In the dissociative disorders it is
presumed that this ability to exercise a conscious and selective control is impaired, to a degree
that can vary from day to day or even from hour to hour. It is usually very difficult to assess
the extent to which some of the loss of functions might be under voluntary control.
These disorders have previously been classified as various types of "conversion hysteria", but it now
seems best to avoid the term "hysteria" as far as possible, in view of its many and varied
- 123 meanings.
Dissociative disorders as described here are presumed to be "psychogenic" in
origin, being associated closely in time with traumatic events, insoluble and intolerable
problems, or disturbed relationships. It is therefore often possible to make interpretations
and presumptions about the individual's means of dealing within intolerable stress, but
concepts derived from any one particular theory, such as "unconscious motivation" and
"secondary gain", are not included among the guidelines or criteria for diagnosis.
The term "conversion" is widely applied to some of these disorders, and implies that the unpleasant
affect, engendered by the problems and conflicts that the individual cannot solve, is somehow
transformed into the symptoms.
The onset and termination of dissociative states are often reported as being sudden, but they are rarely
observed except during contrived interactions or procedures such as hypnosis or abreaction.
Change in or disappearance of a dissociative state may be limited to the duration of such
procedures. All types of dissociative state tend to remit after a few weeks or months,
particularly if their onset was associated with a
traumatic life event. More chronic states, particularly paralyses and anaesthesias, may develop
(sometimes more slowly) if they are associated with insoluble problems or interpersonal
difficulties. Dissociative states that have endured for more than 1-2 years before coming to
psychiatric attention are often resistant to therapy.
Individuals with dissociative disorders often show a striking denial of problems or difficulties that may
be obvious to others. Any problems that they themselves recognize may be attributed by
patients to the dissociative symptoms.
Depersonalization and derealization are not included here, since in these syndromes only limited
aspects of personal identity are usually affected, and there is no associated loss of performance
in terms of sensations, memories, or movements.
Diagnostic guidelines
For a definite diagnosis the following should be present:
(a)the clinical features as specified for the individual disorders in F44.-;
(b)no evidence of a physical disorder that might explain the symptoms;
(c)evidence for psychological causation, in the form of clear association in time with stressful events
and problems or disturbed relationships (even if denied by the individual).
Convincing evidence of psychological causation may be difficult to find, even though strongly
suspected. In the presence of known disorders of the central or peripheral nervous system,
the diagnosis of dissociative disorder should be made with great caution. In the absence of
evidence for psychological causation, the diagnosis should remain provisional, and enquiry
into both physical and psychological aspects should continue.
Includes: conversion hysteria
conversion reaction
hysteria
hysterical psychosis
Excludes: malingering [conscious simulation] (Z76.5)
F44.0 Dissociative amnesia
The main feature is loss of memory, usually of important recent events, which is not due to
organic mental disorder and is too extensive to be explained by ordinary forgetfulness or
fatigue. The amnesia is usually centred on traumatic events, such as accidents or unexpected
bereavements, and is usually partial and selective. The extent and completeness of the
- 124 amnesia
often vary from day to day and between investigators, but there is a persistent
common core that cannot be recalled in the waking state. Complete and generalized amnesia
is rare; it is usually part of a fugue (F44.1) and, if so, should be classified as such.
The affective states that accompany amnesia are very varied, but severe depression is rare.
Perplexity, distress, and varying degrees of attention-seeking behaviour may be evident, but
calm acceptance is also sometimes striking. Young adults are most commonly affected, the
most extreme instances usually occurring in men subject to battle stress. Nonorganic
dissociative states are rare in the elderly. Purposeless local wandering may occur; it is usually
accompanied by self-neglect and rarely lasts more than a day or two.
Diagnostic guidelines
A definite diagnosis requires:
(a)amnesia, either partial or complete, for recent events that are of a traumatic or stressful
nature (these aspects may emerge only when other informants are available);
(b)absence of organic brain disorders, intoxication, or excessive fatigue.
Differential diagnosis. In organic mental disorders, there are usually other signs of
disturbance in the nervous system, plus obvious and consistent signs of clouding of
consciousness, disorientation, and fluctuating awareness. Loss of very recent memory is more
typical of organic states, irrespective of any possibly traumatic events or problems.
"Blackouts" due to abuse of alcohol or drugs are closely associated with the time of abuse, and
the lost memories can never be regained. The short-term memory loss of the amnesic state
(Korsakov's syndrome), in which immediate recall is normal but recall after only 2-3 minutes
is lost, is not found in dissociative amnesia.
Amnesia following concussion or serious head injury is usually retrograde, although in severe
cases it may be anterograde also; dissociative amnesia is usually predominantly retrograde.
Only dissociative amnesia can be modified by hypnosis or abreaction. Postictal amnesia in
epileptics, and other states of stupor or mutism occasionally found in schizophrenic or
depressive illnesses can usually be differentiated by other characteristics of the underlying
illness.
The most difficult differentiation is from conscious simulation of amnesia (malingering), and
repeated and detailed assessment of premorbid personality and motivation may be required.
Conscious simulation of amnesia is usually associated with obvious problems concerning
money, danger of death in wartime, or possible prison or death sentences.
Excludes: alcohol- or other psychoactive substance-induced amnesic disorder
(F10-F19 with common fourth character . 6)
amnesia NOS (R41.3)
anterograde amnesia (R41.1)
nonalcoholic organic amnesic syndrome (F04)
postictal amnesia in epilepsy (G40.-)
retrograde amnesia (R41.2)
F44.1 Dissociative fugue
Dissociative fugue has all the features of dissociative amnesia, plus an apparently purposeful
journey away from home or place of work during which self-care is maintained. In some
cases, a new identity may be assumed, usually only for a few days but occasionally for long
periods of time and to a surprising degree of completeness. Organized travel may be to places
previously known and of emotional significance. Although there is amnesia for the period of
the fugue, the individual's behaviour during this time may appear completely normal to
independent observers.
- 125 Diagnostic
guidelines
For a definite diagnosis there should be:
(a)the features of dissociative amnesia (F44.0);
(b)purposeful travel beyond the usual everyday range (the differentiation between travel and
wandering must be made by those with local knowledge); and
(c)maintenance of basic self-care (eating, washing, etc.) and simple social interaction with
strangers (such as buying tickets or petrol, asking directions, ordering meals).
Differential diagnosis. Differentiation from postictal fugue, seen particularly after temporal
lobe epilepsy, is usually clear because of the history of epilepsy, the lack of stressful events or
problems, and the less purposeful and more fragmented activities and travel of the epileptic.
As with dissociative amnesia, differentiation from conscious simulation of a fugue may be
very difficult.
F44.2 Dissociative stupor
The individual's behaviour fulfils the criteria for stupor, but examination and investigation
reveal no evidence of a physical cause. In addition, as in other dissociative disorders, there is
positive evidence of psychogenic causation in the form of either recent stressful events or
prominent interpersonal or social problems.
Stupor is diagnosed on the basis of a profound diminution or absence of voluntary movement
and normal responsiveness to external stimuli such as light, noise, and touch. The individual
lies or sits largely motionless for long periods of time. Speech and spontaneous and
purposeful movement are completely or almost completely absent. Although some degree of
disturbance of consciousness may be present, muscle tone, posture, breathing, and sometimes
eye-opening and coordinated eye movements are such that it is clear that the individual is
neither asleep nor unconscious.
Diagnostic guidelines
For a definite diagnosis there should be:
(a)stupor, as described above;
(b)absence of a physical or other psychiatric disorder that might explain the stupor; and
(c)evidence of recent stressful events or current problems.
Differential diagnosis. Dissociative stupor must be differentiated from catatonic stupor and
depressive or manic stupor. The stupor of catatonic schizophrenia is often preceded by
symptoms or behaviour suggestive of schizophrenia. Depressive and manic stupor usually
develop comparatively slowly, so a history from another informant should be decisive. Both
depressive and manic stupor are increasingly rare in many countries as early treatment of
affective illness becomes more widespread.
F44.3 Trance and possession disorders
Disorders in which there is a temporary loss of both the sense of personal identity and full
awareness of the surroundings; in some instances the individual acts as if taken over by
another personality, spirit, deity, or "force". Attention and awareness may be limited to or
concentrated upon only one or two aspects of the immediate environment, and there is often
a limited but repeated set of movements, postures, and utterances. Only trance disorders that
are involuntary or unwanted, and that intrude into ordinary activities by occurring outside
(or being a prolongation of) religious or other culturally accepted situations should be
included here.
- 126 Trance
disorders occurring during the course of schizophrenic or acute psychoses with
hallucinations or delusions, or multiple personality should not be included here, nor should
this category be used if the trance disorder is judged to be closely associated with any physical
disorder (such as temporal lobe epilepsy or head injury) or with psychoactive substance
intoxication.
F44.4-F44.7 Dissociative disorders of movement and sensation
In these disorders there is a loss of or interference with movements or loss of sensations
(usually cutaneous). The patient therefore presents as having a physical disorder, although
none can be found that would explain the symptoms. The symptoms can often be seen to
represent the patient's concept of physical disorder, which may be at variance with
physiological or anatomical principles. In addition, assessment of the patient's mental state
and social situation usually suggests that the disability resulting from the loss of functions is
helping the patient to escape from an unpleasant conflict, or to express dependency or
resentment indirectly. Although problems or conflicts may be evident to others, the patient
often denies their presence and attributes any distress to the symptoms or the resulting
disability.
The degree of disability resulting from all these types of symptom may vary from occasion to
occasion, depending upon the number and type of other people present, and upon the
emotional state of the patient. In other words, a variable amount of attention-seeking
behaviour may be present in addition to a central and unvarying core of loss of movement or
sensation which is not under voluntary control.
In some patients, the symptoms usually develop in close relationship to psychological stress,
but in others this link does not emerge. Calm acceptance ("belle indifférence") of serious
disability may be striking, but is not universal; it is also found in well-adjusted individuals
facing obvious and serious physical illness.
Premorbid abnormalities of personal relationships and personality are usually found, and
close relatives and friends may have suffered from physical illness with symptoms resembling
those of the patient. Mild and transient varieties of these disorders are often seen in
adolescence, particularly in girls, but the chronic varieties are usually found in young adults.
A few individuals establish a repetitive pattern of reaction to stress by the production of these
disorders, and may still manifest this in middle and old age.
Disorders involving only loss of sensations are included here; disorders involving additional
sensations such as pain, and other complex sensations mediated by the autonomic nervous
system are included in somatoform disorders (F45.-).
Diagnostic guidelines
The diagnosis should be made with great caution in the presence of physical disorders of the
nervous system, or in a previously well-adjusted individual with normal family and social
relationships.
For a definite diagnosis:
(a)there should be no evidence of physical disorder; and
(b)sufficient must be known about the psychological and social setting and personal
relationships of the patient to allow a convincing formulation to be made of the
reasons for the appearance of the disorder.
The diagnosis should remain probable or provisional if there is any doubt about the
contribution of actual or possible physical disorders, or if it is impossible to achieve an
understanding of why the disorder has developed. In cases that are puzzling or not clear-cut,
- 127 the
possibility of the later appearance of serious physical or psychiatric disorders should
always be kept in mind.
Differential diagnosis. The early stages of progressive neurological disorders, particularly
multiple sclerosis and systemic lupus erythematosus, may be confused with dissociative
disorders of movement and sensation. Patients reacting to early multiple sclerosis with
distress and attention-seeking behaviour pose especially difficult problems; comparatively
long periods of assessment and observation may be needed before the diagnostic probabilities
become clear.
Multiple and ill-defined somatic complaints should be classified elsewhere, under
somatoform disorders (F45.-) or neurasthenia (F48.0).
Isolated dissociative symptoms may occur during major mental disorders such as
schizophrenia or severe depression, but these disorders are usually obvious and should take
precedence over the dissociative symptoms for diagnostic and coding purposes.
Conscious simulation of loss of movement and sensation is often very difficult to distinguish
from dissociation; the decision will rest upon detailed observation, and upon obtaining an
understanding of the personality of the patient, the circumstances surrounding the onset of
the disorder, and the consequences of recovery versus continued disability.
F44.4 Dissociative motor disorders
The commonest varieties of dissociative motor disorder are loss of ability to move the whole
or a part of a limb or limbs. Paralysis may be partial, with movements being weak or slow, or
complete. Various forms and variable degrees of incoordination (ataxia) may be evident,
particularly in the legs, resulting in bizarre gait or inability to stand unaided (astasia-abasia).
There may also be exaggerated trembling or shaking of one or more extremities or the whole
body. There may be close resemblance to almost any variety of ataxia, apraxia, akinesia,
aphonia, dysarthria, dyskinesia, or paralysis.
Includes: psychogenic aphonia
psychogenic dysphonia
F44.5 Dissociative convulsions
Dissociative convulsions (pseudoseizures) may mimic epileptic seizures very closely in terms
of movements, but tongue-biting, serious bruising due to falling, and incontinence of urine
are rare in dissociative convulsion, and loss of consciousness is absent or replaced by a state of
stupor or trance.
F44.6 Dissociative anaesthesia and sensory loss
Anaesthetic areas of skin often have boundaries which make it clear that they are associated
more with the patient's ideas about bodily functions than with medical knowledge. There
may also be differential loss between the sensory modalities which cannot be due to a
neurological lesion. Sensory loss may be accompanied by complaints of paraesthesia.
Loss of vision is rarely total in dissociative disorders, and visual disturbances are more often a
loss of acuity, general blurring of vision, or "tunnel vision". In spite of complaints of visual
loss, the patient's general mobility and motor performance are often surprisingly well
preserved.
Dissociative deafness and anosmia are far less common than loss of sensation or vision.
Includes: psychogenic deafness
F44.7 Mixed dissociative [conversion] disorders
Mixtures of the disorders specified above (F44.0-F44.6) should be coded here.
- 128 F44.8
Other dissociative [conversion] disorders
F44.80 Ganser's syndrome
The complex disorder described by Ganser, which is characterized by "approximate
answers", usually accompanied by several other dissociative symptoms, often in
circumstances that suggest a psychogenic etiology, should be coded here.
F44.81 Multiple personality disorder
This disorder is rare, and controversy exists about the extent to which it is iatrogenic or
culture-specific. The essential feature is the apparent existence of two or more distinct
personalities within an individual, with only one of them being evident at a time. Each
personality is complete, with its own memories, behaviour, and preferences; these may be in
marked contrast to the single premorbid personality.
In the common form with two personalities, one personality is usually dominant but neither
has access to the memories of the other and the two are almost always unaware of each
other's existence. Change from one personality to another in the first instance is usually
sudden and closely associated with traumatic events. Subsequent changes are often limited
to dramatic or stressful events, or occur during sessions with a therapist that involve
relaxation, hypnosis, or abreaction.
F44.82 Transient dissociative [conversion] disorders occurring in childhood and adolescence
F44.88 Other specified dissociative [conversion] disorders
Includes: psychogenic confusion
twilight state
F44.9 Dissociative [conversion] disorder, unspecified
- 129 F45
Somatoform disorders
The main feature of somatoform disorders is repeated presentation of physical symptoms, together
with persistent requests for medical investigations, in spite of repeated negative findings and
reassurances by doctors that the symptoms have no physical basis. If any physical disorders are
present, they do not explain the nature and extent of the symptoms or the distress and preoccupation
of the patient. Even when the onset and continuation of the symptoms bear a close relationship with
unpleasant life events or with difficulties or conflicts, the patient usually resists attempts to discuss the
possibility of psychological causation; this may even be the case in the presence of obvious depressive
and anxiety symptoms. The degree of understanding, either physical or psychological, that can be
achieved about the cause of the symptoms is often disappointing and frustrating for both patient and
doctor.
In these disorders there is often a degree of attention-seeking (histrionic) behaviour, particularly in
patients who are resentful of their failure to persuade doctors of the essentially physical nature of their
illness and of the need for further investigations or examinations.
Differential diagnosis. Differentiation from hypochondriacal delusions usually depends upon close
acquaintance with the patient. Although the beliefs are long-standing and appear to be held against
reason, the degree of conviction is usually susceptible, to some degree and in the short term, to
argument, reassurance, and the performance of yet another examination or investigation. In addition,
the presence of unpleasant and frightening physical sensations can be regarded as a culturally
acceptable explanation for the development and persistence of a conviction of physical illness.
Excludes: dissociative disorders (F44.-)
hair-plucking (F98.4)
lalling (F80.0)
lisping (F80.8)
nail-biting (F98.8)
psychological or behavioural factors associated with disorders or diseases classified elsewhere
(F54)
sexual dysfunction, not caused by organic disorder or disease (F52.-)
thumb-sucking (F98.8)
tic disorders (in childhood and adolescence) (F95.-)
Tourette's syndrome (F95.2)
trichotillomania (F63.3)
F45.0 Somatization disorder
The main features are multiple, recurrent, and frequently changing physical symptoms, which have
usually been present for several years before the patient is referred to a psychiatrist. Most patients have
a long and complicated history of contact with both primary and specialist medical services, during
which many negative investigations or fruitless operations may have been carried out. Symptoms
may be referred to any part or system of the body, but gastrointestinal sensations (pain, belching,
regurgitation, vomiting, nausea, etc.), and abnormal skin sensations (itching, burning, tingling,
numbness, soreness, etc.) and blotchiness are among the commonest. Sexual and menstrual
complaints are also common.
Marked depression and anxiety are frequently present and may justify specific treatment.
The course of the disorder is chronic and fluctuating, and is often associated with long-standing
disruption of social, interpersonal, and family behaviour. The disorder is far more common in women
than in men, and usually starts in early adult life.
Dependence upon or abuse of medication (usually sedatives and analgesics) often results from the
frequent courses of medication.
Diagnostic guidelines
- 130 A
definite diagnosis requires the presence of all of the following:
(a)at least 2 years of multiple and variable physical symptoms for which no adequate physical
explanation has been found;
(b)persistent refusal to accept the advice or reassurance of several doctors that there is no physical
explanation for the symptoms;
(c)some degree of impairment of social and family functioning attributable to the nature of the
symptoms and resulting behaviour.
Includes: multiple complaint syndrome
multiple psychosomatic disorder
Differential diagnosis. In diagnosis, differentiation from the following disorders is essential:
Physical disorders. Patients with long-standing somatization disorder have the same chance of
developing independent physical disorders as any other person of their age, and further
investigations or consultations should be considered if there is a shift in the emphasis or stability of
the physical complaints which suggests possible physical disease.
Affective (depressive) and anxiety disorders. Varying degrees of depression and anxiety commonly
accompany somatization disorders, but need not be specified separately unless they are sufficiently
marked and persistent as to justify a diagnosis in their own right. The onset of multiple somatic
symptoms after the age of 40 years may be an early manifestation of a primarily depressive
disorder.
Hypochondriacal disorder. In somatization disorders, the emphasis is on the symptoms
themselves and their individual effects, whereas in hypochondriacal disorder, attention is directed
more to the presence of an underlying progressive and serious disease process and its disabling
consequences. In hypochondriacal disorder, the patient tends to ask for investigations to
determine or confirm the nature of the underlying disease, whereas the patient with somatization
disorder asks for treatment to remove the symptoms. In somatization disorder there is usually
excessive drug use, together with noncompliance over long periods, whereas patients with
hypochondriacal disorder fear drugs and their side-effects, and seek for reassurance by frequent
visits to different physicians.
Delusional disorders (such as schizophrenia with somatic delusions, and depressive disorders with
hypochondriacal delusions). The bizarre qualities of the beliefs, together with fewer physical
symptoms of more constant nature, are most typical of the delusional disorders.
Short-lived (e.g. less than 2 years) and less striking symptom patterns are better classified as
undifferentiated somatoform disorder (F45.1).
F45.1 Undifferentiated somatoform disorder
When physical complaints are multiple, varying and persistent, but the complete and typical
clinical picture of somatization disorder is not fulfilled, this category should be considered. For
instance, the forceful and dramatic manner of complaint may be lacking, the complaints may be
comparatively few in number, or the associated impairment of social and family functioning may
be totally absent. There may or may not be grounds for presuming a psychological causation, but
there must be no physical basis for the symptoms upon which the psychiatric diagnosis is based.
If a distinct possibility of underlying physical disorder still exists, or if the psychiatric assessment is
not completed at the time of diagnostic coding, other categories from the relevant chapters of
ICD-10 should be used.
Includes: undifferentiated psychosomatic disorder
- 131 Differential
diagnosis. As for the full syndrome of somatization disorder (F45.0).
F45.2 Hypochondriacal disorder
The essential feature is a persistent preoccupation with the possibility of having one or more
serious and progressive physical disorders. Patients manifest persistent somatic complaints or
persistent preoccupation with their physical appearance. Normal or commonplace sensations and
appearances are often interpreted by a patient as abnormal and distressing, and attention is usually
focused on only one or two organs or systems of the body. The feared physical disorder or
disfigurement may be named by the patient, but even so the degree of conviction about its
presence and the emphasis upon one disorder rather than another usually varies between
consultations; the patient will usually entertain the possibility that other or additional physical
disorders may exist in addition to the one given pre-eminence.
Marked depression and anxiety are often present, and may justify additional diagnosis. The
disorders rarely present for the first time after the age of 50 years, and the course of both symptoms
and disability is usually chronic and fluctuating. There must be no fixed delusions about bodily
functions or shape. Fears of the presence of one or more diseases (nosophobia) should be classified
here.
This syndrome occurs in both men and women, and there are no special familial characteristics (in
contrast to somatization disorder).
Many individuals, especially those with milder forms of the disorder, remain within primary care
or nonpsychiatric medical specialties. Psychiatric referral is often resented, unless accomplished
early in the development of the disorder and with tactful collaboration between physician and
psychiatrist. The degree of associated disability is very variable; some individuals dominate or
manipulate family and social networks as a result of their symptoms, in contrast to a minority who
function almost normally.
Diagnostic guidelines
For a definite diagnosis, both of the following should be present:
(a)persistent belief in the presence of at least one serious physical illness underlying the presenting
symptom or symptoms, even though repeated investigations and examinations have
identified no adequate physical explanation, or a persistent preoccupation with a
presumed deformity or disfigurement;
(b)persistent refusal to accept the advice and reassurance of several different doctors that there is
no physical illness or abnormality underlying the symptoms.
Includes:body dysmorphic disorder
dysmorphophobia (nondelusional)
hypochondriacal neurosis
hypochondriasis
nosophobia
Differential diagnosis. Differentiation from the following disorders is essential:
Somatization disorder. Emphasis is on the presence of the disorder itself and its future
consequences, rather than on the individual symptoms as in somatization disorder. In
hypochondriacal disorder, there is also likely to be preoccupation with only one or two possible
physical disorders, which will be named consistently, rather than with the more numerous and
often changing possibilities in somatization disorder. In hypochondriacal disorder there is no
marked sex
differential rate, nor are there any special familial connotations.
- 132 Depressive
disorders. If depressive symptoms are particularly prominent and precede the
development of hypochondriacal ideas, the depressive disorder may be primary.
Delusional disorders. The beliefs in hypochondriacal disorder do not have the same fixity as those
in depressive and schizophrenic disorders accompanied by somatic delusions. A disorder in which
the patient is convinced that he or she has an unpleasant appearance or is physically misshapen
should be classified under delusional disorder (F22.-).
Anxiety and panic disorders. The somatic symptoms of anxiety are sometimes interpreted as signs
of serious physical illness, but in these disorders the patients are usually reassured by physiological
explanations, and convictions about the presence of physical illness do not develop.
F45.3 Somatoform autonomic dysfunction
The symptoms are presented by the patient as if they were due to a physical disorder of a system
or organ that is largely or completely under autonomic innervation and control, i.e. the
cardiovascular, gastrointestinal, or respiratory system. (Some aspects of the genitourinary system
are also included here.) The most common and striking examples affect the cardiovascular system
("cardiac neurosis"), the respiratory system (psychogenic hyperventilation and hiccough) and the
gastrointestinal system ("gastric neurosis" and "nervous diarrhoea"). The symptoms are usually of
two types, neither of which indicates a physical disorder of the organ or system concerned. The
first type, upon which this diagnosis largely depends, is characterized by complaints based upon
objective signs of autonomic arousal, such as palpitations, sweating, flushing, and tremor. The
second type is characterized by more idiosyncratic, subjective, and nonspecific symptoms, such as
sensations of fleeting aches and pains, burning, heaviness, tightness, and sensations of being
bloated or distended; these are referred by the patient to a specific organ or system (as the
autonomic symptoms may also be). It is the combination of clear autonomic involvement,
additional nonspecific subjective complaints, and persistent referral to a particular organ or system
as the cause of the disorder that gives the characteristic clinical picture.
In many patients with this disorder there will also be evidence of psychological stress, or current
difficulties and problems that appear to be related to the disorder; however, this is not the case in a
substantial proportion of patients who nevertheless clearly fulfil the criteria for this condition.
In some of these disorders, some minor disturbance of physiological function may also be present,
such as hiccough, flatulence, and hyperventilation, but these do not of themselves disturb the
essential physiological function of the relevant organ or system.
Diagnostic guidelines
Definite diagnosis requires all of the following:
(a)symptoms of autonomic arousal, such as palpitations, sweating, tremor, flushing, which are
persistent and troublesome;
(b)additional subjective symptoms referred to a specific organ or system;
(c)preoccupation with and distress about the possibility of a serious (but often unspecified)
disorder of the stated organ or system, which does not respond to repeated explanation
and reassurance by doctors;
(d)no evidence of a significant disturbance of structure or function of the stated system or organ.
Differential diagnosis. Differentiation from generalized anxiety disorder is based on the
predominance of the psychological, components of autonomic arousal, such as fear and anxious
foreboding in generalized anxiety disorder, and the lack of a
consistent physical focus for the other symptoms. In somatization disorders, autonomic symptoms
may occur but they are neither prominent nor persistent in comparison with the many other
sensations and feelings, and the symptoms are not so persistently attributed to one stated organ or
system.
- 133 Excludes:
psychological and behavioural factors associated with disorders or
diseases classified elsewhere (F54)
A fifth character may be used to classify the individual disorders in this group, indicating the organ
or system regarded by the patient as the origin of the symptoms:
F45.30 Heart and cardiovascular system
Includes: cardiac neurosis
Da Costa's syndrome
neurocirculatory asthenia
F45.31 Upper gastrointestinal tract
Includes: gastric neurosis
psychogenic aerophagy, hiccough, dyspepsia, and pylorospasm
F45.32 Lower gastrointestinal tract
Includes: psychogenic flatulence, irritable bowel syndrome, and diarrhoea gas
syndrome
F45.33 Respiratory system
Includes: psychogenic forms of cough and hyperventilation
F45.34 Genitourinary system
Includes: psychogenic increase of frequency of micturition and dysuria
F45.38 Other organ or system
F45.4 Persistent somatoform pain disorder
The predominant complaint is of persistent, severe, and distressing pain, which cannot be
explained fully by a physiological process or a physical disorder. Pain occurs in association with
emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are
the main causative influences. The result is usually a marked increase in support and attention,
either personal or medical.
Pain presumed to be of psychogenic origin occurring during the course of depressive disorder or
schizophrenia should not be included here. Pain due to known or inferred psychophysiological
mechanisms such as muscle tension pain or migraine, but still believed to have a psychogenic
cause, should be coded by the use of F54 (psychological or behavioural factors associated with
disorders or diseases classified elsewhere) plus an additional code from elsewhere in ICD-10
(e.g. migraine, G43.-).
Includes: psychalgia
psychogenic backache or headache
somatoform pain disorder
Differential diagnosis. The commonest problem is to differentiate this disorder from the histrionic
elaboration of organically caused pain. Patients with organic pain for whom a definite physical
diagnosis has not yet been reached may easily become frightened or resentful, with resulting
attention-seeking behaviour. A variety of aches and pains are common in somatization disorders
but are not so persistent or so dominant over the other complaints.
Excludes: backache NOS (M54.9)
- 134 pain
NOS (acute/chronic) (R52.-)
tension-type headache (G44.2)
F45.8 Other somatoform disorders
In these disorders the presenting complaints are not mediated through the autonomic nervous
system, and are limited to specific systems or parts of the body. This is in contrast to the multiple
and often changing complaints of the origin of symptoms and distress found in somatization
disorder (F45.0) and undifferentiated somatoform disorder (F45.1). Tissue damage is not
involved.
Any other disorders of sensation not due to physical disorders, which are closely associated in time
with stressful events or problems, or which result in significantly increased attention for the
patient, either personal or medical, should also be classified here. Sensations of swelling,
movements on the skin, and paraesthesias (tingling and/or numbness) are common examples.
Disorders such as the following should also be included here:
(a)"globus hystericus" (a feeling of a lump in the throat causing dysphagia) and other forms of
dysphagia;
(b)psychogenic torticollis, and other disorders of spasmodic movements (but excluding Tourette's
syndrome);
(c)psychogenic pruritus (but excluding specific skin lesions such as alopecia, dermatitis, eczema, or
urticaria of psychogenic origin (F54));
(d)psychogenic dysmenorrhoea (but excluding dyspareunia (F52.6) and frigidity (F52.0));
(e)teeth-grinding
F45.9 Somatoform disorder, unspecified
Includes: unspecified psychophysiological or psychosomatic disorder
F48 Other neurotic disorders
F48.0 Neurasthenia
Considerable cultural variations occur in the presentation of this disorder; two main types occur,
with substantial overlap. In one type, the main feature is a complaint of increased fatigue after
mental effort, often associated with some decrease in occupational performance or coping
efficiency in daily tasks. The mental fatiguability is typically described as an unpleasant intrusion
of distracting associations or recollections, difficulty in concentrating, and generally inefficient
thinking. In the other type, the emphasis is on feelings of bodily or physical weakness and
exhaustion after only minimal effort, accompanied by a feeling of muscular aches and pains and
inability to relax. In both types, a variety of other unpleasant physical feelings, such as dizziness,
tension headaches, and a sense of general instability, is common. Worry about decreasing mental
and bodily well-being, irritability, anhedonia, and varying minor degrees of both depression and
anxiety are all common. Sleep is often disturbed in its initial and middle phases but hypersomnia
may also be prominent.
Diagnostic guidelines
Definite diagnosis requires the following:
(a)either persistent and distressing complaints of increased fatigue after mental effort, or persistent
and distressing complaints of bodily weakness and exhaustion after minimal effort;
(b)at least two of the following:
- feelings of muscular aches and pains
- dizziness
- tension headaches
- sleep disturbance
- 135 -
inability to relax
- irritability
- dyspepsia;
(c)any autonomic or depressive symptoms present are not sufficiently persistent and severe to fulfil
the criteria for any of the more specific disorders in this classification.
Includes: fatigue syndrome
Differential diagnosis. In many countries neurasthenia is not generally used as a diagnostic
category. Many of the cases so diagnosed in the past would meet the current criteria for depressive
disorder or anxiety disorder. There are, however, cases that fit the description of neurasthenia
better than that of any other neurotic syndrome, and such cases seem to be more frequent in some
cultures than in others. If the diagnostic category of neurasthenia is used, an attempt should be
made first to rule out a depressive illness or an anxiety disorder. Hallmarks of the syndrome are
the patient's emphasis on fatiguability and weakness and concern about lowered mental and
physical efficiency (in contrast to the somatoform disorders, where bodily complaints and
preoccupation with physical disease dominate the picture). If the neurasthenic syndrome develops
in the aftermath of a physical illness (particularly influenza, viral hepatitis, or infectious
mononucleosis), the diagnosis of the latter should also be recorded.
Excludes: asthenia NOS (R53)
burn-out (Z73.0)
malaise and fatigue (R53)
postviral fatigue syndrome (G93.3)
psychasthenia (F48.8)
F48.1 Depersonalization-derealization syndrome
A disorder in which the sufferer complains that his or her mental activity, body, and/or
surroundings are changed in their quality, so as to be unreal, remote, or automatized. Individuals
may feel that they are no longer doing their own thinking, imaging, or remembering; that their
movements and behaviour are somehow not their own; that their body seems lifeless, detached, or
otherwise anomalous; and that their surroundings seem to lack colour and life and appear as
artificial, or as a stage on which people are acting contrived roles. In some cases, they may feel as if
they were viewing themselves from a distance or as if they were dead. The complaint of loss of
emotions is the most frequent among these varied phenomena.
The number of individuals who experience this disorder in a pure or isolated form is small. More
commonly, depersonalization-derealization phenomena occur in the context of depressive
illnesses, phobic disorder, and obsessive-compulsive disorder. Elements of the syndrome may also
occur in mentally healthy individuals in states of fatigue, sensory deprivation, hallucinogen
intoxication, or as a hypnogogic/ hypnopompic phenomenon. The
depersonalization-derealization phenomena are similar to the so-called "near-death experiences"
associated with moments of extreme danger to life.
Diagnostic guidelines
For a definite diagnosis, there must be either or both of (a) and (b), plus (c) and (d):
(a)depersonalization symptoms, i.e. the individual feels that his or her own feelings and/or
experiences are detached, distant, not his or her own, lost, etc;
(b)derealization symptoms, i.e. objects, people, and/or surroundings seem unreal, distant, artificial,
colourless, lifeless, etc;
(c)an acceptance that this is a subjective and spontaneous change, not imposed by outside forces or
other people (i.e. insight);
(d)a clear sensorium and absence of toxic confusional state or epilepsy.
- 136 Differential
diagnosis. The disorder must be differentiated from other disorders in which "change
of personality" is experienced or presented, such as schizophrenia (delusions of transformation or
passivity and control experiences), dissociative disorders (where awareness of change is lacking),
and some instances of early dementia. The preictal aura of temporal lobe epilepsy and some
postictal states may include depersonalization and derealization syndromes as secondary
phenomena.
If the depersonalization-derealization syndrome occurs as part of a diagnosable depressive, phobic,
obsessive-compulsive, or schizophrenic disorder, the latter should be given precedence as the main
diagnosis.
F48.8 Other specified neurotic disorders
This category includes mixed disorders of behaviour, beliefs, and emotions which are of uncertain
etiology and nosological status and which occur with particular frequency in certain cultures;
examples include Dhat syndrome (undue concern about the debilitating effects of the passage of
semen), koro (anxiety and fear that the penis will retract into the abdomen and cause death), and
latah (imitative and automatic response behaviour). The strong association of these syndromes
with locally accepted cultural beliefs and patterns of behaviour indicates that they are probably
best regarded as not delusional.
Includes: Briquet's disorder
Dhat syndrome
koro
latah
occupational neurosis, including writer's cramp
psychasthenia
psychasthenic neurosis
psychogenic syncope
F48.9 Neurotic disorder, unspecified
Includes: neurosis NOS
F50-F59
Behavioural syndromes associated with physiological
disturbances and physical factors
Overview of this block
F50 Eating disorders
F50.0 Anorexia nervosa
F50.1 Atypical anorexia nervosa
F50.2 Bulimia nervosa
F50.3 Atypical bulimia nervosa
F50.4 Overeating associated with other psychological disturbances
F50.5 Vomiting associated with other psychological disturbances
F50.8 Other eating disorders
F50.9 Eating disorder, unspecified
F51 Nonorganic sleep disorders
F51.0 Nonorganic insomnia
F51.1 Nonorganic hypersomnia
F51.2 Nonorganic disorder of the sleep - wake schedule
F51.3 Sleepwalking [somnambulism]
- 137 F51.4
Sleep terrors [night terrors]
F51.5 Nightmares
F51.8 Other nonorganic sleep disorders
F51.9 Nonorganic sleep disorder, unspecified
F52 Sexual dysfunction, not caused by organic disorder or disease
F52.0 Lack or loss of sexual desire
F52.1 Sexual aversion and lack of sexual enjoyment
.10 Sexual aversion
.11 Lack of sexual enjoyment
F52.2 Failure of genital response
F52.3 Orgasmic dysfunction
F52.4 Premature ejaculation
F52.5 Nonorganic vaginismus
F52.6 Nonorganic dyspareunia
F52.7 Excessive sexual drive
F52.8 Other sexual dysfunction, not caused by organic disorder or disease
F52.9 Unspecified sexual dysfunction, not caused by organic disorder or disease
F53 Mental and behavioural disorders associated with the puerperium, not
elsewhere classified
F53.0Mild mental and behavioural disorders associated with the puerperium, not
elsewhere classified
F53.1Severe mental and behavioural disorders associated with the puerperium, not
elsewhere classified
F53.8Other mental and behavioural disorders associated with the puerperium, not
elsewhere classified
F53.9Puerperal mental disorder, unspecified
F54Psychological and behavioural factors associated with disorders or diseases classified
elsewhere
F55Abuse of non-dependence-producing substances
F55.0 Antidepressants
F55.1 Laxatives
F55.2 Analgesics
F55.3 Antacids
F55.4 Vitamins
F55.5 Steroids or hormones
F55.6 Specific herbal or folk remedies
F55.8 Other substances that do not produce dependence
F55.9 Unspecified
F59Unspecified behavioural syndromes associated with physiological
disturbances and physical factors
- 138 F50
Eating disorders
Under the heading of eating disorders, two important and clear-cut
syndromes are described: anorexia nervosa and bulimia nervosa. Less
specific bulimic disorders also deserve place, as does overeating when
it is associated with psychological disturbances. A brief note is
provided on vomiting associated with psychological disturbances.
Excludes: anorexia or loss of appetite NOS (R63.0)
feeding difficulties and mismanagement (R63.3)
feeding disorder in infancy and childhood (F98.2)
pica in children (F98.3)
F50.0 Anorexia nervosa
Anorexia nervosa is a disorder characterized by deliberate weight loss, induced
and/or sustained by the patient. The disorder occurs most commonly in
adolescent girls and young women, but adolescent boys and young men may be
affected more rarely, as may children approaching puberty and older women up
to the menopause. Anorexia nervosa constitutes an independent syndrome in the
following sense:
(a)the clinical features of the syndrome are easily recognized, so that diagnosis is
reliable with a high level of agreement between clinicians;
(b)follow-up studies have shown that, among patients who do not recover, a
considerable number continue to show the same main features of anorexia
nervosa, in a chronic form.
Although the fundamental causes of anorexia nervosa remain elusive, there is
growing evidence that interacting sociocultural and biological factors contribute to
its causation, as do less specific psychological mechanisms and a vulnerability of
personality. The disorder is associated with undernutrition of varying severity,
with resulting secondary endocrine and metabolic changes and disturbances of
bodily function. There remains some doubt as to whether the characteristic
endocrine disorder is entirely due to the undernutrition and the direct effect of
various behaviours that have brought it about (e.g. restricted dietary choice,
excessive exercise and alterations in body composition, induced vomiting and
purgation and the consequent electrolyte disturbances), or whether uncertain
factors are also involved.
Diagnostic guidelines
For a definite diagnosis, all the following are required:
(a)Body weight is maintained at least 15% below that expected (either lost or
never achieved), or Quetelet's body-mass index4
is 17.5 or less.
4
Quetelet's body-mass index = weight (kg) to be
used for age 16 or more
- 139 Prepubertal
patients may show failure to make the expected weight gain
during the period of growth.
(b)The weight loss is self-induced by avoidance of "fattening foods". One or more
of the following may also be present: self-induced vomiting; self-induced
purging; excessive exercise; use of appetite suppressants and/or diuretics.
(c)There is body-image distortion in the form of a specific psychopathology
whereby a dread of fatness persists as an intrusive, overvalued idea and the
patient imposes a low weight threshold on himself or herself.
(d)A widespread endocrine disorder involving the hypothalamic - pituitary gonadal
axis is manifest in women as amenorrhoea and in men as a loss of
sexual interest and potency. (An apparent exception is the persistence of
vaginal bleeds in anorexic women who are receiving replacement
hormonal therapy, most commonly taken as a contraceptive pill.) There
may also be elevated levels of growth hormone, raised levels of cortisol,
changes in the peripheral metabolism of the thyroid hormone, and
abnormalities of insulin secretion.
(e)If onset is prepubertal, the sequence of pubertal events is delayed or even
arrested (growth ceases; in girls the breasts do not develop and there is a
primary amenorrhoea; in boys the genitals remain juvenile). With
recovery, puberty is often completed normally, but the menarche is late.
Differential diagnosis. There may be associated depressive or obsessional
symptoms, as well as features of a personality disorder, which may make
differentiation difficult and/or require the use of more than one diagnostic code.
Somatic causes of weight loss in young patients that must be distinguished
include chronic debilitating diseases, brain tumors, and intestinal disorders such
as Crohn's disease or a malabsorption syndrome.
Excludes: loss of appetite (R63.0)
psychogenic loss of appetite (F50.8)
F50.1 Atypical anorexia nervosa
This term should be used for those individuals in whom one or more of the key
features of anorexia nervosa (F50.0), such as amenorrhoea or significant weight
loss, is absent, but who otherwise present a fairly typical clinical picture. Such
people are usually encountered in psychiatric liaison services in general hospitals
or in primary care. Patients who have all the key symptoms but to only a mild
degree may also be best described by this term. This term should not be used for
eating disorders that resemble anorexia nervosa but that are due to known
physical illness.
F50.2 Bulimia nervosa
Bulimia nervosa is a syndrome characterized by repeated bouts of overeating and
an excessive preoccupation with the control of body weight, leading the patient to
adopt extreme measures so as to mitigate the "fattening" effects of ingested food.
The term should be restricted to the form of the disorder that is related to
[height (m)]2
- 140 anorexia
nervosa by virtue of sharing the same psychopathology. The age and sex
distribution is similar to that of anorexia nervosa, but the age of presentation tends
to be slightly later. The disorder may be viewed as a sequel to persistent anorexia
nervosa (although the reverse sequence may also occur). A previously anorexic
patient may first appear to improve as a result of weight gain and possibly a return
of menstruation, but a pernicious pattern of overeating and vomiting then
becomes established. Repeated vomiting is likely to give rise to disturbances of
body electrolytes, physical complications (tetany, epileptic seizures, cardiac
arrhythmias, muscular weakness), and further severe loss of weight.
Diagnostic guidelines
For a definite diagnosis, all the following are required:
(a)There is a persistent preoccupation with eating, and an irresistible craving for
food; the patient succumbs to episodes of overeating in which large
amounts of food are consumed in short periods of time.
(b)The patient attempts to counteract the "fattening" effects of food by one or
more of the following: self-induced vomiting; purgative abuse, alternating
periods of starvation; use of drugs such as appetite suppressants, thyroid
preparations or diuretics. When bulimia occurs in diabetic patients they
may choose to neglect their insulin treatment.
(c)The psychopathology consists of a morbid dread of fatness and the patient sets
herself or himself a sharply defined weight threshold, well below the
premorbid weight that constitutes the optimum or healthy weight in the
opinion of the physician. There is often, but not always, a history of an
earlier episode of anorexia nervosa, the interval between the two disorders
ranging from a few months to several years. This earlier episode may have
been fully expressed, or may have assumed a minor cryptic form with a
moderate loss of weight and/or a transient phase of amenorrhoea.
Includes: bulimia NOS
hyperorexia nervosa
Differential diagnosis. Bulimia nervosa must be differentiated from:
(a)upper gastrointestinal disorders leading to repeated vomiting (the characteristic
psychopathology is absent);
(b)a more general abnormality of personality (the eating disorder may coexist with
alcohol dependence and petty offenses such as shoplifting);
(c)depressive disorder (bulimic patients often experience depressive symptoms).
F50.3 Atypical bulimia nervosa
This term should be used for those individuals in whom one or more of the key
features listed for bulimia nervosa (F50.2) is absent, but who otherwise present a
fairly typical clinical picture. Most commonly this applies to people with normal
or even excessive weight but with typical periods of overeating followed by
vomiting or purging. Partial syndromes together with depressive symptoms are
- 141 also
not uncommon, but if the depressive symptoms justify a separate diagnosis of
a depressive disorder two separate diagnoses should be made.
Includes: normal weight bulimia
F50.4 Overeating associated with other psychological disturbances
Overeating that has led to obesity as a reaction to distressing events should be
coded here. Bereavements, accidents, surgical operations, and emotionally
distressing events may be followed by a "reactive obesity", especially in
individuals predisposed to weight gain.
Obesity as a cause of psychological disturbance should not be coded here. Obesity
may cause the individual to feel sensitive about his or her appearance and give rise
to a lack of confidence in personal relationships; the subjective appraisal of body
size may be exaggerated. Obesity as a cause of psychological disturbance should
be coded in a category such as F38.- (other mood [affective] disorders), F41.2
(mixed anxiety and depressive disorder), or F48.9 (neurotic disorder, unspecified),
plus a code from E66.- of ICD-10 to indicate the type of obesity.
Obesity as an undesirable effect of long-term treatment with neuroleptic
antidepressants or other type of medication should not be coded here, but under
E66.1 (drug-induced obesity) plus an additional code from Chapter XX (External
causes) of ICD-10, to identify the drug.
Obesity may be the motivation for dieting, which in turn results in minor affective
symptoms (anxiety, restlessness, weakness, and irritability) or, more rarely, severe
depressive symptoms ("dieting depression"). The appropriate code from F30-F39
or F40-F49 should be used to cover the symptoms as above, plus F50.8 (other
eating disorder) to indicate the dieting, plus a code from E66.- to indicate the type
of obesity.
Includes: psychogenic overeating
Excludes: obesity (E66.-)
polyphagia NOS (R63.2)
F50.5 Vomiting associated with other psychological disturbances
Apart from the self-induced vomiting of bulimia nervosa, repeated vomiting may
occur in dissociative disorders (F44.-), in hypochondriacal disorder (F45.2) when
vomiting may be one of several bodily symptoms, and in pregnancy when
emotional factors may contribute to recurrent nausea and vomiting.
Includes: psychogenic hyperemesis gravidarum
psychogenic vomiting
Excludes: nausea and vomiting NOS (R11)
F50.8 Other eating disorders
- 142 Includes:
pica of nonorganic origin in adults
psychogenic loss of appetite
F50.9 Eating disorder, unspecified
F51 Nonorganic sleep disorders
This group of disorders includes:
(a)dyssomnias: primarily psychogenic conditions in which the predominant
disturbance is in the amount, quality, or timing of sleep due to emotional
causes, i.e. insomnia, hypersomnia, and disorder of sleep - wake schedule;
and
(b)parasomnias: abnormal episodic events occurring during sleep; in childhood
these are related mainly to the child's development, while in adulthood
they are predominantly psychogenic, i.e. sleepwalking, sleep terrors, and
nightmares.
This section includes only those sleep disorders in which emotional causes are
considered to be a primary factor. Sleep disorders of organic origin such as
Kleine-Levin syndrome (G47.8) are coded in Chapter VI (G47.-) of ICD-10.
Nonpsychogenic disorders including narcolepsy and cataplexy (G47.4) and
disorders of the sleep - wake schedule (G47.2) are also listed in Chapter VI, as are
sleep apnoea (G47.3) and episodic movement disorders which include nocturnal
myoclonus (G25.3). Finally, enuresis (F98.0) is listed with other emotional and
behavioural disorders with onset specific to childhood and adolescence, while
primary nocturnal enuresis (R33.8), which is considered to be due to a
maturational delay of bladder control during sleep, is listed in Chapter XVIII of
ICD-10 among the symptoms involving the urinary system.
In many cases, a disturbance of sleep is one of the symptoms of another disorder,
either mental or physical. Even when a specific sleep disorder appears to be
clinically independent, a number of associated psychiatric and/or physical factors
may contribute to its occurrence. Whether a sleep disorder in a given individual
is an independent condition or simply one of the features of another disorder
(classified elsewhere in Chapter V or in other chapters of ICD-10) should be
determined on the basis of its clinical presentation and course, as well as of
therapeutic considerations and priorities at the time of the consultation. In any
event, whenever the disturbance of sleep is among the predominant complaints, a
sleep disorder should be diagnosed. Generally, however, it is preferable to list the
diagnosis of the specific sleep disorder along with as many other pertinent
diagnoses as are necessary to describe adequately the psychopathology and/or
pathophysiology involved in a given case.
Excludes: sleep disorders (organic) (G47.-)
F51.0 Nonorganic insomnia
- 143 Insomnia
is a condition of unsatisfactory quantity and/or quality of sleep, which
persists for a considerable period of time. The actual degree of deviation from
what is generally considered as a normal amount of sleep should not be the
primary consideration in the diagnosis of insomnia, because some individuals (the
so-called short sleepers) obtain a minimal amount of sleep and yet do not consider
themselves as insomniacs. Conversely, there are people who suffer immensely
from the poor quality of their sleep, while sleep quantity is judged subjectively
and/or objectively as within normal limits.
Among insomniacs, difficulty falling asleep is the most prevalent complaint,
followed by difficulty staying asleep and early final wakening. Usually, however,
patients report a combination of these complaints. Typically, insomnia develops
at a time of increased life-stress and tends to be more prevalent among women,
older individuals and psychologically disturbed and socioeconomically
disadvantaged people. When insomnia is repeatedly experienced, it can lead to an
increased fear of sleeplessness and a preoccupation with its consequences. This
creates a vicious circle which tends to perpetuate the individual's problem.
Individuals with insomnia describe themselves as feeling tense, anxious, worried,
or depressed at bedtime, and as though their thoughts are racing. They
frequently ruminate over getting enough sleep, personal problems, health status,
and even death. Often they attempt to cope with their tension by taking
medication or alcohol. In the morning, they frequently report feeling physically
and mentally tired; during the day, they characteristically feel depressed, worried,
tense, irritable, and preoccupied with themselves.
Children are often said to have difficulty sleeping when in reality the problem is a
difficulty in the management of bedtime routines (rather than of sleep per se);
bedtime difficulties should not be coded here, but in Chapter XXI of ICD-10
(Z62.0, inadequate parental supervision and control).
Diagnostic guidelines
The following are essential clinical features for a definite diagnosis:
(a)the complaint is either of difficulty falling asleep or maintaining sleep, or of
poor quality of sleep;
(b)the sleep disturbance has occurred at least three times per week for at least 1
month;
(c)there is preoccupation with the sleeplessness and excessive concern over its
consequences at night and during the day;
(d)the unsatisfactory quantity and/or quality of sleep either causes marked
distress or interferes with ordinary activities in daily living.
Whenever unsatisfactory quantity and/or quality of sleep is the patient's only
complaint, the disorder should be coded here. The presence of other psychiatric
symptoms such as depression, anxiety or obsessions does not invalidate the
diagnosis of insomnia, provided that insomnia is the primary complaint or the
chronicity and severity of insomnia cause the patient to perceive it as the primary
- 144 disorder.
Other coexisting disorders should be coded if they are sufficiently
marked and persistent to justify treatment in their own right. It should be noted
that most chronic insomniacs are usually preoccupied with their sleep disturbance
and deny the existence of any emotional problems. Thus, careful clinical
assessment is necessary before ruling out a psychological basis for the complaint.
Insomnia is a common symptom of other mental disorders, such as affective,
neurotic, organic, and eating disorders, substance use, and schizophrenia, and of
other sleep disorders such as nightmares. Insomnia may also be associated with
physical disorders in which there is pain and discomfort or with taking certain
medications. If insomnia occurs only as one of the multiple symptoms of a mental
disorder or a physical condition, i.e. does not dominate the clinical picture, the
diagnosis should be limited to that of the underlying mental or physical disorder.
Moreover, the diagnosis of another sleep disorder, such as nightmare, disorder of
the sleep-wake schedule, sleep apnoea and nocturnal myoclonus, should be made
only when these disorders lead to a reduction in the quantity or quality of sleep.
However, in all of the above instances, if insomnia is one of the major complaints
and is perceived as a condition in itself, the present code should be added after
that of the principal diagnosis.
The present code does not apply to so-called "transient insomnia". Transient
disturbances of sleep are a normal part of everyday life. Thus, a few nights of
sleeplessness related to a psychosocial stressor would not be coded here, but could
be considered as part of an acute stress reaction (F43.0) or adjustment disorder
(F43.2) if accompanied by other clinically significant features.
F51.1 Nonorganic hypersomnia
Hypersomnia is defined as a condition of either excessive daytime sleepiness and
sleep attacks (not accounted for by an inadequate amount of sleep) or prolonged
transition to the fully aroused state upon awakening. When no definite evidence
of organic etiology can be found, this condition is usually associated with mental
disorders. It is often found to be a symptom of a bipolar affective disorder
currently depressed (F31.3, F31.4 or F31.5), a recurrent depressive disorder
(F33.-) or a depressive episode (F32.-). At times, however, the criteria for the
diagnosis of another mental disorder cannot be met, although there is often some
evidence of a psychopathological basis for the complaint.
Some patients will themselves make the connection between their tendency to fall
asleep at inappropriate times and certain unpleasant daytime experiences. Others
will deny such a connection even when a skilled clinician identifies the presence
of these experiences. In other cases, no emotional or other psychological factors
can be readily identified, but the presumed absence of organic factors suggests
that the hypersomnia is most likely of psychogenic origin.
Diagnostic guidelines
The following clinical features are essential for a definite diagnosis:
- 145 (a)excessive
daytime sleepiness or sleep attacks, not accounted for by an
inadequate amount of sleep, and/or prolonged transition to the fully
aroused state upon awakening (sleep drunkenness);
(b)sleep disturbance occurring daily for more than 1 month or for recurrent
periods of shorter duration, causing either marked distress or interference
with ordinary activities in daily living;
(c)absence of auxiliary symptoms of narcolepsy (cataplexy, sleep paralysis,
hypnagogic hallucinations) or of clinical evidence for sleep apnoea
(nocturnal breath cessation, typical intermittent snorting sounds, etc.);
(d)absence of any neurological or medical condition of which daytime somnolence
may be symptomatic.
If hypersomnia occurs only as one of the symptoms of a mental disorder, such as
an affective disorder, the diagnosis should be that of the underlying disorder. The
diagnosis of psychogenic hypersomnia should be added, however, if hypersomnia
is the predominant complaint in patients with other mental disorders. When
another diagnosis cannot be made, the present code should be used alone.
Differential diagnosis. Differentiating hypersomnia from narcolepsy is essential.
In narcolepsy (G47.4), one or more auxiliary symptoms such as cataplexy, sleep
paralysis, and hypnagogic hallucinations are usually present; the sleep attacks are
irresistible and more refreshing; and nocturnal sleep is fragmented and curtailed.
By contrast, daytime sleep attacks in hypersomnia are usually fewer per day,
although each of longer duration; the patient is often able to prevent their
occurrence; nocturnal sleep is usually prolonged, and there is a marked difficulty
in achieving the fully aroused state upon awakening (sleep drunkenness).
It is important to differentiate nonorganic hypersomnia from hypersomnia related
to sleep apnoea and other organic hypersomnias. In addition to the symptom of
excessive daytime sleepiness, most patients with sleep apnoea have a history of
nocturnal cessation of breathing, typical intermittent snorting sounds, obesity,
hypertension, impotence, cognitive impairment, nocturnal hypermotility and
profuse sweating, morning headaches and incoordination. When there is a strong
suspicion of sleep apnoea, confirmation of the diagnosis and quantification of the
apnoeic events by means of sleep laboratory recordings should be considered.
Hypersomnia due to a definable organic cause (encephalitis, meningitis,
concussion and other brain damage, brain tumours, cerebrovascular lesions,
degenerative and other neurologic diseases, metabolic disorders, toxic conditions,
endocrine abnormalities, post-radiation syndrome) can be differentiated from
nonorganic hypersomnia by the presence of the insulting organic factor, as
evidenced by the patient's clinical presentation and the results of appropriate
laboratory tests.
F51.2 Nonorganic disorder of the sleep-wake schedule
A disorder of the sleep-wake schedule is defined as a lack of synchrony between
the individual's sleep-wake schedule and the desired sleep-wake schedule for the
environment, resulting in a complaint of either insomnia or hypersomnia. This
disorder may be either psychogenic or of presumed organic origin, depending on
- 146 the
relative contribution of psychological or organic factors. Individuals with
disorganized and variable sleeping and waking times most often present with
significant psychological disturbance, usually in association with various
psychiatric conditions such as personality disorders and affective disorders. In
individuals who frequently change work shifts or travel across time zones, the
circadian dysregulation is basically biological, although a strong emotional
component may also be operating since many such individuals are distressed.
Finally, in some individuals there is a phase advance to the desired sleep-wake
schedule, which may be due to either an intrinsic malfunction of the circadian
oscillator (biological clock) or an abnormal processing of the time-cues that drive
the biological clock (the latter may in fact be related to an emotional and/or
cognitive disturbance).
The present code is reserved for those disorders of the sleep-wake schedule in
which psychological factors play the most important role, whereas cases of
presumed organic origin should be classified under G47.2, i.e. as non-psychogenic
disorders of the sleep-wake schedule. Whether or not psychological factors are of
primary importance and, therefore, whether the present code or G47.2 should be
used is a matter for clinical judgement in each case.
Diagnostic guidelines
The following clinical features are essential for a definite diagnosis:
(a)the individual's sleep-wake pattern is out of synchrony with the sleep-wake
schedule that is normal for a particular society and shared by most people
in the same cultural environment;
(b)insomnia during the major sleep period and hypersomnia during the waking
period are experienced nearly every day for at least 1 month or recurrently
for shorter periods of time;
(c)the unsatisfactory quantity, quality, and timing of sleep cause marked distress
or interfere with ordinary activities in daily living.
Whenever there is no identifiable psychiatric or physical cause of the disorder, the
present code should be used alone. None the less, the presence of psychiatric
symptoms such as anxiety, depression, or hypomania does not invalidate the
diagnosis of a nonorganic disorder of the sleep-wake schedule, provided that this
disorder is predominant in the patient's clinical picture. When other psychiatric
symptoms are sufficiently marked and persistent, the specific mental disorder(s)
should be diagnosed separately.
Includes: psychogenic inversion of circadian, nyctohemeral, or sleep rhythm
F51.3 Sleepwalking [somnambulism]
Sleepwalking or somnambulism is a state of altered consciousness in which
phenomena of sleep and wakefulness are combined. During a sleepwalking
episode the individual arises from bed, usually during the first third of nocturnal
sleep, and walks about, exhibiting low levels of awareness, reactivity, and motor
skill. A sleepwalker will sometimes leave the bedroom and at times may actually
- 147 walk
out of the house, and is thus exposed to considerable risks of injury during
the episode. Most often, however, he or she will return quietly to bed, either
unaided or when gently led by another person. Upon awakening either from the
sleepwalking episode or the next morning, there is usually no recall of the event.
Sleepwalking and sleep terrors (F51.4) are very closely related. Both are
considered as disorders of arousal, particularly arousal from the deepest stages of
sleep (stages 3 and 4). Many individuals have a positive family history for either
condition as well as a personal history of having experienced both. Moreover,
both conditions are much more common in childhood, which indicates the role of
developmental factors in their etiology. In addition, in some cases, the onset of
these conditions coincides with a febrile illness. When they continue beyond
childhood or are first observed in adulthood, both conditions tend to be associated
with significant psychological disturbance; the conditions may also occur for the
first time in old age or in the early stages of dementia. Based upon the clinical and
pathogenetic similarities between sleepwalking and sleep terrors, and the fact that
the differential diagnosis of these disorders is usually a matter of which of the two
is predominant, they have both been considered recently to be part of the same
nosologic continuum. For consistency with tradition, however, as well as to
emphasize the differences in the intensity of clinical manifestations, separate codes
are provided in this classification.
Diagnostic guidelines
The following clinical features are essential for a definite diagnosis:
(a)the predominant symptom is one or more episodes of rising from bed, usually
during the first third of nocturnal sleep, and walking about;
(b)during an episode, the individual has a blank, staring face, is relatively
unresponsive to the efforts of others to influence the event or to
communicate with him or her, and can be awakened only with
considerable difficulty;
(c)upon awakening (either from an episode or the next morning), the individual
has no recollection of the episode;
(d)within several minutes of awakening from the episode, there is no impairment
of mental activity or behaviour, although there may initially be a short
period of some confusion and disorientation;
(e)there is no evidence of an organic mental disorder such as dementia, or a
physical disorder such as epilepsy.
Differential diagnosis. Sleepwalking should be differentiated from psychomotor
epileptic seizures. Psychomotor epilepsy very seldom occurs only at night.
During the epileptic attack the individual is completely unresponsive to
environmental stimuli, and perseverative movements such as swallowing and
rubbing the hands are common. The presence of epileptic discharges in the EEG
confirms the diagnosis, although a seizure disorder does not preclude coexisting
sleepwalking.
- 148 Dissociative
fugue (see F44.1) must also be differentiated from sleepwalking. In
dissociative disorders the episodes are much longer in duration and patients are
more alert and capable of complex and purposeful behaviours. Further, these
disorders are rare in children and typically begin during the hours of wakefulness.
F51.4 Sleep terrors [night terrors]
Sleep terrors or night terrors are nocturnal episodes of extreme terror and panic
associated with intense vocalization, motility, and high levels of autonomic
discharge. The individual sits up or gets up with a panicky scream, usually
during the first third of nocturnal sleep, often rushing to the door as if trying to
escape, although he or she very seldom leaves the room. Efforts of others to
influence the sleep terror event may actually lead to more intense fear, since the
individual not only is relatively unresponsive to such efforts but may become
disoriented for a few minutes. Upon awaking there is usually no recollection of
the episode. Because of these clinical characteristics, individuals are at great risk
of injury during the episodes of sleep terrors.
Sleep terrors and sleepwalking (F51.3) are closely related: genetic, developmental,
organic, and psychological factors all play a role in their development, and the two
conditions share the same clinical and pathophysiological characteristics. On the
basis of their many similarities, these two conditions have been considered
recently to be part of the same nosologic continuum.
Diagnostic guidelines
The following clinical features are essential for a definite diagnosis:
(a)the predominant symptom is that one or more episodes of awakening from
sleep begin with a panicky scream, and are characterized by intense
anxiety, body motility, and autonomic hyperactivity, such as tachycardia,
rapid breathing, dilated pupils, and sweating;
(b)these repeated episodes typically last 1-10 minutes and usually occur during the
first third of nocturnal sleep;
(c)there is relative unresponsiveness to efforts of others to influence the sleep
terror event and such efforts are almost invariably followed by at least
several minutes of disorientation and perseverative movements;
(d)recall of the event, if any, is minimal (usually limited to one or two fragmentary
mental images);
(e)there is no evidence of a physical disorder, such as brain tumour or epilepsy.
Differential diagnosis. Sleep terrors should be differentiated from nightmares.
The latter are the common "bad dreams" with limited, if any, vocalization and
body motility. In contrast to sleep terrors, nightmares occur at any time of the
night, and the individual is quite easy to arouse and has a very detailed and vivid
recall of the event.
In differentiating sleep terrors from epileptic seizures, the physician should keep
in mind that seizures very seldom occur only during the night; an abnormal
clinical EEG, however, favours the diagnosis of epilepsy.
- 149 F51.5
Nightmares
Nightmares are dream experiences loaded with anxiety or fear, of which the
individual has very detailed recall. The dream experiences are extremely vivid
and usually include themes involving threats to survival, security, or self-esteem.
Quite often there is a recurrence of the same or similar frightening nightmare
themes. During a typical episode there is a degree of autonomic discharge but no
appreciable vocalization or body motility. Upon awakening, the individual
rapidly becomes alert and oriented. He or she can fully communicate with others,
usually giving a detailed account of the dream experience both immediately and
the next morning.
In children, there is no consistently associated psychological disturbance, as
childhood nightmares are usually related to a specific phase of emotional
development. In contrast, adults with nightmares are often found to have
significant psychological disturbance, usually in the form of a personality disorder.
The use of certain psychotropic drugs such as reserpine, thioridazine, tricyclic
antidepressants, and benzodiazepines has also been found to contribute to the
occurrence of nightmares. Moreover, abrupt withdrawal of drugs such as
non-benzodiazepine hypnotics, which suppress REM sleep (the stage of sleep
related to dreaming), may lead to enhanced dreaming and nightmare through
REM rebound.
Diagnostic guidelines
The following clinical features are essential for a definite diagnosis:
(a)awakening from nocturnal sleep or naps with detailed and vivid recall of
intensely frightening dreams, usually involving threats to survival, security,
or self-esteem; the awakening may occur at any time during the sleep
period, but typically during the second half;
(b)upon awakening from the frightening dreams, the individual rapidly becomes
oriented and alert;
(c)the dream experience itself, and the resulting disturbance of sleep, cause
marked distress to the individual.
Includes: dream anxiety disorder
Differential diagnosis. It is important to differentiate nightmares from sleep
terrors. In the latter, the episodes occur during the first third of the sleep period
and are marked by intense anxiety, panicky screams, excessive body motility, and
extreme autonomic discharge. Further, in sleep terrors there is no detailed
recollection of the dream, either immediately following the episode or upon
awakening in the morning.
F51.8 Other nonorganic sleep disorders
F51.9 Nonorganic sleep disorder, unspecified
- 150 Includes:
emotional sleep disorder NOS
F52 Sexual dysfunction, not caused by organic disorder or disease
Sexual dysfunction covers the various ways in which an individual is unable to
participate in a sexual relationship as he or she would wish. There may be lack of
interest, lack of enjoyment, failure of the physiological responses necessary for
effective sexual interaction (e.g. erection), or inability to control or experience
orgasm.
Sexual response is a psychosomatic process; and both psychological and
somatic processes are usually involved in the causation of sexual dysfunction. It
may be possible to identify an unequivocal psychogenic or organic etiology, but
more commonly, particularly with such problems as erectile failure or
dyspareunia, it is difficult to ascertain the relative importance of psychological
and/or organic factors. In such cases, it is appropriate to categorize the condition
as being of either mixed or uncertain etiology.
Some types of dysfunction (e.g. lack of sexual desire) occur in both men
and women. Women, however, tend to present more commonly with complaints
about the subjective quality of the sexual experience (e.g. lack of enjoyment or
interest) rather than failure of a specific response. The complaint of orgasmic
dysfunction is not unusual, but when one aspect of a women's sexual response is
affected, others are also likely to be impaired. For example, if a woman is unable
to experience orgasm, she will often find herself unable to enjoy other aspects of
lovemaking and will thus lose much of her sexual appetite. Men, on the other
hand, though complaining of failure of a specific response such as erection or
ejaculation, often report a continuing sexual appetite. It is therefore necessary to
look beyond the presenting complaint to find the most appropriate diagnostic
category.
Excludes: Dhat syndrome (F48.8)
koro (F48.8)
F52.0 Lack or loss of sexual desire
Loss of sexual desire is the principal problem and is not secondary to other sexual
difficulties, such as erectile failure or dyspareunia. Lack of sexual desire does not
preclude sexual enjoyment or arousal, but makes the initiation of sexual activity
less likely.
Includes: frigidity
hypoactive sexual desire disorder
F52.1 Sexual aversion and lack of sexual enjoyment
F52.10 Sexual aversion
The prospect of sexual interaction with a partner is associated with strong
negative feelings and produces sufficient fear or anxiety that sexual activity is
avoided.
- 151 F52.11
Lack of sexual enjoyment
Sexual responses occur normally and orgasm is experienced but there is a lack of
appropriate pleasure. This complaint is much more common in women than in
men.
Includes: anhedonia (sexual)
F52.2 Failure of genital response
In men, the principal problem is erectile dysfunction, i.e. difficulty in developing or
maintaining an erection suitable for satisfactory intercourse. If erection occurs
normally in certain situations, e.g. during masturbation or sleep or with a different
partner, the causation is likely to be psychogenic. Otherwise, the correct diagnosis of
nonorganic erectile dysfunction may depend on special investigations (e.g.
measurement of nocturnal penile tumescence) or the response to psychological
treatment.
In women, the principal problem is vaginal dryness or failure of lubrication. The cause
can be psychogenic or pathological (e.g. infection) or estrogen deficiency (e.g.
postmenopausal). It is unusual for women to complain primarily of vaginal dryness
except as a symptom of postmenopausal estrogen deficiency.
Includes: female sexual arousal disorder
male erectile disorder
psychogenic impotence
F52.3 Orgasmic dysfunction
Orgasm either does not occur or is markedly delayed. This may be situational (i.e.
occur only in certain situations), in which case etiology is likely to be psychogenic, or
invariable, when physical or constitutional factors cannot be easily excluded except
by a positive response to psychological treatment. Orgasmic dysfunction is more
common in women than in men.
Includes: inhibited orgasm (male) (female)
psychogenic anorgasmy
F52.4 Premature ejaculation
The inability to control ejaculation sufficiently for both partners to enjoy sexual
interaction. In severe cases, ejaculation may occur before vaginal entry or in the
absence of an erection. Premature ejaculation is unlikely to be of organic origin but
can occur as a psychological reaction to organic impairment, e.g. erectile failure or
pain. Ejaculation may also appear to be premature if erection requires prolonged
stimulation, causing the time interval between satisfactory erection and ejaculation
to be shortened; the primary problem in such a case is delayed erection.
F52.5 Nonorganic vaginismus
Spasm of the muscles that surround the vagina, causing occlusion of the vaginal
opening. Penile entry is either impossible or painful. Vaginismus may be a secondary
reaction to some local cause of pain, in which case this category should not be used.
Includes: psychogenic vaginismus
F52.6 Nonorganic dyspareunia
- 152 Dyspareunia
(pain during sexual intercourse) occurs in both women and men. It can
often be attributed to a local pathological condition and should then be
appropriately categorized. In some cases, however, no obvious cause is apparent
and emotional factors may be important. This category is to be used only if there is no
other more primary sexual dysfunction (e.g. vaginismus or vaginal dryness).
Includes: psychogenic dyspareunia
F52.7 Excessive sexual drive
Both men and women may occasionally complain of excessive sexual drive as a
problem is its own right, usually during late teenage or early adulthood. When the
excessive sexual drive is secondary to an affective disorder (F30-F39) or when it occurs
during the early stages of dementia (F00-F03), the underlying disorder should be
coded.
Includes: nymphomania
satyriasis
F52.8 Other sexual dysfunction, not caused by organic disorder or disease
F52.9 Unspecified sexual dysfunction, not caused by organic disorder or disease
F53 Mental and behavioural disorders associated with the puerperium, not
elsewhere classified
This classification should be used only for mental disorders associated with the
puerperium (commencing within 6 weeks of delivery) that do not meet the criteria for
disorders classified elsewhere in this book, either because insufficient information is
available, or because it is considered that special additional clinical features are
present which make classification elsewhere inappropriate. It will usually be possible
to classify mental disorders associated with the puerperium by using two other codes:
the first is from elsewhere in Chapter V(F) and indicates the specific type of mental
disorder (usually affective (F30-F39), and the second is 099.3 (mental diseases and
diseases of the nervous system complicating the puerperium) of ICD-10.
F53.0Mild mental and behavioural disorders associated with the puerperium, not elsewhere
classified
Includes: postnatal depression NOS
postpartum depression NOS
F53.1Severe mental and behavioural disorders associated with the puerperium, not
elsewhere classified
Includes: puerperal psychosis NOS
F53.8 Other mental and behavioural disorders associated with the puerperium, not
elsewhere classified
F53.9 Puerperal mental disorder, unspecified
- 153 F54
Psychological and behavioural factors associated with disorders or
diseases classified elsewhere
This category should be used to record the presence of psychological or
behavioural influences thought to have played a major part in the manifestation of
physical disorders that can be classified by using other chapters of ICD-10. Any
resulting mental disturbances are usually mild and often prolonged (such as
worry, emotional conflict, apprehension), and do not of themselves justify the use
of any of the categories described in the rest of this book. An additional code
should be used to identify the physical disorder. (In the rare instances in which
an overt psychiatric disorder is thought to have caused a physical disorder, a
second additional code should be used to record the psychiatric disorder.)
Examples of the use of this category are: asthma (F54 plus J45.-); dermatitis and
eczema (F54 plus L23-L25); gastric ulcer (F54 plus K25.-); mucous colitis (F54
plus K58.-); ulcerative colitis (F54 plus K51.-); and urticaria (F54 plus L50.-).
Includes: psychological factors affecting physical conditions
Excludes: tension-type headache (G44.2)
F55 Abuse of non-dependence-producing substances
A wide variety of medicaments, proprietary drugs, and folk remedies may be
involved, but three particularly important groups are: psychotropic drugs that do
not produce dependence, such as antidepressants; laxatives; and analgesics that
can be purchased without medical prescription, such as aspirin and paracetamol.
Although the medication may have been medically prescribed or recommended
in the first instance, prolonged, unnecessary, and often excessive dosage develops,
which is facilitated by the availability of the substances without medical
prescription.
Persistent and unjustified use of these substances is usually associated with
unnecessary expense, often involves unnecessary contacts with medical
professionals or supporting staff, and is sometimes marked by the harmful
physical effects of the substances. Attempts to discourage or forbid the use of the
substances are often met with resistance; for laxatives and analgesics this may be
in spite of warnings about (or even the development of) physical problems such as
renal dysfunction or electrolyte disturbances. Although it is usually clear that the
patient has a strong motivation to take the substance, there is no development of
dependence (F1x.2) or withdrawal symptoms (F1x.3) as in the case of the
psychoactive substances specified in F10-F19.
A fourth character may be used to identify the type of substance involved.
F55.0 Antidepressants
(such as tricyclic and tetracyclic antidepressants and monamine oxidase
inhibitors)
- 154 F55.1
Laxatives
F55.2 Analgesics
(such as aspirin, paracetamol, phenacetin, not specified as psycho-active in
F10-F19)
F55.3 Antacids
F55.4 Vitamins
F55.5 Steroids or hormones
F55.6 Specific herbal or folk remedies
F55.8 Other substances that do not produce dependence
(such as diuretics)
F55.9 Unspecified
Excludes: abuse of (dependence-producing) psychoactive substance (F10-F19)
F59 Unspecified behavioural syndromes associated with physiological
disturbances and physical factors
Includes: psychogenic physiological dysfunction NOS
F60-F69
Disorders of adult personality and behaviour
Overview of this block
F60 Specific personality disorders
F60.0 Paranoid personality disorder
F60.1 Schizoid personality disorder
F60.2 Dissocial personality disorder
F60.3 Emotionally unstable personality disorder
.30 Impulsive type
.31 Borderline type
F60.4 Histrionic personality disorder
F60.5 Anankastic personality disorder
F60.6 Anxious [avoidant] personality disorder
F60.7 Dependent personality disorder
F60.8 Other specific personality disorders
F60.9 Personality disorder, unspecified
F61 Mixed and other personality disorders
F61.01 Mixed personality disorders
F61.11 Troublesome personality changes
F62 Enduring personality changes, not attributable to brain damage and
disease
F62.0 Enduring personality change after catastrophic experience
- 155 F62.1
Enduring personality change after psychiatric illness
F62.8 Other enduring personality changes
F62.9 Enduring personality change, unspecified
F63 Habit and impulse disorders
F63.0 Pathological gambling
F63.1 Pathological fire-setting [pyromania]
F63.2 Pathological stealing [kleptomania]
F63.3 Trichotillomania
F63.8 Other habit and impulse disorders
F63.9 Habit and impulse disorder, unspecified
F64 Gender identity disorders
F64.0 Transsexualism
F64.1 Dual-role transvestism
F64.2 Gender identity disorder of childhood
F64.8 Other gender identity disorders
F64.9 Gender identity disorder, unspecified
F65 Disorders of sexual preference
F65.0 Fetishism
F65.1 Fetishistic transvestism
F65.2 Exhibitionism
F65.3 Voyeurism
F65.4 Paedophilia
F65.5 Sadomasochism
F65.6Multiple disorders of sexual preference
F65.8 Other disorders of sexual preference
F65.9 Disorder of sexual preference, unspecified
F66 Psychological and behavioural disorders associated with sexual
development and orientation
F66.0 Sexual maturation disorder
F66.1 Egodystonic sexual orientation
F66.2 Sexual relationship disorder
F66.8 Other psychosexual development disorders
F66.9 Psychosexual development disorder, unspecified
A fifth character may be used to indicate association with:
.x0 Heterosexuality
.x1 Homosexuality
.x2 Bisexuality
.x8 Other, including prepubertal
F68 Other disorders of adult personality and behaviour
F68.0 Elaboration of physical symptoms for psychological reasons
F68.1Intentional production or feigning of symptoms or disabilities either physical or
psychological [factitious disorder]
F68.8Other specified disorders of adult personality and behaviour
F69 Unspecified disorder of adult personality and behaviour
- 156 -
Introduction
This block includes a variety of clinically significant conditions and behaviour
patterns which tend to be persistent and are the expression of an individual's
characteristic lifestyle and mode of relating to self and others. Some of these
conditions and patterns of behaviour emerge early in the course of individual
development, as a result of both constitutional factors and social experience, while
others are acquired later in life.
F60-F62 Specific personality disorders, mixed and other personality
disorders, and enduring personality changes
These types of condition comprise deeply ingrained and enduring behaviour
patterns, manifesting themselves as inflexible responses to a broad range of
personal and social situations. They represent either extreme or significant
deviations from the way the average individual in a given culture perceives,
thinks, feels, and particularly relates to others. Such behaviour patterns tend to be
stable and to encompass multiple domains of behaviour and psychological
functioning. They are frequently, but not always, associated with various degrees
of subjective distress and problems in social functioning and performance.
Personality disorders differ from personality change in their timing and the mode
of their emergence: they are developmental conditions, which appear in childhood
or adolescence and continue into adulthood. They are not secondary to another
mental disorder or brain disease, although they may precede and coexist with
other disorders. In contrast, personality change is acquired, usually during adult
life, following severe or prolonged stress, extreme environmental deprivation,
serious psychiatric disorder, or brain disease or injury (see F07.-).
Each of the conditions in this group can be classified according to its predominant
behavioural manifestations. However, classification in this area is currently
limited to the description of a series of types and subtypes, which are not mutually
exclusive and which overlap in some of their characteristics.
Personality disorders are therefore subdivided according to clusters of traits that
correspond to the most frequent or conspicuous behavioural manifestations. The
subtypes so described are widely recognized as major forms of personality
deviation. In making a diagnosis of personality disorder, the clinician should
consider all aspects of personal functioning, although the diagnostic formulation,
to be simple and efficient, will refer to only those dimensions or traits for which
the suggested thresholds for severity are reached.
The assessment should be based on as many sources of information as possible.
Although it is sometimes possible to evaluate a personality condition in a single
interview with the patient, it is often necessary to have more than one interview
and to collect history data from informants.
- 157 Cyclothymia
and schizotypal disorders were formerly classified with the
personality disorders but are now listed elsewhere (cyclothymia in F30-F39 and
schizotypal disorder in F20-F29), since they seem to have many aspects in
common with the other disorders in those blocks (e.g. phenomena, family
history).
The subdivision of personality change is based on the cause or antecedent of such
change, i.e. catastrophic experience, prolonged stress or strain, and psychiatric
illness (excluding residual schizophrenia, which is classified under F20.5).
It is important to separate personality conditions from the disorders included in
other categories of this book. If a personality condition precedes or follows a
time-limited or chronic psychiatric disorder, both should be diagnosed. Use of
the multiaxial format accompanying the core classification of mental disorders and
psychosocial factors will facilitate the recording of such conditions and disorders.
Cultural or regional variations in the manifestations of personality conditions are
important, but specific knowledge in this area is still scarce. Personality
conditions that appear to be frequently recognized in a given part of the world but
do not correspond to any one of the specified subtypes below may be classified as
"other" personality disorders and identified through a five-character code
provided in an adaptation of this classification for that particular country or
region. Local variations in the manifestations of a personality disorder may also
be reflected in the wording of the diagnostic guidelines set for such conditions.
F60 Specific personality disorders
A specific personality disorder is a severe disturbance in the
characterological constitution and behavioural tendencies of the individual,
usually involving several areas of the personality, and nearly always
associated with considerable personal and social disruption. Personality
disorder tends to appear in late childhood or adolescence and continues to
be manifest into adulthood. It is therefore unlikely that the diagnosis of
personality disorder will be appropriate before the age of 16 or 17 years.
General diagnostic guidelines applying to all personality disorders are
presented below; supplementary descriptions are provided with each of the
subtypes.
Diagnostic guidelines
Conditions not directly attributable to gross brain damage or disease, or to
another psychiatric disorder, meeting the following criteria:
(a)markedly disharmonious attitudes and behaviour, involving usually
several areas of functioning, e.g. affectivity, arousal, impulse control,
ways of perceiving and thinking, and style of relating to others;
(b)the abnormal behaviour pattern is enduring, of long standing, and not
limited to episodes of mental illness;
- 158 (c)the
abnormal behaviour pattern is pervasive and clearly maladaptive to a
broad range of personal and social situations;
(d)the above manifestations always appear during childhood or
adolescence and continue into adulthood;
(e)the disorder leads to considerable personal distress but this may only
become apparent late in its course;
(f)the disorder is usually, but not invariably, associated with significant
problems in occupational and social performance.
For different cultures it may be necessary to develop specific sets of criteria
with regard to social norms, rules and obligations. For diagnosing most of
the subtypes listed below, clear evidence is usually required of the presence
of at least three of the traits or behaviours given in the clinical description.
F60.0 Paranoid personality disorder
Personality disorder characterized by:
(a)excessive sensitiveness to setbacks and rebuffs;
(b)tendency to bear grudges persistently, e.g. refusal to forgive insults and
injuries or slights;
(c)suspiciousness and a pervasive tendency to distort experience by
misconstruing the neutral or friendly actions of others as hostile or
contemptuous;
(d)a combative and tenacious sense of personal rights out of keeping with
the actual situation;
(e)recurrent suspicions, without justification, regarding sexual fidelity of
spouse or sexual partner;
(f)tendency to experience excessive self-importance, manifest in a
persistent self-referential attitude;
(g)preoccupation with unsubstantiated "conspiratorial" explanations of
events both immediate to the patient and in the world at large.
Includes: expansive paranoid, fanatic, querulant and sensitive paranoid
personality (disorder)
Excludes: delusional disorder (F22.-)
schizophrenia (F20.-)
F60.1 Schizoid personality disorder
Personality disorder meeting the following description:
(a)few, if any, activities, provide pleasure;
(b)emotional coldness, detachment or flattened affectivity;
(c)limited capacity to express either warm, tender feelings or anger towards
others;
(d)apparent indifference to either praise or criticism;
(e)little interest in having sexual experiences with another person (taking
into account age);
(f)almost invariable preference for solitary activities;
- 159 (g)excessive
preoccupation with fantasy and introspection;
(h)lack of close friends or confiding relationships (or having only one) and
of desire for such relationships;
(i)marked insensitivity to prevailing social norms and conventions.
Excludes: Asperger's syndrome (F84.5)
delusional disorder (F22.0)
schizoid disorder of childhood (F84.5)
schizophrenia (F20.-)
schizotypal disorder (F21)
F60.2 Dissocial personality disorder
Personality disorder, usually coming to attention because of a gross
disparity between behaviour and the prevailing social norms, and
characterized by:
(a)callous unconcern for the feelings of others;
(b)gross and persistent attitude of irresponsibility and disregard for social
norms, rules and obligations;
(c)incapacity to maintain enduring relationships, though having no
difficulty in establishing them;
(d)very low tolerance to frustration and a low threshold for discharge of
aggression, including violence;
(e)incapacity to experience guilt or to profit from experience, particularly
punishment;
(f)marked proneness to blame others, or to offer plausible rationalizations,
for the behaviour that has brought the patient into conflict with
society.
There may also be persistent irritability as an associated feature. Conduct
disorder during childhood and adolescence, though not invariably present,
may further support the diagnosis.
Includes: amoral, antisocial, asocial, psychopathic, and sociopathic
personality (disorder)
Excludes: conduct disorders (F91.-)
emotionally unstable personality disorder (F60.3)
F60.3 Emotionally unstable personality disorder
A personality disorder in which there is a marked tendency to act
impulsively without consideration of the consequences, together with
affective instability. The ability to plan ahead may be minimal, and
outbursts of intense anger may often lead to violence or "behavioural
explosions"; these are easily precipitated when impulsive acts are criticized
or thwarted by others. Two variants of this personality disorder are
specified, and both share this general theme of impulsiveness and lack of
self-control.
- 160 F60.30
Impulsive type
The predominant characteristics are emotional instability and lack of
impulse control. Outbursts of violence or threatening behaviour are
common, particularly in response to criticism by others.
Includes: explosive and aggressive personality (disorder)
Excludes: dissocial personality disorder (F60.2)
F60.31 Borderline type
Several of the characteristics of emotional instability are present; in
addition, the patient's own self-image, aims, and internal preferences
(including sexual) are often unclear or disturbed. There are usually
chronic feelings of emptiness. A liability to become involved in intense
and unstable relationships may cause repeated emotional crises and may be
associated with excessive efforts to avoid abandonment and a series of
suicidal threats or acts of self-harm (although these may occur without
obvious precipitants).
Includes: borderline personality (disorder)
F60.4 Histrionic personality disorder
Personality disorder characterized by:
(a)self-dramatization, theatricality, exaggerated expression of emotions;
(b)suggestibility, easily influenced by others or by circumstances;
(c)shallow and labile affectivity;
(d)continual seeking for excitement and activities in which the patient is
the centre of attention;
(e)inappropriate seductiveness in appearance or behaviour;
(f)over-concern with physical attractiveness.
Associated features may include egocentricity, self-indulgence, continuous
longing for appreciation, feelings that are easily hurt, and persistent
manipulative behaviour to achieve own needs.
Includes: hysterical and psychoinfantile personality (disorder)
F60.5 Anankastic personality disorder
Personality disorder characterized by:
(a)feelings of excessive doubt and caution;
(b)preoccupation with details, rules, lists, order, organization or schedule;
(c)perfectionism that interferes with task completion;
(d)excessive conscientiousness, scrupulousness, and undue preoccupation
with productivity to the exclusion of pleasure and interpersonal
relationships;
(e)excessive pedantry and adherence to social conventions;
(f)rigidity and stubbornness;
- 161 (g)unreasonable
insistence by the patient that others submit to exactly his
or her way of doing things, or unreasonable reluctance to allow
others to do things;
(h)intrusion of insistent and unwelcome thoughts or impulses.
Includes: compulsive and obsessional personality (disorder)
obsessive-compulsive personality disorder
Excludes: obsessive-compulsive disorder (F42.-)
F60.6 Anxious [avoidant] personality disorder
Personality disorder characterized by:
(a)persistent and pervasive feelings of tension and apprehension;
(b)belief that one is socially inept, personally unappealing, or inferior to
others;
(c)excessive preoccupation with being criticized or rejected in social
situations;
(d)unwillingness to become involved with people unless certain of being
liked; (e)restrictions in lifestyle because of need to have
physical security;
(f)avoidance of social or occupational activities that involve significant
interpersonal contact because of fear of criticism, disapproval, or
rejection.
Associated features may include hypersensitivity to rejection and criticism.
F60.7 Dependent personality disorder
Personality disorder characterized by:
(a)encouraging or allowing others to make most of one's important life
decisions;
(b)subordination of one's own needs to those of others on whom one is
dependent, and undue compliance with their wishes;
(c)unwillingness to make even reasonable demands on the people one
depends on;
(d)feeling uncomfortable or helpless when alone, because of exaggerated
fears of inability to care for oneself;
(e)preoccupation with fears of being abandoned by a person with whom
one has a close relationship, and of being left to care for oneself;
(f)limited capacity to make everyday decisions without an excessive
amount of advice and reassurance from others.
Associated features may include perceiving oneself as helpless,
incompetent, and lacking stamina.
Includes:asthenic, inadequate, passive, and self-defeating personality
(disorder)
- 162 F60.8
Other specific personality disorders
A personality disorder that fits none of the specific rubrics F60.0-F60.7.
Includes: eccentric, "haltlose" type, immature, narcissistic, passiveaggressive,
and psychoneurotic personality (disorder)
F60.9 Personality disorder, unspecified
Includes: character neurosis NOS
pathological personality NOS
F61 Mixed and other personality disorders
This category is intended for personality disorders and abnormalities that
are often troublesome but do not demonstrate the specific patterns of
symptoms that characterize the disorders described in F60.-. As a result
they are often more difficult to diagnose than the disorders in that category.
Two types are specified here by the fourth character; any other different
types should be coded as F60.8.
F61.05 Mixed personality disorders
With features of several of the disorders in F60.- but without a
predominant set of symptoms that would allow a more specific diagnosis.
F61.11 Troublesome personality changes
Not classifiable in F60.- or F62.- and regarded as secondary to a main
diagnosis of a coexisting affective or anxiety disorder.
Excludes: accentuation of personality traits (Z73.1)
F62 Enduring personality changes, not attributable to brain damage
and disease
This group includes disorders of adult personality and behaviour which
develop following catastrophic or excessive prolonged stress, or following a
severe psychiatric illness, in people with no previous personality disorder.
These diagnoses should be made only when there is evidence of a definite
and enduring change in a person's pattern of perceiving, relating to, or
thinking about the environment and the self. The personality change
should be significant and associated with inflexible and maladaptive
behaviour which was not present before the pathogenic experience. The
change should not be a manifestation of another mental disorder, or a
residual symptom of any antecedent mental disorder. Such enduring
personality change is most often seen following devastating traumatic
experience but may also develop in the aftermath of a severe, recurrent, or
5
This four-character code is not included in Chapter
V(F) of ICD-10.
- 163 prolonged
mental disorder. It may be difficult to differentiate between an
acquired personality change and the unmasking or exacerbation of an
existing personality disorder following stress, strain, or psychotic
experience. Enduring personality change should be diagnosed only when
the change represents a permanent and different way of being, which can
be etiologically traced back to a profound, existentially extreme
experience.The diagnosis should not be made if the personality disorder is
secondary to brain damage or disease (category F07.0 should be used
instead).
Excludes:personality and behavioural disorder due to brain disease,
damage and dysfunction (F07.-)
62.0 Enduring personality change after catastrophic experience
Enduring personality change may follow the experience of catastrophic
stress. The stress must be so extreme that it is unnecessary to consider
personal vulnerability in order to explain its profound effect on the
personality. Examples include concentration camp experiences, torture,
disasters, prolonged exposure to life-threatening circumstances (e.g.
hostage situations - prolonged captivity with an imminent possibility of
being killed). Post-traumatic stress disorder (F43.1) may precede this type
of personality change, which may then be seen as a chronic, irreversible
sequel of stress disorder. In other instances, however, enduring personality
change meeting the description given below may develop without an
interim phase of a manifest post-traumatic stress disorder. However, longterm
change in personality following short-term exposure to a lifethreatening
experience such as a car accident should not be included in
this category, since recent research indicates that such a development
depends on a pre-existing psychological vulnerability.
Diagnostic guidelines
The personality change should be enduring and manifest as inflexible and
maladaptive features leading to an impairment in interpersonal, social, and
occupational functioning. Usually the personality change has to be
confirmed by a key informant. In order to make the diagnosis, it is essential
to establish the presence of features not previously seen, such as:
(a) a hostile or mistrustful attitude towards the world;
(b) social withdrawal;
(c) feelings of emptiness or hopelessness;
(d) a chronic feeling of being "on edge", as if constantly threatened
(e) estrangement.
This personality change must have been present for at least 2 years, and
should not be attributable to a pre-existing personality disorder or to a
mental disorder other than post-traumatic stress disorder (F43.1). The
- 164 presence
of brain damage or disease which may cause similar clinical
features should be ruled out.
Includes:personality change after concentration camp experiences,
disasters, prolonged captivity with imminent possibility of
being killed, prolonged exposure to life-threatening
situations such as being a victim of terrorism or torture
Excludes: post-traumatic stress disorder (F43.1)
62.1 Enduring personality change after psychiatric illness
Personality change attributable to the traumatic experience of suffering
from a severe psychiatric illness. The change cannot be explained by preexisting
personality disorder and should be differentiated from residual
schizophrenia and other states of incomplete recovery from an antecedent
mental disorder.
Diagnostic guidelines
The personality change should be enduring and manifest as an inflexible
and maladaptive pattern of experiencing and functioning, leading to longstanding
problems in interpersonal, social, or occupational functioning and
subjective distress. There should be no evidence of a pre-existing
personality disorder that can explain the personality change, and the
diagnosis should not be based on any residual symptoms of the antecedent
mental disorder. The change in personality develops following clinical
recovery from a mental disorder that must have been experienced as
emotionally extremely stressful and shattering to the patient's self-image.
Other people's attitudes or reactions to the patient following the illness are
important in determining and reinforcing his or her perceived level of
stress. This type of personality change cannot be fully understood without
taking into consideration the subjective emotional experience and the
previous personality, its adjustment, and its specific vulnerabilities.
Diagnostic evidence for this type of personality change should include
such clinical features as the following:
(a) excessive dependence on and a demanding attitude towards others;
(b)conviction of being changed or stigmatized by the preceding illness,
leading to an inability to form and maintain close and confiding
personal relationships and to social isolation;
(c)passivity, reduced interests, and diminished involvement in leisure
activities;
(d)persistent complaints of being ill, which may be associated with
hypochondriacal claims and illness behaviour;
(e)dysphoric or labile mood, not due to the presence of a current mental
disorder or antecedent mental disorder with residual affective
symptoms;
- 165 (f)significant
impairment in social and occupational functioning compared
with the premorbid situation.
The above manifestations must have been present over a period of 2 or
more years. The change is not attributable to gross brain damage or
disease. A previous diagnosis of schizophrenia does not preclude the
diagnosis.
62.8 Other enduring personality changes
Includes:enduring personality disorder after experiences not mentioned in
F62.0 and F62.1, such as chronic pain personality syndrome
and enduring personality change after bereavement
62.9 Enduring personality change, unspecified
F63 Habit and impulse disorders
This category includes certain behavioural disorders that are not
classifiable under other rubrics. They are characterized by repeated acts
that have no clear rational motivation and that generally harm the patient's
own interests and those of other people. The patient reports that the
behaviour is associated with impulses to action that cannot be controlled.
The causes of these conditions are not understood; the disorders are
grouped together because of broad descriptive similarities, not because
they are known to share any other important features. By convention, the
habitual excessive use of alcohol or drugs (F10-F19) and impulse and habit
disorders involving sexual (F65.-) or eating (F52.-) behaviour are excluded.
F63.0 Pathological gambling
The disorder consists of frequent, repeated episodes of gambling which
dominate the individual's life to the detriment of social, occupational,
material, and family values and commitments.
Those who suffer from this disorder may put their jobs at risk, acquire
large debts, and lie or break the law to obtain money or evade payment of
debts. They describe an intense urge to gamble, which is difficult to
control, together with preoccupation with ideas and images of the act of
gambling and the circumstances that surround the act. These
preoccupations and urges often increase at times when life is stressful.
This disorder is also called "compulsive gambling" but this term is less
appropriate because the behaviour is not compulsive in the technical sense,
nor is the disorder related to obsessive-compulsive neurosis.
Diagnostic guidelines
- 166 The
essential feature of the disorder is persistently repeated gambling,
which continues and often increases despite adverse social consequences
such as impoverishment, impaired family relationships, and disruption of
personal life.
Includes: compulsive gambling
Differential diagnosis. Pathological gambling should be distinguished
from:
(a)gambling and betting (Z72.6) (frequent gambling for excitement, or in
an attempt to make money; people in this category are likely to curb
their habit when confronted with heavy losses, or other adverse
effects);
(b)excessive gambling by manic patients (F30.-);
(c)gambling by sociopathic personalities (F60.2) (in which there is a wider
persistent disturbance of social behaviour, shown in acts that are
aggressive or in other ways demonstrate a marked lack of concern
for the well-being and feelings of other people).
F63.1 Pathological fire-setting [pyromania]
The disorder is characterized by multiple acts of, or attempts at, setting fire
to property or other objects, without apparent motive, and by a persistent
preoccupation with subjects related to fire and burning. There may also be
an abnormal interest in fire-engines and other fire-fighting equipment, in
other associations of fires, and in calling out the fire service.
Diagnostic guidelines
The essential features are:
(a)repeated fire-setting without any obvious motive such as monetary gain,
revenge, or political extremism;
(b)an intense interest in watching fires burn; and
(c)reported feelings of increasing tension before the act, and intense
excitement immediately after it has been carried out.
Differential diagnosis. Pathological fire-setting should be distinguished
from:
(a)deliberate fire-setting without a manifest psychiatric disorder (in these
cases there is an obvious motive) (Z03.2, observation for suspected
mental disorder);
(b)fire-setting by a young person with conduct disorder (F91.1), where
there is evidence of other disordered behaviour such as stealing,
aggression, or truancy;
(c)fire-setting by an adult with sociopathic personality disorder (F60.2),
where there is evidence of other persistent disturbance of social
- 167 behaviour
such as aggression, or other indications of lack of concern
with the interests and feelings of other people;
(d)fire-setting in schizophrenia (F20.-), when fires are typically started in
response to delusional ideas or commands from hallucinated voices;
(e)fire-setting in organic psychiatric disorders (F00-F09), when fires are
started accidentally as a result of confusion, poor memory, or lack of
awareness of the consequences of the act, or a combination of these
factors.
Dementia or acute organic states may also lead to inadvertent fire-setting;
acute drunkenness, chronic alcoholism or other drug intoxication
(F10-F19) are other causes.
F63.2 Pathological stealing [kleptomania]
The disorder is characterized by repeated failure to resist impulses to steal
objects that are not acquired for personal use or monetary gain. The
objects may instead be discarded, given away, or hoarded.
Diagnostic guidelines
There is an increasing sense of tension before, and a sense of gratification
during and immediately after, the act. Although some effort at
concealment is usually made, not all the opportunities for this are taken.
The theft is a solitary act, not carried out with an accomplice. The
individual may express anxiety, despondency, and guilt between episodes
of stealing from shops (or other premises) but this does not prevent
repetition. Cases meeting this description alone, and not secondary to one
of the disorders listed below, are uncommon.
Differential diagnosis. Pathological stealing should be distinguished from:
(a)recurrent shoplifting without a manifest psychiatric disorder, when the
acts are more carefully planned, and there is an obvious motive of
personal gain (Z03.2, observation for suspected mental disorder);
(b)organic mental disorder (F00-F09), when there is recurrent failure to
pay for goods as a consequence of poor memory and other kinds of
intellectual deterioration;
(c)depressive disorder with stealing (F30-F33); some depressed individuals
steal, and may do so repeatedly as long as the depressive disorder
persists.
F63.3 Trichotillomania
A disorder characterized by noticeable hair loss due to a recurrent failure to
resist impulses to pull out hairs. The hair-pulling is usually preceded by
mounting tension and is followed by a sense of relief or gratification. This
diagnosis should not be made if there is a pre-existing inflammation of the
skin, or if the hairpulling
is in response to a delusion or a hallucination.
- 168 Excludes:
stereotyped movement disorder with hair-plucking (F98.4)
F63.8 Other habit and impulse disorders
This category should be used for other kinds of persistently repeated
maladaptive behaviour that are not secondary to a recognized psychiatric
syndrome, and in which it appears that there is repeated failure to resist
impulses to carry out the behaviour. There is a prodromal period of
tension with a feeling of release at the time of the act.
Includes: intermittent explosive (behaviour) disorder
F63.9 Habit and impulse disorder, unspecified
F64 Gender identity disorders
F64.0 Transsexualism
A desire to live and be accepted as a member of the opposite sex, usually
accompanied by a sense of discomfort with, or inappropriateness of, one's
anatomic sex and a wish to have hormonal treatment and surgery to make
one's body as congruent as possible with the preferred sex.
Diagnostic guidelines
For this diagnosis to be made, the transsexual identity should have been
present persistently for at least 2 years, and must not be a symptom of another
mental disorder, such as schizophrenia, or associated with any intersex,
genetic, or sex chromosome abnormality.
F64.1 Dual-role transvestism
The wearing of clothes of the opposite sex for part of the individual's existence
in order to enjoy the temporary experience of membership of the opposite
sex, but without any desire for a more permanent sex change or associated
surgical reassignment. No sexual excitement accompanies the cross-dressing,
which distinguishes the disorder from fetishistic transvestism (F65.1).
Includes:gender identify disorder of adolescence or adulthood,
nontranssexual type
Excludes:fetishistic transvestism (F65.1)
F64.2 Gender identity disorder of childhood
Disorders, usually first manifest during early childhood (and always well
before puberty), characterized by a persistent and intense distress about
assigned sex, together with a desire to be (or insistence that one is) of the
other sex. There is a persistent preoccupation with the dress and/or
activities of the opposite sex and/or repudiation of the patient's own sex.
These disorders are thought to be relatively uncommon and should not be
confused with the much more frequent nonconformity wit stereotypic sexrole
behaviour. The diagnosis of gender identify disorder in childhood
requires a profound disturbance of the normal sense of maleness or
femaleness; mere 'tomboyishness' in girls or 'girlish' behaviour in boys is
- 169 not
sufficient. The diagnosis cannot be made when the individual has
reached puberty.
Because gender identity disorder of childhood has many features in
common with the other identity disorders in this section, it has been
classified in F64.- rather than in F90 - F98.
Diagnostic guidelines
The essential diagnostic feature is the child's pervasive and persistent
desire to be (or insistence that he or she is of) the opposite sex to that
assigned, together with an intense rejection of the behaviour, attributes,
and/or attire of the assigned sex. Typically, this is first manifest during the
preschool years; for the diagnosis to be made, the disorder must have been
apparent before puberty. In both sexes, there may be repudiation of the
anatomical structures of their own sex, but this is an uncommon, probably
rare, manifestation. Characteristically, children with a gender identity
disorder deny being disturbed by it, although they may be distressed by
the conflict with the expectations of their family or peers and by the teasing
and/or rejection to which they may be subjected.
More is known about these disorders in boys than in girls. Typically, from
the preschool years onwards, boys are preoccupied with types of play and
other activities stereotypically associated with females, and there may often
be a preference for dressing in girls' or women's clothes. However, such
cross-dressing does not cause sexual excitement (unlike fetishistic
transvestism in adults (F65.1)). They may have a very strong desire to
participate in the games and pastimes of girls, female dolls are often their
favourite toys, and girls are regularly their preferred playmates. Social
ostracism tends to arise during the early years of schooling and is often at a
peak in middle childhood, with humiliating teasing by other boys. Grossly
feminine behaviour may lessen during early adolescence but follow-up
studies indicate that between one-third and two-thirds of boys with gender
identity disorder of childhood show a homosexual orientation during and
after adolescence. However, very few exhibit transsexualism in adult life
(although most adults with transsexualism report having had a gender
identity problem in childhood).
In clinic samples, gender identity disorders are less frequent in girls than in
boys, but it is not known whether this sex ratio applies in the general
population. In girls, as in boys, there is usually an early manifestation of a
preoccupation with behaviour stereotypically associated with the opposite
sex. Typically, girls with these disorders have male companions and show
an avid interest in sports and rough-and-tumble play; they lack interest in
dolls and in taking female roles in make-believe games such as "mothers
and fathers" or playing "house". Girls with a gender identity disorder tend
not to experience the same degree of social ostracism as boys, although
they may suffer from teasing in later childhood or adolescence. Most give
up an exaggerated insistence on male activities and attire as they approach
- 170 adolescence,
but some retain a male identification and go on to show a
homosexual orientation.
Rarely, a gender identity disorder may be associated with a persistent
repudiation of the anatomic structures of the assigned sex. In girls, this
may be manifest by repeated assertions that they have, or will grow, a
penis, by rejection of urination in the sitting position, or by the assertion
that they do not want to grow breasts or to menstruate. In boys, it may be
shown by repeated assertions that they will grow up physically to become a
woman, that penis and testes are disgusting or will disappear, and/or that
it would be better not to have a penis or testes.
Excludes: egodystonic sexual orientation (F66.1)
sexual maturation disorder (F66.0)
F64.8 Other gender identity disorders
F64.9 Gender identity disorder, unspecified
Includes: gender-role disorder NOS
F65 Disorders of sexual preference
Includes: paraphilias
Excludes: problems associated with sexual orientation (F66.-)
F65.0 Fetishism
Reliance on some non-living object as a stimulus for sexual arousal and sexual
gratification. Many fetishes are extensions of the human body, such as articles
of clothing or footware. Other common examples are characterized by some
particular texture such as rubber, plastic, or leather. Fetish objects vary in their
importance to the individual: in some cases they serve simply to enhance
sexual excitement achieved in ordinary ways (e.g. having the partner wear a
particular garment).
Diagnostic guidelines
Fetishism should be diagnosed only if the fetish is the most important source of
sexual stimulation or essential for satisfactory sexual response.
Fetishistic fantasies are common, but they do not amount to a disorder unless
they lead to rituals that are so compelling and unacceptable as to interfere
with sexual intercourse and cause the individual distress.
Fetishism is limited almost exclusively to males.
F65.1 Fetishistic transvestism
The wearing of clothes of the opposite sex principally to obtain sexual
excitement.
- 171 Diagnostic
guidelines
The disorder is to be distinguished from simple fetishism in that the fetishistic
articles of clothing are not only worn, but worn also to create the appearance
of a person of the opposite sex. Usually more than one article is worn and
often a complete outfit, plus wig and makeup. Fetishistic transvestism is
distinguished from transsexual transvestism by its clear association with sexual
arousal and the strong desire to remove the clothing once orgasm occurs and
sexual arousal declines. A history of fetishistic transvestism is commonly
reported as an earlier phase by transsexuals and probably represents a stage
in the development of transsexualism in such cases.
Includes: transvestic fetishism.
F65.2 Exhibitionism
A recurrent or persistent tendency to expose the genitalia to strangers (usually
of the opposite sex) or to people in public places, without inviting or intending
closer contact. There is usually, but not invariably, sexual excitement at the
time of the exposure and the act is commonly followed by masturbation. This
tendency may be manifest only at times of emotional stress or crises,
interspersed with long periods without such overt behaviour.
Diagnostic guidelines
Exhibitionism is almost entirely limited to heterosexual males who expose to
females, adult or adolescent, usually confronting them from a safe distance in
some public place. For some, exhibitionism is their only sexual outlet, but others
continue the habit simultaneously with an active sex life within long-standing
relationships, although their urges may become more pressing at times of
conflict in those relationships. Most exhibitionists find their urges difficult to
control and ego-alien. If the witness appears shocked, frightened, or
impressed, the exhibitionist's excitement is often heightened.
F65.3 Voyeurism
A recurrent or persistent tendency to look at people engaging in sexual or
intimate behaviour such as undressing. This usually leads to sexual excitement
and masturbation and is carried out without the observed people being
aware.
F65.4 Paedophilia
A sexual preference for children, usually of prepubertal or early pubertal age.
Some paedophiles are attracted only to girls, others only to boys, and others
again are interested in both sexes.
Paedophilia is rarely identified in women. Contacts between adults and
sexually mature adolescents are socially disapproved, especially if the
participants are of the same sex, but are not necessarily associated with
paedophilia. An isolated incident, especially if the perpetrator is himself an
adolescent, does not establish the presence of the persistent or predominant
tendency required for the diagnosis. Included among paedophiles, however,
are men who retain a preference for adult sex partners but, because they are
chronically frustrated in achieving appropriate contacts, habitually turn to
children as substitutes. Men who sexually molest their own prepubertal
children occasionally approach other children as well, but in either case their
behaviour is indicative of paedophilia.
- 172 F65.5
Sadomasochism
A preference for sexual activity that involves bondage or the infliction of pain
or humiliation. If the individual prefers to be the recipient of such stimulation
this is called masochism; if the provider, sadism. Often an individual obtains
sexual excitement from both sadistic and masochistic activities.
Mild degrees of sadomasochistic stimulation are commonly used to enhance
otherwise normal sexual activity. This category should be used only if
sadomasochistic activity is the most important source of stimulation or
necessary for sexual gratification.
Sexual sadism is sometimes difficult to distinguish from cruelty in sexual
situations or anger unrelated to eroticism. Where violence is necessary for
erotic arousal, the diagnosis can be clearly established.
Includes: masochism
sadism
F65.6 Multiple disorders of sexual preference
Sometimes more than one disorder of sexual preference occurs in one person
and none has clear precedence. The most common combination is fetishism,
transvestism, and sadomasochism.
F65.8 Other disorders of sexual preference
A variety of other patterns of sexual preference and activity may occur, each
being relatively uncommon. These include such activities as making obscene
telephone calls, rubbing up against people for sexual stimulation in crowded
public places (frotteurism), sexual activity with animals, use of strangulation or
anoxia for intensifying sexual excitement, and a preference for partners with
some particular anatomical abnormality such as an amputated limb.
Erotic practices are too diverse and many too rare or idiosyncratic to justify a
separate term for each. Swallowing urine, smearing faeces, or piercing
foreskin or nipples may be part of the behavioural repertoire in
sadomasochism. Masturbatory rituals of various kinds are common, but the
more extreme practices, such as the insertion of objects into the rectum or
penile urethra, or partial self-strangulation, when they take the place of
ordinary sexual contacts, amount to abnormalities. Necrophilia should also be
coded here.
Includes: frotteurism
necrophilia
F65.9 Disorder of sexual preference, unspecified
Includes: sexual deviation NOS
F66 Psychological and behavioural disorders associated with
sexual development and orientation
Note: Sexual orientation alone is not to be regarded as a disorder.
- 173 The
following five-character codes may be used to indicate variations of
sexual development or orientation that may be problematic for the
individual:
F66.x0 Heterosexual
F66.x1 Homosexual
F66.x2 Bisexual
To be used only when there is clear evidence of sexual attraction to
members of both sexes.
F66.x8 Other, including prepubertal
F66.0 Sexual maturation disorder
The individual suffers from uncertainty about his or her gender identity or
sexual orientation, which causes anxiety or depression. Most commonly
this occurs in adolescents who are not certain whether they are
homosexual, heterosexual, or bisexual in orientation, or in individuals who
after a period of apparently stable sexual orientation, often within a
long-standing relationship, find that their sexual orientation is changing.
F66.1 Egodystonic sexual orientation
The gender identity or sexual preference is not in doubt but the individual
wishes it were different because of associated psychological and
behavioural disorders and may seek treatment in order to change it.
F66.2 Sexual relationship disorder
The gender identity or sexual preference abnormality is responsible for
difficulties in forming or maintaining a relationship with a sexual partner.
F66.8 Other psychosexual development disorders
F66.9 Psychosexual development disorder, unspecified
F68 Other disorders of adult personality and behaviour
F68.0 Elaboration of physical symptoms for psychological reasons
Physical symptoms compatible with and originally due to a confirmed physical
disorder, disease, or disability become exaggerated or prolonged due to the
psychological state of the patient. An attention-seeking (histrionic)
behavioural syndrome develops, which may also contain additional (and
usually nonspecific) complaints that are not of physical origin. The patient is
commonly distressed by this pain or disability and is often preoccupied with
worries, which may be justified, of the possibility of prolonged or progressive
disability or pain. Dissatisfaction with the result of treatment or investigations, or
disappointment with the amount of personal attention received in wards and
clinics may also be a motivating factor. Some cases appear to be clearly
motivated by the possibility of financial compensation following accidents or
injuries, but the syndrome does not necessarily resolve rapidly even after
successful litigation.
- 174 Includes:
compensation neurosis
F68.1 Intentional production or feigning of symptoms or disabilities, either physical or
psychological [factitious disorder]
In the absence of a confirmed physical or mental disorder, disease, or
disability, the individual feigns symptoms repeatedly and consistently. For
physical symptoms this may even extend to self-infliction of cuts or abrasions
to produce bleeding, or to self-injection of toxic substances.The imitation of
pain and the insistence upon the presence of bleeding may be so convincing
and persistent that repeated investigations and operations are performed at
several different hospitals or clinics, in spite of repeatedly negative findings.
The motivation for this behaviour is almost always obscure and presumably
internal, and the condition is best interpreted as a disorder of illness behaviour
and the sick role. Individuals with this pattern of behaviour usually show signs
of a number of other marked abnormalities of personality and relationships.
Malingering, defined as the intentional production or feigning of either
physical or psychological symptoms or disabilities, motivated by external
stresses or incentives, should be coded as Z76.5 of ICD-10, and not by one of
the codes in this book. The commonest external motives for malingering
include evading criminal prosecution. obtaining illicit drugs, avoiding military
conscription or dangerous military duty, and attempts to obtain sickness
benefits or improvements in living conditions such as housing. Malingering is
comparatively common in legal and military circles, and comparatively
uncommon in ordinary civilian life.
Includes: hospital hopper syndrome
Munchhausen's syndrome
peregrinating patient
Excludes: battered baby or child syndrome NOS (T74.1)
factitial dermatitis (unintentionally produced) (L98.1)
malingering (person feigning illness) (Z76.5)
Munchhausen by proxy (child abuse) (T74.8)
F68.8 Other specified disorders of adult personality and behaviour
This category should be used for coding any specified disorder of adult
personality and behaviour that cannot be classified under any one of the
preceding headings.
Includes: character disorder NOS
relationship disorder NOS
F69 Unspecified disorder of adult personality and behaviour
This code should be used only as a last resort, if the presence of a disorder
of adult personality and behaviour can be assumed, but information to
allow its diagnosis and allocation to a specific category is lacking.
F70-F79
Mental retardation
Overview of this block
- 175 F70
Mild mental retardation
F71 Moderate mental retardation
F72 Severe mental retardation
F73 Profound mental retardation
F78 Other mental retardation
F79 Unspecified mental retardation
A fourth character may be used to specify the extent of associated behavioural
impairment:
F7x.0 No, or minimal, impairment of behaviour
F7x.1 Significant impairment of behaviour requiring attention or treatment
F7x.8 Other impairments of behaviour
F7x.9 Without mention of impairment of behaviour
- 176 -
Introduction
Mental retardation is a condition of arrested or incomplete development of the
mind, which is especially characterized by impairment of skills manifested during
the developmental period, which contribute to the overall level of intelligence, i.e.
cognitive, language, motor, and social abilities. Retardation can occur with or
without any other mental or physical disorder. However, mentally retarded
individuals can experience the full range of mental disorders, and the prevalence
of other mental disorders is at least three to four times greater in this population
than in the general population. In addition, mentally retarded individuals are at
greater risk of exploitation and physical/sexual abuse. Adaptive behaviour is
always impaired, but in protected social environments where support is available
this impairment may not be at all obvious in subjects with mild mental
retardation.
A fourth character may be used to specify the extent of the behavioural
impairment, if this is not due to an associated disorder:
F7x.0 No, or minimal, impairment of behaviour
F7x.1 Significant impairment of behaviour requiring attention or treatment
F7x.8 Other impairments of behaviour
F7x.9 Without mention of impairment of behaviour
If the cause of the mental retardation is known, an additional code from ICD-10
should be used (e.g. F72 severe mental retardation plus E00.- (congenital
iodine-deficiency syndrome)).
The presence of mental retardation does not rule out additional diagnoses coded
elsewhere in this book. However, communication difficulties are likely to make it
necessary to rely more than usual for the diagnosis upon objectively observable
symptoms such as, in the case of a depressive episode, psychomotor retardation,
loss of appetite and weight, and sleep disturbance.
Diagnostic guidelines
Intelligence is not a unitary characteristic but is assessed on the basis of a large
number of different, more-or-less specific skills. Although the general tendency is
for all these skills to develop to a similar level in each individual, there can be large
discrepancies, especially in persons who are mentally retarded. Such people may
show severe impairments in one particular area (e.g. language), or may have a
particular area of higher skill (e.g. in simple visuo-spatial tasks) against a
background of severe mental retardation. This presents problems when
determining the diagnostic category in which a retarded person should be
classified. The assessment of intellectual level should be based on whatever
information is available, including clinical findings, adaptive behaviour (judged in
relation to the individual's cultural background), and psychometric test
performance.
- 177 For
a definite diagnosis, there should be a reduced level of intellectual functioning
resulting in diminished ability to adapt to the daily demands of the normal social
environment. Associated mental or physical disorders have a major influence on
the clinical picture and the use made of any skills. The diagnostic category chosen
should therefore be based on global assessments of ability and not on any single
area of specific impairment or skill. The IQ levels given are provided as a guide
and should not be applied rigidly in view of the problems of cross-cultural
validity. The categories given below are arbitrary divisions of a complex
continuum, and cannot be defined with absolute precision. The IQ should be
determined from standardized, individually administered intelligence tests for
which local cultural norms have been determined, and the test selected should be
appropriate to the individual's level of functioning and additional specific
handicapping conditions, e.g. expressive language problems, hearing impairment,
physical involvement. Scales of social maturity and adaptation, again locally
standardized, should be completed if at all possible by interviewing a parent or
care-provider who is familiar with the individual's skills in everyday life. Without
the use of standardized procedures, the diagnosis must be regarded as a
provisional estimate only.
F70 Mild mental retardation
Mildly retarded people acquire language with some delay but most achieve
the ability to use speech for everyday purposes, to hold conversations, and
to engage in the clinical interview. Most of them also achieve full
independence in self-care (eating, washing, dressing, bowel and bladder
control) and in practical and domestic skills, even if the rate of
development is considerably slower than normal. The main difficulties are
usually seen in academic school work, and many have particular problems
in reading and writing. However, mildly retarded people can be greatly
helped by education designed to develop their skills and compensate for
their handicaps. Most of those in the higher ranges of mild mental
retardation are potentially capable of work demanding practical rather than
academic abilities, including unskilled or semiskilled manual labour. In a
sociocultural context requiring little academic achievement, some degree
of mild retardation may not itself represent a problem. However, if there is
also noticeable emotional and social immaturity, the consequences of the
handicap, e.g. inability to cope with the demands of marriage or
child-rearing, or difficulty fitting in with cultural traditions and
expectations, will be apparent.
In general, the behavioural, emotional, and social difficulties of the mildly
mentally retarded, and the needs for treatment and support arising from
them, are more closely akin to those found in people of normal intelligence
than to the specific problems of the moderately and severely retarded. An
organic etiology is being identified in increasing proportions of patients,
although not yet in the majority.
Diagnostic guidelines
- 178 If
the proper standardized IQ tests are used, the range 50 to 69 is indicative
of mild retardation. Understanding and use of language tend to be delayed
to a varying degree, and executive speech problems that interfere with the
development of independence may persist into adult life. An organic
etiology is identifiable in only a minority of subjects. Associated conditions
such as autism, other developmental disorders, epilepsy, conduct disorders,
or physical disability are found in varying proportions. If such disorders
are present, they should be coded independently.
Includes: feeble-mindedness
mild mental subnormality
mild oligophrenia
moron
F71 Moderate mental retardation
Individuals in this category are slow in developing comprehension and use
of language, and their eventual achievement in this area is limited.
Achievement of self-care and motor skills is also retarded, and some need
supervision throughout life. Progress in school work is limited, but a
proportion of these individuals learn the basic skills needed for reading,
writing, and counting. Educational programmes can provide
opportunities for them to develop their limited potential and to acquire
some basic skills; such programmes are appropriate for slow learners with a
low ceiling of achievement. As adults, moderately retarded people are
usually able to do simple practical work, if the tasks are carefully structured
and skilled supervision is provided. Completely independent living in
adult life is rarely achieved. Generally, however, such people are fully
mobile and physically active and the majority show evidence of social
development in their ability to establish contact, to communicate with
others, and to engage in simple social activities.
Diagnostic guidelines
The IQ is usually in the range 35 to 49. Discrepant profiles of abilities are
common in this group, with some individuals achieving higher levels in
visuo-spatial skills than in tasks dependent on language, while others are
markedly clumsy but enjoy social interaction and simple conversation.
The level of development of language is variable: some of those affected
can take part in simple conversations while others have only enough
language to communicate their basic needs. Some never learn to use
language, though they may understand simple instructions and may learn
to use manual signs to compensate to some extent for their speech
disabilities. An organic etiology can be identified in the majority of
moderately mentally retarded people. Childhood autism or other pervasive
developmental disorders are present in a substantial minority, and have a
major effect upon the clinical picture and the type of management needed.
Epilepsy, and neurological and physical disabilities are also common,
- 179 although
most moderately retarded people are able to walk without
assistance. It is sometimes possible to identify other psychiatric conditions,
but the limited level of language development may make diagnosis difficult
and dependent upon information obtained from others who are familiar
with the individual. Any such associated disorders should be coded
independently.
Includes: imbecility
moderate mental subnormality
moderate oligophrenia
F72 Severe mental retardation
This category is broadly similar to that of moderate mental retardation in
terms of the clinical picture, the presence of an organic etiology, and the
associated conditions. The lower levels of achievement mentioned under
F71 are also the most common in this group. Most people in this category
suffer from a marked degree of motor impairment or other associated
deficits, indicating the presence of clinically significant damage to or
maldevelopment of the central nervous system.
Diagnostic guidelines
The IQ is usually in the range of 20 to 34.
Includes: severe mental subnormality
severe oligophrenia
F73 Profound mental retardation
The IQ in this category is estimated to be under 20, which means in
practice that affected individuals are severely limited in their ability to
understand or comply with requests or instructions. Most such individuals
are immobile or severely restricted in mobility, incontinent, and capable at
most of only very rudimentary forms of nonverbal communication. They
possess little or no ability to care for their own basic needs, and require
constant help and supervision.
Diagnostic guidelines
The IQ is under 20. Comprehension and use of language is limited to, at
best, understanding basic commands and making simple requests. The
most basic and simple visuo-spatial skills of sorting and matching may be
acquired, and the affected person may be able with appropriate supervision
and guidance to take a small part in domestic and practical tasks. An
organic etiology can be identified in most cases. Severe neurological or
other physical disabilities affecting mobility are common, as are epilepsy
and visual and hearing impairments. Pervasive developmental disorders in
- 180 their
most severe form, especially atypical autism, are particularly frequent,
especially in those who are mobile.
Includes: idiocy
profound mental subnormality
profound oligophrenia
F78 Other mental retardation
This category should be used only when assessment of the degree of
intellectual retardation by means of the usual procedures is rendered
particularly difficult or impossible by associated sensory or physical
impairments, as in blind, deaf-mute, and severely behaviourally disturbed
or physically disabled people.
F79 Unspecified mental retardation
There is evidence of mental retardation, but insufficient information is
available to assign the patient to one of the above categories.
Includes: mental deficiency NOS
mental subnormality NOS
oligophrenia NOS
F80-F89
Disorders of psychological development
Overview of this block
F80 Specific developmental disorders of speech and language
F80.0 Specific speech articulation disorder
F80.1 Expressive language disorder
F80.2 Receptive language disorder
F80.3 Acquired aphasia with epilepsy [Landau-Kleffner syndrome]
F80.8 Other developmental disorders of speech and language
F80.9 Developmental disorder of speech and language, unspecified
F81 Specific developmental disorders of scholastic skills
F81.0 Specific reading disorder
F81.1 Specific spelling disorder
F81.2 Specific disorder of arithmetical skills
F81.3 Mixed disorder of scholastic skills
F81.8 Other developmental disorders of scholastic skills
F81.9 Developmental disorder of scholastic skills, unspecified
F82 Specific developmental disorder of motor function
F83 Mixed specific developmental disorders
- 181 F84
Pervasive developmental disorders
F84.0 Childhood autism
F84.1 Atypical autism
F84.2 Rett's syndrome
F84.3 Other childhood disintegrative disorder
F84.4Overactive disorder associated with mental retardation and stereotyped
movements
F84.5 Asperger's syndrome
F84.8 Other pervasive developmental disorders
F84.9 Pervasive developmental disorder, unspecified
F88 Other disorders of psychological development
F89 Unspecified disorder of psychological development
- 182 -
Introduction
The disorders included in F80-F89 have the following features in common:
(a)an onset that is invariably during infancy or childhood;
(b)an impairment or delay in the development of functions that are strongly
related to biological maturation of the central nervous system; and
(c)a steady course that does not involve the remissions and relapses that tend to be
characteristic of many mental disorders.
In most cases, the functions affected include language, visuo-spatial skills and/or
motor coordination. It is characteristic for the impairments to lessen progressively
as children grow older (although milder deficits often remain in adult life).
Usually, the history is of a delay or impairment that has been present from as early
as it could be reliably detected, with no prior period of normal development.
Most of these conditions are several times more common in boys than in girls.
It is characteristic of developmental disorders that a family history of similar or
related disorders is common, and there is presumptive evidence that genetic
factors play an important role in the etiology of many (but not all) cases.
Environmental factors often influence the developmental functions affected but in
most cases they are not of paramount influence. However, although there is
generally good agreement on the overall conceptualization of disorders in this
section, the etiology in most cases is unknown and there is continuing uncertainty
regarding both the boundaries and the precise subdivisions of developmental
disorders. Moreover, two types of condition are included in this block that do not
entirely meet the broad conceptual definition outlined above. First, there are
disorders in which there has been an undoubted phase of prior normal
development, such as the childhood disintegrative disorder, the Landau-Kleffner
syndrome, and some cases of autism. These conditions are included because,
although their onset is different, their characteristics and course have many
similarities with the group of developmental disorders; moreover it is not known
whether or not they are etiologically distinct. Second, there are disorders that are
defined primarily in terms of deviance rather than delay in developmental
functions; this applies especially to autism. Autistic disorders are included in this
block because, although defined in terms of deviance, developmental delay of
some degree is almost invariable. Furthermore, there is overlap with the other
developmental disorders in terms of both the features of individual cases and
familiar clustering.
F80 Specific developmental disorders of speech and language
These are disorders in which normal patterns of language acquisition are
disturbed from the early stages of development. The conditions are not
directly attributable to neurological or speech mechanism abnormalities,
sensory impairments, mental retardation, or environmental factors. The
child may be better able to communicate or understand in certain very
- 183 familiar
situations than in others, but language ability in every setting is
impaired.
Differential diagnosis. As with other developmental disorders, the first
difficulty in diagnosis concerns the differentiation from normal variations
in development. Normal children vary widely in the age at which they
first acquire spoken language and in the pace at which language skills
become firmly established. Such normal variations are of little or no
clinical significance, as the great majority of "slow speakers" go on to
develop entirely normally. In sharp contrast, children with specific
developmental disorders of speech and language, although most ultimately
acquire a normal level of language skills, have multiple associated
problems. Language delay is often followed by difficulties in reading and
spelling, abnormalities in interpersonal relationships, and emotional and
behavioural disorders. Accordingly, early and accurate diagnosis of specific
developmental disorders of speech and language is important. There is no
clear-cut demarcation from the extremes of normal variation, but four
main criteria are useful in suggesting the occurrence of a clinically
significant disorder: severity, course, pattern, and associated problems.
As a general rule, a language delay that is sufficiently severe to fall outside
the limits of 2 standard deviations may be regarded as abnormal. Most
cases of this severity have associated problems. The level of severity in
statistical terms is of less diagnostic use in older children, however, because
there is a natural tendency towards progressive improvement. In this
situation the course provides a useful indicator. If the current level of
impairment is mild but there is nevertheless a history of a previously severe
degree of impairment, the likelihood is that the current functioning
represents the sequelae of a significant disorder rather than just normal
variation. Attention should be paid to the pattern of speech and language
functioning; if the pattern is abnormal (i.e. deviant and not just of a kind
appropriate for an earlier phase of development), or if the child's speech or
language includes qualitatively abnormal features, a clinically significant
disorder is likely. Moreover, if a delay in some specific aspect of speech or
language development is accompanied by scholastic deficits (such as
specific retardation in reading or spelling), by abnormalities in
interpersonal relationships, and/or by emotional or behavioural
disturbance, the delay is unlikely to constitute just a normal variation.
The second difficulty in diagnosis concerns the differentiation from mental
retardation or global developmental delay. Because intelligence includes
verbal skills, it is likely that a child whose IQ is substantially below average
will also show language development that is somewhat below average.
The diagnosis of a specific developmental disorder implies that the specific
delay is significantly out of keeping with the general level of cognitive
functioning. Accordingly, when a language delay is simply part of a more
pervasive mental retardation or global developmental delay, a mental
retardation coding (F70-F79) should be used, not an F80.- coding.
However, it is common for mental retardation to be associated with an
- 184 uneven
pattern of intellectual performance and especially with a degree of
language impairment that is more severe than the retardation in nonverbal
skills. When this disparity is of such a marked degree that it is evident in
everyday functioning, a specific developmental disorder of speech and
language should be coded in addition to a coding for mental retardation
(F70-F79).
The third difficulty concerns the differentiation from a disorder secondary
to severe deafness or to some specific neurological or other structural
abnormality. Severe deafness in early childhood will almost always lead to
a marked delay and distortion of language development; such conditions
should not be included here, as they are a direct consequence of the
hearing impairment. However, it is not uncommon for the more severe
developmental disorders of receptive language to be accompanied by
partial selective hearing impairments (especially of high frequencies). The
guideline is to exclude these disorders from F80-F89 if the severity of
hearing loss constitutes a sufficient explanation for the language delay, but
to include them if partial hearing loss is a complicating factor but not a
sufficient direct cause. However, a hard and fast distinction is impossible
to make. A similar principle applies with respect to neurological
abnormalities and structural defects. Thus, an articulation abnormality
directly due to a cleft palate or to a dysarthria resulting from cerebral palsy
would be excluded from this block. On the other hand, the presence of
subtle neurological abnormalities that could not have directly caused the
speech or language delay would not constitute a reason for exclusion.
F80.0 Specific speech articulation disorder
A specific developmental disorder in which the child's use of speech
sounds is below the appropriate level for his or her mental age, but in
which there is a normal level of language skills.
Diagnostic guidelines
The age of acquisition of speech sounds, and the order in which these
sounds develop, show considerable individual variation.
Normal development. At the age of 4 years, errors in speech sound
production are common, but the child is able to be understood easily by
strangers. By the age of 6-7, most speech sounds will be acquired.
Although difficulties may remain with certain sound combinations, these
should not result in any problems of communication. By the age of 11-12
years, mastery of almost all speech sounds should be acquired.
Abnormal development occurs when the child's acquisition of speech
sounds is delayed and/or deviant, leading to: misarticulations in the child's
speech with consequent difficulties for others in understanding him or her;
omissions, distortions, or substitutions of speech sounds; and
- 185 inconsistencies
in the co-occurrence of sounds (i.e. the child may produce
phonemes correctly in some word positions but not in others).
The diagnosis should be made only when the severity of the articulation
disorder is outside the limits of normal variation for the child's mental age;
nonverbal intelligence is within the normal range; expressive and receptive
language skills are within the normal range; the articulation abnormalities
are not directly attributable to a sensory, structural or neurological
abnormality; and the mispronunciations are clearly abnormal in the
context of colloquial usage in the child's subculture.
Includes: developmental articulation disorder
developmental phonological disorder
dyslalia
functional articulation disorder
lalling
Excludes: articulation disorder due to:
aphasia NOS (R47.0)
apraxia (R48.2)
articulation impairments associated with a developmental
disorder of expressive or receptive language (F80.1, F80.2)
cleft palate or other structural abnormalities of the oral
structures involved in speech (Q35-Q38)
hearing loss (H90-H91)
mental retardation (F70-F79)
F80.1 Expressive language disorder
A specific developmental disorder in which the child's ability to use
expressive spoken language is markedly below the appropriate level for his
or her mental age, but in which language comprehension is within normal
limits. There may or may not be abnormalities in articulation.
Diagnostic guidelines
Although considerable individual variation occurs in normal language
development, the absence of single words (or word approximations) by the
age of 2 years, and the failure to generate simple two-word phrases by 3
years, should be taken as significant signs of delay. Later difficulties
include: restricted vocabulary development; overuse of a small set of
general words, difficulties in selecting appropriate words, and word
substitutions; short utterance length; immature sentence structure;
syntactical errors, especially omissions of word endings or prefixes; and
misuse of or failure to use grammatical features such as prepositions,
pronouns, articles, and verb and noun inflexions. Incorrect
overgeneralizations of rules may also occur, as may a lack of sentence
fluency and difficulties in sequencing when recounting past events.
- 186 It
is frequent for impairments in spoken language to be accompanied by
delays or abnormalities in word-sound production.
The diagnosis should be made only when the severity of the delay in the
development of expressive language is outside the limits of normal
variation for the child's mental age, but receptive language skills are within
normal limits (although may often be somewhat below average). The use
of nonverbal cues (such as smiles and gesture) and "internal" language as
reflected in imaginative or make-believe play should be relatively intact,
and the ability to communicate socially without words should be relatively
unimpaired. The child will seek to communicate in spite of the language
impairment and will tend to compensate for lack of speech by use of
demonstration, gesture, mime, or non-speech vocalizations. However,
associated difficulties in peer relationships, emotional disturbance,
behavioural disruption, and/or overactivity and inattention are not
uncommon, particularly in school-age children. In a minority of cases
there may be some associated partial (often selective) hearing loss, but this
should not be of a severity sufficient to account for the language delay.
Inadequate involvement in conversational interchanges, or more general
environmental privation, may play a major or contributory role in the
impaired development of expressive language. Where this is the case, the
environmental causal factor should be noted by means of the appropriate Z
code from Chapter XXI of ICD-10.The impairment in spoken language
should have been evident from infancy without any clear prolonged phase
of normal language usage. However, a history of apparently normal first
use of a few single words, followed by a setback or failure to progress, is
not uncommon.
Includes: developmental dysphasia or aphasia, expressive type
Excludes: acquired aphasia with epilepsy [Landau-Kleffner syndrome]
(F80.3)
developmental aphasia or dysphasia, receptive type (F80.2)
dysphasia and aphasia NOS (R47.0)
elective mutism (F94.0)
mental retardation (F70-F79)
pervasive developmental disorders (F84.-)
F80.2 Receptive language disorder
A specific developmental disorder in which the child's understanding of
language is below the appropriate level for his or her mental age. In almost
all cases, expressive language is markedly disturbed and abnormalities in
word-sound production are common.
Diagnostic guidelines
Failure to respond to familiar names (in the absence of nonverbal clues) by
the first birthday, inability to identify at least a few common objects by 18
months, or failure to follow simple, routine instructions by the age of 2
years should be taken as significant signs of delay. Later difficulties
- 187 include
inability to understand grammatical structures (negatives,
questions, comparatives, etc.), and lack of understanding of more subtle
aspects of language (tone of voice, gesture, etc.).
The diagnosis should be made only when the severity of the delay in
receptive language is outside the normal limits of variation for the child's
mental age, and when the criteria for a pervasive developmental disorder
are not met. In almost all cases, the development of expressive language is
also severely delayed and abnormalities in word-sound production are
common. Of all the varieties of specific developmental disorders of speech
and language, this has the highest rate of associated
socio-emotional-behavioural disturbance. Such disturbances do not take
any specific form, but hyperactivity and inattention, social ineptness and
isolation from peers, and anxiety, sensitivity, or undue shyness are all
relatively frequent. Children with the most severe forms of receptive
language impairment may be somewhat delayed in their social
development, may echo language that they do not understand, and may
show somewhat restricted interest patterns. However, they differ from
autistic children in usually showing normal social reciprocity, normal
make-believe play, normal use of parents for comfort, near-normal use of
gesture, and only mild impairments in nonverbal communication. Some
degree of high-frequency hearing loss is not infrequent, but the degree of
deafness is not sufficient to account for the language impairment.
Includes: congenital auditory imperception
developmental aphasia or dysphasia, receptive type
developmental Wernicke's aphasia
word deafness
Excludes: acquired aphasia with epilepsy [Landau-Kleffner syndrome]
(F80.3)
autism (F84.0, F84.1)
dysphasia and aphasia, NOS (R47.0) or expressive type
(F80.1)
elective mutism (F94.0)
language delay due to deafness (H90-H91)
mental retardation (F70-F79)
F80.3 Acquired aphasia with epilepsy [Landau-Kleffner syndrome]
A disorder in which the child, having previously made normal progress in
language development, loses both receptive and expressive language skills
but retains general intelligence. Onset of the disorder is accompanied by
paroxysmal abnormalities on the EEG (almost always from the temporal
lobes, usually bilateral, but often with more widespread disturbance), and
in the majority of cases also by epileptic seizures. Typically the onset is
between the ages of 3 and 7 years but the disorder can arise earlier or later
in childhood. In a quarter of cases the loss of language occurs gradually
over a period of some months, but more often the loss is abrupt, with skills
being lost over days or weeks. The temporal association between onset of
- 188 seizures
and loss of language is rather variable, with either one preceding
the other by a few months to 2 years. It is highly characteristic that the
impairment of receptive language is profound, with difficulties in auditory
comprehension often being the first manifestation of the condition. Some
children become mute, some are restricted to jargon-like sounds, and some
show milder deficits in word fluency and output often accompanied by
misarticulations. In a few cases voice quality is affected, with a loss of
normal inflexions. Sometimes language functions appear fluctuating in
the early phases of the disorder. Behavioural and emotional disturbances
are quite common in the months after the initial language loss, but they
tend to improve as the child acquires some means of communication.
The etiology of the condition is not known but the clinical characteristics
suggest the possibility of an inflammatory encephalitic process. The
course of the disorder is quite variable: about two-thirds of the children are
left with a more or less severe receptive language deficit and about a third
make a complete recovery.
Excludes: acquired aphasia due to cerebral trauma, tumour or other
known
disease process
autism (F84.0, F84.1)
other disintegrative disorder of childhood (F84.3)
F80.8 Other developmental disorders of speech and language
Includes: lisping
F80.9 Developmental disorder of speech and language, unspecified
This category should be avoided as far as possible and should be used only
for unspecified disorders in which there is significant impairment in the
development of speech or language that cannot be accounted for by mental
retardation, or by neurological, sensory or physical impairments that
directly affect speech or language.
Includes: language disorder NOS
F81 Specific developmental disorders of scholastic skills
The concept of specific developmental disorders of scholastic skills is
directly comparable to that of specific developmental disorders of speech
and language (see F80.-) and essentially the same issues of definition and
measurement apply. These are disorders in which the normal patterns of
skill acquisition are disturbed from the early stages of development. They
are not simply a consequence of a lack of opportunity to learn, nor are they
due to any form of acquired brain trauma or disease. Rather, the disorders
are thought to stem from abnormalities in cognitive processing that derive
largely from some type of biological dysfunction. As with most other
- 189 developmental
disorders, the conditions are substantially more common in
boys than in girls.
Five kinds of difficulty arise in diagnosis. First, there is the need to
differentiate the disorders from normal variations in scholastic
achievement. The considerations are similar to those in language
disorders, and the same criteria are proposed for the assessment of
abnormality (with the necessary modifications that arise from evaluation of
scholastic achievement rather than language). Second, there is the need to
take developmental course into account. This is important for two
different reasons:
(a)Severity: the significance of one year's retardation in reading at age 7
years is quite different from that of one year's retardation at 14
years.
(b)Change in pattern: it is common for a language delay in the preschool
years to resolve so far as spoken language is concerned but to be
followed by a specific reading retardation which, in turn,
diminishes in adolescence; the principal problem remaining in early
adulthood is a severe spelling disorder. The condition is the same
throughout but the pattern alters with increasing age; the diagnostic
criteria need to take into account this developmental change.
Third, there is the difficulty that scholastic skills have to be taught and
learned: they are not simply a function of biological maturation. Inevitably
a child's level of skills will depend on family circumstances and schooling,
as well as on his or her own individual characteristics. Unfortunately,
there is no straightforward and unambiguous way of differentiating
scholastic difficulties due to lack of adequate experiences from those due to
some individual disorder. There are good reasons for supposing that the
distinction is real and clinically valid but the diagnosis in individual cases is
difficult. Fourth, although research findings provide support for the
hypothesis of underlying abnormalities in cognitive processing, there is no
easy way in the individual child to differentiate those that cause reading
difficulties from those that derive from or are associated with poor reading
skills. The difficulty is compounded by the finding that reading disorders
may stem from more than one type of cognitive abnormality. Fifth, there
are continuing uncertainties over the best way of subdividing the specific
developmental disorders of scholastic skills.
Children learn to read, write, spell, and perform arithmetical computations
when they are introduced to these activities at home and at school.
Countries vary widely in the age at which formal schooling is started, in
the syllabus followed within schools, and hence in the skills that children
are expected to have acquired by different ages. This disparity of
expectations is greater during elementary or primary school years (i.e. up
to age about 11 years) and complicates the issue of devising operational
definitions of disorders of scholastic skills that have cross-national validity.
- 190 Nevertheless,
within all education settings, it is clear that each
chronological age group of schoolchildren contains a wide spread of
scholastic attainments and that some children are underachieving in
specific aspects of attainment relative to their general level of intellectual
functioning.
Specific developmental disorders of scholastic skills (SDDSS) comprise
groups of disorders manifested by specific and significant impairments in
learning of scholastic skills. These impairments in learning are not the
direct result of other disorders (such as mental retardation, gross
neurological deficits, uncorrected visual or auditory problems, or emotional
disturbances), although they may occur concurrently with such conditions.
SDDSS frequently occur in conjunction with other clinical syndromes
(such as attention deficit disorder or conduct disorder) or other
developmental disorders (such as specific developmental disorder of motor
function or specific developmental disorders of speech and language).
The etiology of SDDSS is not known, but there is an assumption of the
primacy of biological factors which interact with nonbiological factors
(such as opportunity for learning and quality of teaching) to produce the
manifestations. Although these disorders are related to biological
maturation, there is no implication that children with these disorders are
simply at the lower end of a normal continuum and will therefore "catch
up" with time. In many instances, traces of these disorders may continue
through adolescence into adulthood. Nevertheless, it is a necessary
diagnostic feature that the disorders were manifest in some form during
the early years of schooling. Children can fall behind in their scholastic
performance at a later stage in their educational careers (because of lack of
interest, poor teaching, emotional disturbance, an increase or change in
pattern of task demands, etc.), but such problems do not form part of the
concept of SDDSS.
Diagnostic guidelines
There are several basic requirements for the diagnosis of any of the specific
developmental disorders of scholastic skills. First, there must be a
clinically significant degree of impairment in the specified scholastic skill.
This may be judged on the basis of severity as defined in scholastic terms
(i.e. a degree that may be expected to occur in less than 3% of
schoolchildren); on developmental precursors (i.e. the scholastic difficulties
were preceded by developmental delays or deviance - most often in speech
or language - in the preschool years); on associated problems (such as
inattention, overactivity, emotional disturbance, or conduct difficulties); on
pattern (i.e. the presence of qualitative abnormalities that are not usually
part of normal development); and on response (i.e. the scholastic
difficulties do not rapidly and readily remit with increased help at home
and/or at school).
- 191 Second,
the impairment must be specific in the sense that it is not solely
explained by mental retardation or by lesser impairments in general
intelligence. Because IQ and scholastic achievement do not run exactly in
parallel, this distinction can be made only on the basis of individually
administered standardized tests of achievement and IQ that are
appropriate for the relevant culture and educational system. Such tests
should be used in connection with statistical tables that provide data on the
average expected level of achievement for any given IQ level at any given
chronological age. This last requirement is necessary because of the
importance of statistical regression effects: diagnoses based on subtractions
of achievement age from mental age are bound to be seriously misleading.
In routine clinical practice, however, it is unlikely that these requirements
will be met in most instances. Accordingly, the clinical guideline is simply
that the child's level of attainment must be very substantially below that
expected for a child of the same mental age.
Third, the impairment must be developmental, in the sense that it must
have been present during the early years of schooling and not acquired
later in the educational process. The history of the child's school progress
should provide evidence on this point.
Fourth, there must be no external factors that could provide a sufficient
reason for the scholastic difficulties. As indicated above, a diagnosis of
SDDSS should generally rest on positive evidence of clinically significant
disorder of scholastic achievement associated with factors intrinsic to the
child's development. To learn effectively, however, children must have
adequate learning opportunities. Accordingly, if it is clear that the poor
scholastic achievement is directly due to very prolonged school absence
without teaching at home or to grossly inadequate education, the disorders
should not be coded here. Frequent absences from school or educational
discontinuities resulting from changes in school are usually not sufficient
to give rise to scholastic retardation of the degree necessary for diagnosis of
SDDSS. However, poor schooling may complicate or add to the problem,
in which case the school factors should be coded by means of a Z code
from Chapter XXI of ICD-10.
Fifth, the SDDSS must not be directly due to uncorrected visual or
hearing impairments.
Differential diagnosis. It is clinically important to differentiate between
SDDSS that arise in the absence of any diagnosable neurological disorder
and those that are secondary to some neurological condition such as
cerebral palsy. In practice this differentiation is often difficult to make
(because of the uncertain significance of multiple "soft" neurological signs),
and research findings do not show any clear-cut differentiation in either
the pattern or course of SDDSS according to the presence or absence of
overt neurological dysfunction. Accordingly, although this does not form
part of the diagnostic criteria, it is necessary that the presence of any
- 192 associated
disorder be separately coded in the appropriate neurological
section of the classification.
F81.0 Specific reading disorder
The main feature of this disorder is a specific and significant impairment in
the development of reading skills, which is not solely accounted for by
mental age, visual acuity problems, or inadequate schooling. Reading
comprehension skill, reading word recognition, oral reading skill, and
performance of tasks requiring reading may all be affected. Spelling
difficulties are frequently associated with specific reading disorder and
often remain into adolescence even after some progress in reading has been
made. Children with specific reading disorder frequently have a history of
specific developmental disorders of speech and language, and
comprehensive assessment of current language functioning often reveals
subtle contemporaneous difficulties. In addition to academic failure, poor
school attendance and problems with social adjustment are frequent
complications, particularly in the later elementary and secondary school
years. The condition is found in all known languages, but there is
uncertainty as to whether or not its frequency is affected by the nature of
the language and of the written script.
Diagnostic guidelines
The child's reading performance should be significantly below the level
expected on the basis of age, general intelligence, and school placement.
Performance is best assessed by means of an individually administered,
standardized test of reading accuracy and comprehension. The precise
nature of the reading problem depends on the expected level of reading,
and on the language and script. However, in the early stages of learning an
alphabetic script, there may be difficulties in reciting the alphabet, in
giving the correct names of letters, in giving simple rhymes for words, and
in analysing or categorizing sounds (in spite of normal auditory acuity).
Later, there may be errors in oral reading skills such as shown by:
(a)omissions, substitutions, distortions, or additions of words or parts of
words;
(b) slow reading rate;
(c)false starts, long hesitations or "loss of place" in text, and inaccurate
phrasing; and
(d)reversals of words in sentences or of letters within words.
There may also be deficits in reading comprehension, as shown by, for
example:
(e)an inability to recall facts read;
(f)inability to draw conclusions or inferences from material read; and
(g)use of general knowledge as background information rather than of
information from a particular story to answer questions about a
story read.
- 193 In
later childhood and in adult life, it is common for spelling difficulties to
be more profound than the reading deficits. It is characteristic that the
spelling difficulties often involve phonetic errors, and it seems that both the
reading and spelling problems may derive in part from an impairment in
phonological analysis. Little is known about the nature or frequency of
spelling errors in children who have to read non-phonetic languages, and
little is known about the types of error in non-alphabetic scripts.
Specific developmental disorders of reading are commonly preceded by a
history of disorders in speech or language development. In other cases,
children may pass language milestones at the normal age but have
difficulties in auditory processing as shown by problems in sound
categorization, in rhyming, and possibly by deficits in speech sound
discrimination, auditory sequential memory, and auditory association. In
some cases, too, there may be problems in visual processing (such as in
letter discrimination); however, these are common among children who
are just beginning to learn to read and hence are probably not directly
causally related to the poor reading. Difficulties in attention, often
associated with overactivity and impulsivity, are also common. The
precise pattern of developmental difficulties in the preschool period varies
considerably from child to child, as does their severity; nevertheless such
difficulties are usually (but not invariably) present.
Associated emotional and/or behavioural disturbances are also common
during the school-age period. Emotional problems are more common
during the early school years, but conduct disorders and hyperactivity
syndromes are most likely to be present in later childhood and adolescence.
Low self-esteem is common and problems in school adjustment and in
peer relationships are also frequent.
Includes: "backward reading"
developmental dyslexia
specific reading retardation
spelling difficulties associated with a reading disorder
Excludes: acquired alexia and dyslexia (R48.0)
acquired reading difficulties secondary to emotional
disturbance
(F93.-)
spelling disorder not associated with reading difficulties
(F81.1)
F81.1 Specific spelling disorder
The main feature of this disorder is a specific and significant impairment in
the development of spelling skills in the absence of a history of specific
reading disorder, which is not solely accounted for by low mental age,
visual acuity problems, or inadequate schooling. The ability to spell orally
and to write out words correctly are both affected. Children whose
- 194 problem
is solely one of handwriting should not be included, but in some
cases spelling difficulties may be associated with problems in writing.
Unlike the usual pattern of specific reading disorder, the spelling errors
tend to be predominantly phonetically accurate.
Diagnostic guidelines
The child's spelling performance should be significantly below the level
expected on the basis of his or her age, general intelligence, and school
placement, and is best assessed by means of an individually administered,
standardized test of spelling. The child's reading skills (with respect to
both accuracy and comprehension) should be within the normal range and
there should be no history of previous significant reading difficulties. The
difficulties in spelling should not be mainly due to grossly inadequate
teaching or to the direct effects of deficits of visual, hearing, or neurological
function, and should not have been acquired as a result of any
neurological, psychiatric, or other disorder.
Although it is known that a "pure" spelling disorder differs from reading
disorders associated with spelling difficulties, little is known of the
antecedents, course, correlates, or outcome of specific spelling disorders.
Includes: specific spelling retardation (without reading disorder)
Excludes: acquired spelling disorder (R48.8)
spelling difficulties associated with a reading disorder (F81.0)
spelling difficulties mainly attributable to inadequate
teaching
(Z55.8)
F81.2 Specific disorder of arithmetical skills
This disorder involves a specific impairment in arithmetical skills, which is
not solely explicable on the basis of general mental retardation or of grossly
inadequate schooling. The deficit concerns mastery of basic computational
skills of addition, subtraction, multiplication, and division (rather than of
the more abstract mathematical skills involved in algebra, trigonometry,
geometry, or calculus).
Diagnostic guidelines
The child's arithmetical performance should be significantly below the
level expected on the basis of his or her age, general intelligence, and
school placement, and is best assessed by means of an individually
administered, standardized test of arithmetic. Reading and spelling skills
should be within the normal range expected for the child's mental age,
preferably as assessed on individually administered, appropriately
standardized tests. The difficulties in arithmetic should not be mainly due
to grossly inadequate teaching, or to the direct effects of defects of visual,
- 195 hearing,
or neurological function, and should not have been acquired as a
result of any neurological, psychiatric, or other disorder.
Arithmetical disorders have been studied less than reading disorders, and
knowledge of antecedents, course, correlates, and outcome is quite limited.
However, it seems that children with these disorders tend to have
auditory-perceptual and verbal skills within the normal range, but
impaired visuo-spatial and visual-perceptual skills; this is in contrast to
many children with reading disorders. Some children have associated
socio-emotional-behavioural problems but little is known about their
characteristics or frequency. It has been suggested that difficulties in social
interactions may be particularly common.
The arithmetical difficulties that occur are various but may include: failure
to understand the concepts underlying particular arithmetical operations;
lack of understanding of mathematical terms or signs; failure to recognize
numerical symbols; difficulty in carrying out standard arithmetical
manipulations; difficulty in understanding which numbers are relevant to
the arithmetical problem being considered; difficulty in properly aligning
numbers or in inserting decimal points or symbols during calculations;
poor spatial organization of arithmetical calculations; and inability to learn
multiplication tables satisfactorily.
Includes: developmental acalculia
developmental arithmetical disorder
developmental Gerstmann syndrome
Excludes: acquired arithmetical disorder (acalculia) (R48.8)
arithmetical difficulties associated with a reading or spelling
disorder
(F81.1)
arithmetical difficulties mainly attributable to inadequate
teaching
(Z55.8)
F81.3 Mixed disorder of scholastic skills
This is an ill-defined, inadequately conceptualized (but necessary) residual
category of disorders in which both arithmetical and reading or spelling
skills are significantly impaired, but in which the disorder is not solely
explicable in terms of general mental retardation or inadequate schooling.
It should be used for disorders meeting the criteria for F81.2 and either
F81.0 or F81.1.
Excludes: specific disorder of arithmetical skills (F81.2)
specific reading disorder (F81.0)
specific spelling disorder (F81.1)
F81.8 Other developmental disorders of scholastic skills
- 196 Includes:
developmental expressive writing disorder
F81.9 Developmental disorder of scholastic skills, unspecified
This category should be avoided as far as possible and should be used only
for unspecified disorders in which there is a significant disability of
learning that cannot be solely accounted for by mental retardation, visual
acuity problems, or inadequate schooling.
Includes: knowledge acquisition disability NOS
learning disability NOS
learning disorder NOS
F82 Specific developmental disorder of motor function
The main feature of this disorder is a serious impairment in the
development of motor coordination that is not solely explicable in terms of
general intellectual retardation or of any specific congenital or acquired
neurological disorder (other than the one that maybe implicit in the
coordination abnormality). It is usual for the motor clumsiness to be
associated with some degree of impaired performance on visuo-spatial
cognitive tasks.
Diagnostic guidelines
The child's motor coordination, on fine or gross motor tasks, should be
significantly below the level expected on the basis of his or her age and
general intelligence. This is best assessed on the basis of an individually
administered, standardized test of fine and gross motor coordination. The
difficulties in co-ordination should have been present since early in
development (i.e. they should not constitute an acquired deficit), and they
should not be a direct result of any defects of vision or hearing or of any
diagnosable neurological disorder.
The extent to which the disorder mainly involves fine or gross motor
coordination varies, and the particular pattern of motor disabilities varies
with age. Developmental motor milestones may be delayed and there may
be some associated speech difficulties (especially involving articulation).
The young child may be awkward in general gait, being slow to learn to
run, hop, and go up and down stairs. There is likely to be difficulty
learning to tie shoe laces, to fasten and unfasten buttons, and to throw and
catch balls. The child may be generally clumsy in fine and/or gross
movements - tending to drop things, to stumble, to bump into obstacles,
and to have poor handwriting. Drawing skills are usually poor, and
children with this disorder are often poor at jigsaw puzzles, using
constructional toys, building models, ball games, and drawing and
understanding maps.
- 197 In
most cases a careful clinical examination shows marked
neurodevelopmental immaturities such as choreiform movements of
unsupported limbs, or mirror movements and other associated motor
features, as well as signs of poor fine and gross motor coordination
(generally described as "soft" neurological signs because of their normal
occurrence in younger children and their lack of localizing value). Tendon
reflexes may be increased or decreased bilaterally but will not be
asymmetrical.
Scholastic difficulties occur in some children and may occasionally be
severe; in some cases there are associated socio-emotional-behavioural
problems, but little is known of their frequency or characteristics.
There is no diagnosable neurological disorder (such as cerebral palsy or
muscular dystrophy). In some cases, however, there is a history of
perinatal complications, such as very low birth weight or markedly
premature birth.
The clumsy child syndrome has often been diagnosed as "minimal brain
dysfunction", but this term is not recommended as it has so many different
and contradictory meanings.
Includes: clumsy child syndrome
developmental coordination disorder
developmental dyspraxia
Excludes: abnormalities of gait and mobility (R26.-)
lack of coordination (R27.-) secondary to either mental retardation
(F70-F79) or some specific diagnosable neurological
disorder
(G00-G99)
F83 Mixed specific developmental disorders
This is an ill-defined, inadequately conceptualized (but necessary) residual
category of disorders in which there is some admixture of specific
developmental disorders of speech and language, of scholastic skills,
and/or of motor function, but in which none predominates sufficiently to
constitute the prime diagnosis. It is common for each of these specific
developmental disorders to be associated with some degree of general
impairment of cognitive functions, and this mixed category should be used
only when there is a major overlap. Thus, the category should be used
when there are dysfunctions meeting the criteria for two or more of F80.-,
F81.-, and F82.
F84 Pervasive developmental disorders
- 198 This
group of disorders is characterized by qualitative
abnormalities in reciprocal social interactions and in patterns of
communication, and by restricted, stereotyped, repetitive
repertoire of interests and activities. These qualitative
abnormalities are a pervasive feature of the individual's
functioning in all situations, although they may vary in degree. In
most cases, development is abnormal from infancy and, with
only a few exceptions, the conditions become manifest during
the first 5 years of life. It is usual, but not invariable, for there to be
some degree of general cognitive impairment but the disorders
are defined in terms of behaviour that is deviant in relation to
mental age (whether the individual is retarded or not). There is
some disagreement on the subdivision of this overall group of
pervasive developmental disorders.
In some cases the disorders are associated with, and presumably
due to, some medical condition, of which infantile spasms,
congenital rubella, tuberous sclerosis, cerebral lipidosis, and the
fragile X chromosome anomaly are among the most common.
However, the disorder should be diagnosed on the basis of the
behavioural features, irrespective of the presence or absence of
any associated medical conditions; any such associated
condition must, nevertheless, be separately coded. If mental
retardation is present, it is important that it too should be
separately coded, under F70-F79, because it is not a universal
feature of the pervasive developmental disorders.
F84.0 Childhood autism
A pervasive developmental disorder defined by the presence of abnormal
and/or impaired development that is manifest before the age of 3 years,
and by the characteristic type of abnormal functioning in all three areas of
social interaction, communication, and restricted, repetitive behaviour.
The disorder occurs in boys three to four times more often than in girls.
Diagnostic guidelines
Usually there is no prior period of unequivocally normal development but,
if there is, abnormalities become apparent before the age of 3 years. There
are always qualitative impairments in reciprocal social interaction. These
take the form of an inadequate appreciation of socio-emotional cues, as
shown by a lack of responses to other people's emotions and/or a lack of
modulation of behaviour according to social context; poor use of social
signals and a weak integration of social, emotional, and communicative
behaviours; and, especially, a lack of socio-emotional reciprocity.
Similarly, qualitative impairments in communications are universal.
These take the form of a lack of social usage of whatever language skills are
present; impairment in make-believe and social imitative play; poor
synchrony and lack of reciprocity in conversational interchange; poor
- 199 flexibility
in language expression and a relative lack of creativity and
fantasy in thought processes; lack of emotional response to other people's
verbal and nonverbal overtures; impaired use of variations in cadence or
emphasis to reflect communicative modulation; and a similar lack of
accompanying gesture to provide emphasis or aid meaning in spoken
communication.
The condition is also characterized by restricted, repetitive, and
stereotyped patterns of behaviour, interests, and activities. These take the
form of a tendency to impose rigidity and routine on a wide range of
aspects of day-to day functioning; this usually applies to novel activities as
well as to familiar habits and play patterns. In early childhood particularly,
there may be specific attachment to unusual, typically non-soft objects.
The children may insist on the performance of particular routines in rituals
of a nonfunctional character; there may be stereotyped preoccupations
with interests such as dates, routes or timetables; often there are motor
stereotypies; a specific interest in nonfunctional elements of objects (such
as their smell or feel) is common; and there may be a resistance to changes
in routine or in details of the personal environment (such as the movement
of ornaments or furniture in the family home).
In addition to these specific diagnostic features, it is frequent for children
with autism to show a range of other nonspecific problems such as
fear/phobias, sleeping and eating disturbances, temper tantrums, and
aggression. Self-injury (e.g. by wrist-biting) is fairly common, especially
when there is associated severe mental retardation. Most individuals with
autism lack spontaneity, initiative, and creativity in the organization of
their leisure time and have difficulty applying conceptualizations in
decision-making in work (even when the tasks themselves are well within
their capacity). The specific manifestation of deficits characteristic of
autism change as the children grow older, but the deficits continue into
and through adult life with a broadly similar pattern of problems in
socialization, communication, and interest patterns. Developmental
abnormalities must have been present in the first 3 years for the diagnosis
to be made, but the syndrome can be diagnosed in all age groups.
All levels of IQ can occur in association with autism, but there is
significant mental retardation in some three-quarters of cases.
Includes: autistic disorder
infantile autism
infantile psychosis
Kanner's syndrome
Differential diagnosis. Apart from the other varieties of pervasive
developmental disorder it is important to consider: specific developmental
disorder of receptive language (F80.2) with secondary socio-emotional
problems; reactive attachment disorder (F94.1) or disinhibited attachment
disorder (F94.2); mental retardation (F70-F79) with some associated
- 200 emotional/behavioural
disorder; schizophrenia (F20.-) of unusually early
onset; and Rett's syndrome (F84.2).
Excludes: autistic psychopathy (F84.5)
F84.1 Atypical autism
A pervasive developmental disorder that differs from autism in terms
either of age of onset or of failure to fulfil all three sets of diagnostic criteria.
Thus, abnormal and/or impaired development becomes manifest for the
first time only after age 3 years; and/or there are insufficient demonstrable
abnormalities in one or two of the three areas of psychopathology required
for the diagnosis of autism (namely, reciprocal social interactions,
communication, and restrictive, stereotyped, repetitive behaviour) in spite
of characteristic abnormalities in the other area(s). Atypical autism arises
most often in profoundly retarded individuals whose very low level of
functioning provides little scope for exhibition of the specific deviant
behaviours required for the diagnosis of autism; it also occurs in
individuals with a severe specific developmental disorder of receptive
language. Atypical autism thus constitutes a meaningfully separate
condition from autism.
Includes: atypical childhood psychosis
mental retardation with autistic features
F84.2 Rett's syndrome
A condition of unknown cause, so far reported only in girls, which has
been differentiated on the basis of a characteristic onset, course, and
pattern of symptomatology. Typically, apparently normal or near-normal
early development is followed by partial or complete loss of acquired hand
skills and of speech, together with deceleration in head growth, usually
with an onset between 7 and 24 months of age. Hand-wringing
stereotypies, hyperventilation and loss of purposive hand movements are
particularly characteristic. Social and play development are arrested in the
first 2 or 3 years, but social interest tends to be maintained. During middle
childhood, trunk ataxia and apraxia, associated with scoliosis or
kyphoscoliosis tend to develop and sometimes there are choreoathetoid
movements. Severe mental handicap invariably results. Fits frequently
develop during early or middle childhood.
Diagnostic guidelines
In most cases onset is between 7 and 24 months of age. The most
characteristic feature is a loss of purposive hand movements and acquired
fine motor manipulative skills. This is accompanied by loss, partial loss or
lack of development of language; distinctive stereotyped tortuous wringing
or "hand-washing" movements, with the arms flexed in front of the chest
or chin; stereotypic wetting of the hands with saliva; lack of proper
chewing of food; often episodes of hyperventilation; almost always a failure
to gain bowel and bladder control; often excessive drooling and protrusion
- 201 of
the tongue; and a loss of social engagement. Typically, the children
retain a kind of "social smile", looking at or "through" people, but not
interacting socially with them in early childhood (although social
interaction often develops later). The stance and gait tend to become
broad-based, the muscles are hypotonic, trunk movements usually become
poorly coordinated, and scoliosis or kyphoscoliosis usually develops.
Spinal atrophies, with severe motor disability, develop in adolescence or
adulthood in about half the cases. Later, rigid spasticity may become
manifest, and is usually more pronounced in the lower than in the upper
limbs. Epileptic fits, usually involving some type of minor attack, and with
an onset generally before the age of 8 years, occur in the majority of cases.
In contrast to autism, both deliberate self-injury and complex stereotyped
preoccupations or routines are rare.
Differential diagnosis. Initially, Rett's syndrome is differentiated primarily
on the basis of the lack of purposive hand movements, deceleration of head
growth, ataxia, stereotypic "hand-washing" movements, and lack of proper
chewing. The course of the disorder, in terms of progressive motor
deterioration, confirms the diagnosis.
F84.3 Other childhood disintegrative disorder
A pervasive developmental disorder (other than Rett's syndrome) that is
defined by a period of normal development before onset, and by a definite
loss, over the course of a few months, of previously acquired skills in at
least several areas of development, together with the onset of characteristic
abnormalities of social, communicative, and behavioural functioning.
Often there is a prodromic period of vague illness; the child becomes
restive, irritable, anxious, and overactive. This is followed by
impoverishment and then loss of speech and language, accompanied by
behavioural disintegration. In some cases the loss of skills is persistently
progressive (usually when the disorder is associated with a progressive
diagnosable neurological condition), but more often the decline over a
period of some months is followed by a plateau and then a limited
improvement. The prognosis is usually very poor, and most individuals
are left with severe mental retardation. There is uncertainty about the
extent to which this condition differs from autism. In some cases the
disorder can be shown to be due to some associated encephalopathy, but
the diagnosis should be made on the behavioural features. Any associated
neurological condition should be separately coded.
Diagnostic guidelines
Diagnosis is based on an apparently normal development up to the age of
at least 2 years, followed by a definite loss of previously acquired skills; this
is accompanied by qualitatively abnormal social functioning. It is usual for
there to be a profound regression in, or loss of, language, a regression in the
level of play, social skills, and adaptive behaviour, and often a loss of bowel
or bladder control, sometimes with a deteriorating motor control.
Typically, this is accompanied by a general loss of interest in the
- 202 environment,
by stereotyped, repetitive motor mannerisms, and by an
autistic-like impairment of social interaction and communication. In some
respects, the syndrome resembles dementia in adult life, but it differs in
three key respects: there is usually no evidence of any identifiable organic
disease or damage (although organic brain dysfunction of some type is
usually inferred); the loss of skills may be followed by a degree of recovery;
and the impairment in socialization and communication has deviant
qualities typical of autism rather than of intellectual decline. For all these
reasons the syndrome is included here rather than under F00-F09.
Includes: dementia infantilis
disintegrative psychosis
Heller's syndrome
symbiotic psychosis
Excludes: acquired aphasia with epilepsy (F80.3)
elective mutism (F94.0)
Rett's syndrome (F84.2)
schizophrenia (F20.-)
F84.4 Overactive disorder associated with mental retardation and stereotyped
movements
This is an ill-defined disorder of uncertain nosological validity. The
category is included here because of the evidence that children with
moderate to severe mental retardation (IQ below 50) who exhibit major
problems in hyperactivity and inattention frequently show stereotyped
behaviours; such children tend not to benefit from stimulant drugs (unlike
those with an IQ in the normal range) and may exhibit a severe dysphoric
reaction (sometimes with psychomotor retardation) when given
stimulants; in adolescence the overactivity tends to be replaced by
underactivity (a pattern that is not usual in hyperkinetic children with
normal intelligence). It is also common for the syndrome to be associated
with a variety of developmental delays, either specific or global.
The extent to which the behavioural pattern is a function of low IQ or of
organic brain damage is not known, neither is it clear whether the
disorders in children
with mild mental retardation who show the hyperkinetic syndrome would
be better classified here or under F90.-; at present they are included in
F90-.
Diagnostic guidelines
Diagnosis depends on the combination of developmentally inappropriate
severe overactivity, motor stereotypies, and moderate to severe mental
retardation; all three must be present for the diagnosis. If the diagnostic
criteria for F84.0, F84.1 or F84.2 are met, that condition should be
diagnosed instead.
- 203 F84.5
Asperger's syndrome
A disorder of uncertain nosological validity, characterized by the same kind
of qualitative abnormalities of reciprocal social interaction that typify
autism, together with a restricted, stereotyped, repetitive repertoire of
interests and activities. The disorder differs from autism primarily in that
there is no general delay or retardation in language or in cognitive
development. Most individuals are of normal general intelligence but it is
common for them to be markedly clumsy; the condition occurs
predominantly in boys (in a ratio of about eight boys to one girl). It seems
highly likely that at least some cases represent mild varieties of autism, but
it is uncertain whether or not that is so for all. There is a strong tendency
for the abnormalities to persist into adolescence and adult life and it seems
that they represent individual characteristics that are not greatly affected
by environmental influences. Psychotic episodes occasionally occur in
early adult life.
Diagnostic guidelines
Diagnosis is based on the combination of a lack of any clinically significant
general delay in language or cognitive development plus, as with autism,
the presence of qualitative deficiencies in reciprocal social interaction and
restricted, repetitive, stereotyped patterns of behaviour, interests, and
activities. There may or may not be problems in communication similar to
those associated with autism, but significant language retardation would
rule out the diagnosis.
Includes: autistic psychopathy
schizoid disorder of childhood
Excludes: anankastic personality disorder (F60.5)
attachment disorders of childhood (F94.1, F94.2)
obsessive-compulsive disorder (F42.-)
schizotypal disorder (F21)
simple schizophrenia (F20.6)
F84.8 Other pervasive developmental disorders
F84.9 Pervasive developmental disorder, unspecified
This is a residual diagnostic category that should be used for disorders
which fit the general description for pervasive developmental disorders but
in which a lack of adequate information, or contradictory findings, means
that the criteria for any of the other F84 codes cannot be met.
F88 Other disorders of psychological development
Includes: developmental agnosia
- 204 F89
Unspecified disorder of psychological development
Includes: developmental disorder NOS
F90-F98
Behavioural and emotional disorders with onset usually
occurring in childhood and adolescence
F99 Unspecified mental disorder
Overview of this section
F90 Hyperkinetic disorders
F90.0 Disturbance of activity and attention
F90.1 Hyperkinetic conduct disorder
F90.8 Other hyperkinetic disorders
F90.9 Hyperkinetic disorder, unspecified
F91 Conduct disorders
F91.0 Conduct disorder confined to the family context
F91.1 Unsocialized conduct disorder
F91.2 Socialized conduct disorder
F91.3 Oppositional defiant disorder
F91.8 Other conduct disorders
F91.9 Conduct disorder, unspecified
F92 Mixed disorders of conduct and emotions
F92.0 Depressive conduct disorder
F92.8 Other mixed disorders of conduct and emotions
F92.9 Mixed disorder of conduct and emotions, unspecified
F93 Emotional disorders with onset specific to childhood
F93.0 Separation anxiety disorder of childhood
F93.1 Phobic anxiety disorder of childhood
F93.2 Social anxiety disorder of childhood
F93.3 Sibling rivalry disorder
F93.8 Other childhood emotional disorders
F93.9 Childhood emotional disorder, unspecified
F94 Disorders of social functioning with onset specific to childhood and
adolescence
F94.0 Elective mutism
F94.1 Reactive attachment disorder of childhood
F94.2 Disinhibited attachment disorder of childhood
F94.8 Other childhood disorders of social functioning
F94.9 Childhood disorder of social functioning, unspecified
F95 Tic disorders
F95.0 Transient tic disorder
F95.1 Chronic motor or vocal tic disorder
F95.2 Combined vocal and multiple motor tic disorder [de la Tourette's syndrome]
- 205 F95.8
Other tic disorders
F95.9 Tic disorder, unspecified
F98 Other behavioural and emotional disorders with onset usually occurring
in childhood and adolescence
F98.0 Nonorganic enuresis
F98.1 Nonorganic encopresis
F98.2 Feeding disorder of infancy and childhood
F98.3 Pica of infancy and childhood
F98.4 Stereotyped movement disorders
F98.5 Stuttering [stammering]
F98.6 Cluttering
F98.8Other specified behavioural and emotional disorders with onset usually
occurring in childhood and adolescence
F98.9Unspecified behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
F99 Mental disorder, not otherwise specified
- 206 F90
Hyperkinetic disorders
This group of disorders is characterized by: early onset; a combination of
overactive, poorly modulated behaviour with marked inattention and lack of
persistent task involvement; and pervasiveness over situations and persistence
over time of these behavioural characteristics.
It is widely thought that constitutional abnormalities play a crucial role in the
genesis of these disorders, but knowledge on specific etiology is lacking at present.
In recent years the use of the diagnostic term "attention deficit disorder" for these
syndromes has been promoted. It has not been used here because it implies a
knowledge of psychological processes that is not yet available, and it suggests the
inclusion of anxious, preoccupied, or "dreamy" apathetic children whose
problems are probably different. However, it is clear that, from the point of view
of behaviour, problems of inattention constitute a central feature of these
hyperkinetic syndromes.
Hyperkinetic disorders always arise early in development (usually in the first 5
years of life). Their chief characteristics are lack of persistence in activities that
require cognitive involvement, and a tendency to move from one activity to
another without completing any one, together with disorganized, ill-regulated,
and excessive activity. These problems usually persist through school years and
even into adult life, but many affected individuals show a gradual improvement in
activity and attention.
Several other abnormalities may be associated with these disorders. Hyperkinetic
children are often reckless and impulsive, prone to accidents, and find themselves
in disciplinary trouble because of unthinking (rather than deliberately defiant)
breaches of rules. Their relationships with adults are often socially disinhibited,
with a lack of normal caution and reserve; they are unpopular with other children
and may become isolated. Cognitive impairment is common, and specific delays
in motor and language development are disproportionately frequent.
Secondary complications include dissocial behaviour and low self esteem. There
is accordingly considerable overlap between hyperkinesis and other patterns of
disruptive behaviour such as"unsocialized conduct disorder". Nevertheless,
current evidence favours the separation of a group in which hyperkinesis is the
main problem.
Hyperkinetic disorders are several times more frequent in boys than in girls.
Associated reading difficulties (and/or other scholastic problems) are common.
Diagnostic guidelines
The cardinal features are impaired attention and overactivity: both are necessary
for the diagnosis and should be evident in more than one situation (e.g. home,
classroom, clinic).
- 207 Impaired
attention is manifested by prematurely breaking off from tasks and
leaving activities unfinished. The children change frequently from one activity to
another, seemingly losing interest in one task because they become diverted to
another (although laboratory studies do not generally show an unusual degree of
sensory or perceptual distractibility). These deficits in persistence and attention
should be diagnosed only if they are excessive for the child's age and IQ.
Overactivity implies excessive restlessness, especially in situations requiring
relative calm. It may, depending upon the situation, involve the child running
and jumping around, getting up from a seat when he or she was supposed to
remain seated, excessive talkativeness and noisiness, or fidgeting and wriggling.
The standard for judgement should be that the activity is excessive in the context
of what is expected in the situation and by comparison with other children of the
same age and IQ. This behavioural feature is most evident in structured,
organized situations that require a high degree of behavioural self-control.
The associated features are not sufficient for the diagnosis or even necessary, but
help to sustain it. Disinhibition in social relationships, recklessness in situations
involving some danger, and impulsive flouting of social rules (as shown by
intruding on or interrupting others' activities, prematurely answering questions
before they have been completed, or difficulty in waiting turns) are all
characteristic of children with this disorder.
Learning disorders and motor clumsiness occur with undue frequency, and
should be noted separately (under F80-F89) when present; they should not,
however, be part of the actual diagnosis of hyperkinetic disorder.
Symptoms of conduct disorder are neither exclusion nor inclusion criteria for the
main diagnosis, but their presence or absence constitutes the basis for the main
subdivision of the disorder (see below).
The characteristic behaviour problems should be of early onset (before age 6
years) and long duration. However, before the age of school entry, hyperactivity is
difficult to recognize because of the wide normal variation: only extreme levels
should lead to a diagnosis in preschool children.
Diagnosis of hyperkinetic disorder can still be made in adult life. The grounds are
the same, but attention and activity must be judged with reference to
developmentally appropriate norms. When hyperkinesis was present in
childhood, but has disappeared and been succeeded by another condition, such as
dissocial personality disorder or substance abuse, the current condition rather
than the earlier one is coded.
Differential diagnosis. Mixed disorders are common, and pervasive
developmental disorders take precedence when they are present. The major
problems in diagnosis lie in differentiation from conduct disorder: when its
criteria are met, hyperkinetic disorder is diagnosed with priority over conduct
disorder. However, milder degrees of overactivity and inattention are common in
conduct disorder. When features of both hyperactivity and conduct disorder are
- 208 present,
and the hyperactivity is pervasive and severe, "hyperkinetic conduct
disorder" (F90.1) should be the diagnosis.
A further problem stems from the fact that overactivity and inattention, of a rather
different kind from that which is characteristic of a hyperkinetic disorder, may
arise as a symptom of anxiety or depressive disorders. Thus, the restlessness that
is typically part of an agitated depressive disorder should not lead to a diagnosis of
a hyperkinetic disorder. Equally, the restlessness that is often part of severe
anxiety should not lead to the diagnosis of a hyperkinetic disorder. If the criteria
for one of the anxiety disorders (F40.-, F41.-, F43.-, or F93.-) are met, this should
take precedence over hyperkinetic disorder unless there is evidence, apart from
the restlessness associated with anxiety, for the additional presence of a
hyperkinetic disorder. Similarly, if the criteria for a mood disorder (F30-F39) are
met, hyperkinetic disorder should not be diagnosed in addition simply because
concentration is impaired and there is psychomotor agitation. The double
diagnosis should be made only when symptoms that are not simply part of the
mood disturbance clearly indicate the separate presence of a hyperkinetic disorder.
Acute onset of hyperactive behaviour in a child of school age is more probably due
to some type of reactive disorder (psychogenic or organic), manic state,
schizophrenia, or neurological disease (e.g. rheumatic fever).
Excludes: anxiety disorders (F41.- or F93.0)
mood [affective] disorders (F30-F39)
pervasive developmental disorders (F84.-)
schizophrenia (F20.-)
F90.0 Disturbance of activity and attention
There is continuing uncertainty over the most satisfactory subdivision of
hyperkinetic disorders. However, follow-up studies show that the outcome in
adolescence and adult life is much influenced by whether or not there is associated
aggression, delinquency, or dissocial behaviour. Accordingly, the main
subdivision is made according to the presence or absence of these associated
features. The code used should be F90.0 when the overall criteria for
hyperkinetic disorder (F90.-) are met but those for F91.- (conduct disorders) are
not.
Includes: attention deficit disorder or syndrome with hyperactivity
attention deficit hyperactivity disorder
Excludes: hyperkinetic disorder associated with conduct disorder (F90.1)
F90.1 Hyperkinetic conduct disorder
This coding should be used when both the overall criteria for hyperkinetic
disorders (F90.-) and the overall criteria for conduct disorders (F91.-) are met.
F90.8 Other hyperkinetic disorders
F90.9 Hyperkinetic disorder, unspecified
- 209 This
residual category is not recommended and should be used only when there is
a lack of differentiation between F90.0 and F90.1 but the overall criteria for F90.are
fulfilled.
Includes: hyperkinetic reaction or syndrome of childhood or adolescence NOS
F91 Conduct disorders
Conduct disorders are characterized by a repetitive and persistent pattern of
dissocial, aggressive, or defiant conduct. Such behaviour, when at its most
extreme for the individual, should amount to major violations of age-appropriate
social expectations, and is therefore more severe than ordinary childish mischief or
adolescent rebelliousness. Isolated dissocial or criminal acts are not in themselves
grounds for the diagnosis, which implies an enduring pattern of behaviour.
Features of conduct disorder can also be symptomatic of other psychiatric
conditions, in which case the underlying diagnosis should be coded.
Disorders of conduct may in some cases proceed to dissocial personality disorder
(F60.2). Conduct disorder is frequently associated with adverse psychosocial
environments, including unsatisfactory family relationships and failure at school,
and is more commonly noted in boys. Its distinction from emotional disorder is
well validated; its separation from hyperactivity is less clear and there is often
overlap.
Diagnostic guidelines
Judgements concerning the presence of conduct disorder should take into account
the child's developmental level. Temper tantrums, for example, are a normal part
of a 3-year-old's development and their mere presence would not be grounds for
diagnosis. Equally, the violation of other people's civic rights (as by violent crime)
is not within the capacity of most 7-year-olds and so is not a necessary diagnostic
criterion for that age group.
Examples of the behaviours on which the diagnosis is based include the following:
excessive levels of fighting or bullying; cruelty to animals or other people; severe
destructiveness to property; fire-setting; stealing; repeated lying; truancy from
school and running away from home; unusually frequent and severe temper
tantrums; defiant provocative behaviour; and persistent severe disobedience. Any
one of these categories, if marked, is sufficient for the diagnosis, but isolated
dissocial acts are not.
Exclusion criteria include uncommon but serious underlying conditions such as
schizophrenia, mania, pervasive developmental disorder, hyperkinetic disorder,
and depression.
This diagnosis is not recommended unless the duration of the behaviour
described above has been 6 months or longer.
- 210 Differential
diagnosis. Conduct disorder overlaps with other conditions. The
coexistence of emotional disorders of childhood (F93.-) should lead to a diagnosis
of mixed disorder of conduct and emotions (F92.-). If a case also meets the
criteria for hyperkinetic disorder (F90.-), that condition should be diagnosed
instead. However, milder or more situation-specific levels of overactivity and
inattentiveness are common in children with conduct disorder, as are low
self-esteem and minor emotional upsets; neither excludes the diagnosis.
Excludes: conduct disorders associated with emotional disorders (F92.-) or
hyperkinetic disorders (F90.-)
mood [affective] disorders (F30-F39)
pervasive developmental disorders (F84.-)
schizophrenia (F20.-)
F91.0 Conduct disorder confined to the family context
This category comprises conduct disorders involving dissocial or aggressive
behaviour (and not merely oppositional, defiant, disruptive behaviour) in which
the abnormal behaviour is entirely, or almost entirely, confined to the home
and/or to interactions with members of the nuclear family or immediate
household. The disorder requires that the overall criteria for F91 be met; even
severely disturbed parent-child relationships are not of themselves sufficient for
diagnosis. There may be stealing from the home, often specifically focused on the
money or possessions of one or two particular individuals. This may be
accompanied by deliberately destructive behaviour, again often focused on
specific family members - such as breaking of toys or ornaments, tearing of
clothes, carving on furniture, or destruction of prized possessions. Violence
against family members (but not others) and deliberate fire-setting confined to the
home are also grounds for the diagnosis.
Diagnostic guidelines
Diagnosis requires that there be no significant conduct disturbance outside the
family setting and that the child's social relationships outside the family be within
the normal range.
In most cases these family-specific conduct disorders will have arisen in the
context of some form of marked disturbance in the child's relationship with one or
more members of the nuclear family. In some cases, for example, the disorder
may have arisen in relation to conflict with a newly arrived step-parent. The
nosological validity of this category remains uncertain, but it is possible that these
highly situation-specific conduct disorders do not carry the generally poor
prognosis associated with pervasive conduct disturbances.
F91.1 Unsocialized conduct disorder
This type of conduct disorder is characterized by the combination of persistent
dissocial or aggressive behaviour (meeting the overall criteria for F91 and not
merely comprising oppositional, defiant, disruptive behaviour), with a significant
pervasive abnormality in the individual's relationships with other children.
- 211 Diagnostic
guidelines
The lack of effective integration into a peer group constitutes the key distinction
from "socialized" conduct disorders and this has precedence over all other
differentiations. Disturbed peer relationships are evidenced chiefly by isolation
from and/or rejection by or unpopularity with other children, and by a lack of
close friends or of lasting empathic, reciprocal relationships with others in the
same age group. Relationships with adults tend to be marked by discord,
hostility, and resentment. Good relationships with adults can occur (although
usually they lack a close, confiding quality) and, if present, do not rule out the
diagnosis. Frequently, but not always, there is some associated emotional
disturbance (but, if this is of a degree sufficient to meet the criteria of a mixed
disorder, the code F92.- should be used).
Offending is characteristically (but not necessarily) solitary. Typical behaviours
comprise: bullying, excessive fighting, and (in older children) extortion or violent
assault; excessive levels of disobedience, rudeness, uncooperativeness, and
resistance to authority; severe temper tantrums and uncontrolled rages;
destructiveness to property, fire-setting, and cruelty to animals and other children.
Some isolated children, however, become involved in group offending. The
nature of the offence is therefore less important in making the diagnosis than the
quality of personal relationships.
The disorder is usually pervasive across situations but it may be most evident at
school; specificity to situations other than the home is compatible with the
diagnosis.
Includes: conduct disorder, solitary aggressive type
unsocialized aggressive disorder
F91.2 Socialized conduct disorder
This category applies to conduct disorders involving persistent dissocial or
aggressive behaviour (meeting the overall criteria for F91 and not merely
comprising oppositional, defiant, disruptive behaviour) occurring in individuals
who are generally well integrated into their peer group.
Diagnostic guidelines
The key differentiating feature is the presence of adequate, lasting friendships
with others of roughly the same age. Often, but not always, the peer group will
consist of other youngsters involved in delinquent or dissocial activities (in which
case the child's socially unacceptable conduct may well be approved by the peer
group and regulated by the subculture to which it belongs). However, this is not
a necessary requirement for the diagnosis: the child may form part of a
non-delinquent peer group with his or her dissocial behaviour taking place
outside this context. If the dissocial behaviour involves bullying in particular,
there may be disturbed relationships with victims or some other children. Again,
this does not invalidate the diagnosis provided that the child has some peer group
to which he or she is loyal and which involves lasting friendships.
- 212 Relationships
with adults in authority tend to be poor but there may be good
relationships with others. Emotional disturbances are usually minimal. The
conduct disturbance may or may not include the family setting but if it is
confined to the home the diagnosis is excluded. Often the disorder is most
evident outside the family context and specificity to the school (or other
extrafamilial setting) is compatible with the diagnosis.
Includes: conduct disorder, group type
group delinquency
offences in the context of gang membership
stealing in company with others
truancy from school
Excludes: gang activity without manifest psychiatric disorder (Z03.2)
F91.3 Oppositional defiant disorder
This type of conduct disorder is characteristically seen in children below the age
of 9 or 10 years. It is defined by the presence of markedly defiant, disobedient,
provocative behaviour and by the absence of more severe dissocial or aggressive
acts that violate the law or the rights of others. The disorder requires that the
overall criteria for F91 be met: even severely mischievous or naughty behaviour is
not in itself sufficient for diagnosis. Many authorities consider that oppositional
defiant patterns of behaviour represent a less severe type of conduct disorder,
rather than a qualitatively distinct type. Research evidence is lacking on whether
the distinction is qualitative or quantitative. However, findings suggest that, in so
far as it is distinctive, this is true mainly or only in younger children. Caution
should be employed in using this category, especially in the case of older children.
Clinically significant conduct disorders in older children are usually accompanied
by dissocial or aggressive behaviour that go beyond defiance, disobedience, or
disruptiveness, although, not infrequently, they are preceded by oppositional
defiant disorders at an earlier age. The category is included to reflect common
diagnostic practice and to facilitate the classification of disorders occurring in
young children.
Diagnostic guidelines
The essential feature of this disorder is a pattern of persistently negativistic,
hostile, defiant, provocative, and disruptive behaviour, which is clearly outside the
normal range of behaviour for a child of the same age in the same sociocultural
context, and which does not include the more serious violations of the rights of
others as reflected in the aggressive and dissocial behaviour specified for categories
F91.0 and F91.2. Children with this disorder tend frequently and actively to defy
adult requests or rules and deliberately to annoy other people. Usually they tend
to be angry, resentful, and easily annoyed by other people whom they blame for
their own mistakes or difficulties. They generally have a low frustration tolerance
and readily lose their temper. Typically, their defiance has a provocative quality,
so that they initiate confrontations and generally exhibit excessive levels of
rudeness, uncooperativeness, and resistance to authority.
- 213 Frequently,
this behaviour is most evident in interactions with adults or peers
whom the child knows well, and signs of the disorder may not be evident during a
clinical interview.
The key distinction from other types of conduct disorder is the absence of
behaviour that violates the law and the basic rights of others, such as theft, cruelty,
bullying, assault, and destructiveness. The definite presence of any of the above
would exclude the diagnosis. However, oppositional defiant behaviour, as
outlined in the paragraph above, is often found in other types of conduct disorder.
If another type (F91.0-F91.2) is present, it should be coded in preference to
oppositional defiant disorder.
Excludes: conduct disorders including overtly dissocial or aggressive behaviour
(F91.0-F91.2)
F91.8 Other conduct disorders
F91.9 Conduct disorder, unspecified
This residual category is not recommended and should be used only for disorders
that meet the general criteria for F91 but that have not been specified as to
subtype or that do not fulfil the criteria for any of the specified subtypes.
Includes: childhood behavioural disorder NOS
childhood conduct disorder NOS
F92 Mixed disorders of conduct and emotions
This group of disorders is characterized by the combination of persistently
aggressive, dissocial, or defiant behaviour with overt and marked symptoms of
depression, anxiety, or other emotional upsets.
Diagnostic guidelines
The severity should be sufficient that the criteria for both conduct disorders of
childhood (F91.-) and emotional disorders of childhood (F93.-), or for an
adult-type neurotic disorder (F40-49) or mood disorder (F30-39) are met.
Insufficient research has been carried out to be confident that this category should
indeed be separate from conduct disorders of childhood. It is included here for its
potential etiological and therapeutic importance and its contribution to reliability
of classification.
F92.0 Depressive conduct disorder
This category requires the combination of conduct disorder of childhood (F91.-)
with persistent and marked depression of mood, as evidenced by symptoms such
as excessive misery, loss of interest and pleasure in usual activities, self-blame, and
hopelessness. Disturbances of sleep or appetite may also be present.
- 214 Includes:
conduct disorder (F91.-) associated with depressive disorder
(F30-F39)
F92.8 Other mixed disorders of conduct and emotions
This category requires the combination of conduct disorder of childhood (F91.-)
with persistent and marked emotional symptoms such as anxiety, fearfulness,
obsessions or compulsions, depersonalization or derealization, phobias, or
hypochondriasis. Anger and resentment are features of conduct disorder rather
than of emotional disorder; they neither contradict nor support the diagnosis.
Includes: conduct disorder (F91.-) associated with emotional disorder (F93.-)
or neurotic disorder (F40-F48)
F92.9 Mixed disorder of conduct and emotions, unspecified
F93 Emotional disorders with onset specific to childhood
In child psychiatry a differentiation has traditionally been made between
emotional disorders specific to childhood and adolescence and adult-type neurotic
disorders. There have been four main justifications for this differentiation. First,
research findings have been consistent in showing that the majority of children
with emotional disorders go on to become normal adults: only a minority show
neurotic disorders in adult life. Conversely, many adult neurotic disorders appear
to have an onset in adult life without significant psychopathological precursors in
childhood. Hence there is considerable discontinuity between emotional
disorders occurring in these two age periods. Second, many emotional disorders
in childhood seem to constitute exaggerations of normal developmental trends
rather than phenomena that are qualitatively abnormal in themselves. Third,
related to the last consideration, there has often been the theoretical assumption
that the mental mechanisms involved in emotional disorders of childhood may
not be the same as for adult neuroses. Fourth, the emotional disorders of
childhood are less clearly demarcated into supposedly specific entities such as
phobic disorders or obsessional disorders.
The third of these points lacks empirical validation, and epidemiological data
suggest that, if the fourth is correct, it is a matter of degree only (with poorly
differentiated emotional disorders quite common in both childhood and adult
life). Accordingly, the second feature (i.e. developmental appropriateness) is used
as the key diagnostic feature in defining the difference between the emotional
disorders with an onset specific to childhood (F93.-) and the neurotic disorders
(F40-F49). The validity of this distinction is uncertain, but there is some
empirical evidence to suggest that the developmentally appropriate emotional
disorders of childhood have a better prognosis.
F93.0 Separation anxiety disorder of childhood
It is normal for toddlers and preschool children to show a degree of anxiety over
real or threatened separation from people to whom they are attached. Separation
anxiety disorder should be diagnosed only when fear over separation constitutes
- 215 the
focus of the anxiety and when such anxiety arises during the early years. It is
differentiated from normal separation anxiety when it is of such severity that is
statistically unusual (including an abnormal persistence beyond the usual age
period) and when it is associated with significant problems in social functioning.
In addition, the diagnosis requires that there should be no generalized disturbance
of personality development of functioning; if such a disturbance is present, a code
from F40-F49 should be considered. Separation anxiety that arises at a
developmentally inappropriate age (such as during adolescence) should not be
coded here unless it constitutes an abnormal continuation of developmentally
appropriate separation anxiety.
Diagnostic guidelines
The key diagnostic feature is a focused excessive anxiety concerning separation
from those individuals to whom the child is attached (usually parents or other
family members), that is not merely part of a generalized anxiety about multiple
situations. The anxiety may take the form of:
(a)an unrealistic, preoccupying worry about possible harm befalling major
attachment figures or a fear that they will leave and not return;
(b)an unrealistic, preoccupying worry that some untoward event, such as the child
being lost, kidnapped, admitted to hospital, or killed, will separate him or
her from a major attachment figure;
(c)persistent reluctance or refusal to go to school because of fear about separation
(rather than for other reasons such as fear about events at school);
(d)persistent reluctance or refusal to go to sleep without being near or next to a
major attachment figure;
(e)persistent inappropriate fear of being alone, or otherwise without the major
attachment figure, at home during the day;
(f)repeated nightmares about separation;
(g)repeated occurrence of physical symptoms (nausea, stomachache, headache,
vomiting, etc.) on occasions that involve separation from a major
attachment figure, such as leaving home to go to school;
(h)excessive, recurrent distress (as shown by anxiety, crying, tantrums, misery,
apathy, or social withdrawal) in anticipation of, during, or immediately
following separation from a major attachment figure.
Many situations that involve separation also involve other potential stressors or
sources of anxiety. The diagnosis rests on the demonstration that the common
element giving rise to anxiety in the various situations is the circumstance of
separation from a major attachment figure. This arises most commonly, perhaps,
in relation to school refusal (or "phobia"). Often, this does represent separation
anxiety but sometimes (especially in adolescence) it does not. School refusal
arising for the first time in adolescence should not be coded here unless it is
primarily a function of separation anxiety, and that anxiety was first evident to an
abnormal degree during the preschool years. Unless those criteria are met, the
syndrome should be coded in one of the other categories in F93 or under
F40-F48.
- 216 Excludes:
mood [affective] disorders (F30-F39)
neurotic disorders (F40-F48)
phobic anxiety disorder of childhood (F93.1)
social anxiety disorder of childhood (F93.2)
F93.1 Phobic anxiety disorder of childhood
Children, like adults, can develop fear that is focused on a wide range of objects or
situations. Some of these fears (or phobias), for example agoraphobia, are not a
normal part of psychosocial development. When such fears occur in childhood
they should be coded under the appropriate category in F40-F48.However, some
fears show a marked developmental phase specificity and arise (in some degree) in
a majority of children; this would be true, for example, of fear of animals in the
preschool period.
Diagnostic guidelines
This category should be used only for developmental phase-specific fears when
they meet the additional criteria that apply to all disorders in F93, namely that:
(a)the onset is during the developmentally appropriate age period;
(b)the degree of anxiety is clinically abnormal; and
(c)the anxiety does not form part of a more generalized disorder.
Excludes: generalized anxiety disorder (F41.1)
F93.2 Social anxiety disorder of childhood
A wariness of strangers is a normal phenomenon in the second half of the first
year of life and a degree of social apprehension or anxiety is normal during early
childhood when children encounter new, strange, or socially threatening
situations. This category should therefore be used only for disorders that arise
before the age of 6 years, that are both unusual in degree and accompanied by
problems in social functioning, and that are not part of some more generalized
emotional disturbance.
Diagnostic guidelines
Children with this disorder show a persistent or recurrent fear and/or avoidance
of strangers; such fear may occur mainly with adults, mainly with peers, or with
both. The fear is associated with a normal degree of selective attachment to
parents or to other familiar persons. The avoidance or fear of social encounters is
of a degree that is outside the normal limits for the child's age and is associated
with clinically significant problems in social functioning.
Includes: avoidant disorder of childhood or adolescence
F93.3 Sibling rivalry disorder
A high proportion, or even a majority, of young children show some degree of
emotional disturbance following the birth of a younger (usually immediately
- 217 younger)
sibling. In most cases the disturbance is mild, but the rivalry or jealousy
set up during the period after the birth may be remarkably persistent.
Diagnostic guidelines
The disorder is characterized by the combination of:
(a)evidence of sibling rivalry and/or jealousy;
(b)onset during the months following the birth of the younger (usually
immediately younger) sibling;
(c)emotional disturbance that is abnormal in degree and/or persistence and
associated with psychosocial problems.
Sibling rivalry/jealousy may be shown by marked competition with siblings for
the attention and affection of parents; for this to be regarded as abnormal, it
should be associated with an unusual degree of negative feelings. In severe cases
this may be accompanied by overt hostility, physical trauma and/or maliciousness
towards, and undermining of, the sibling. In lesser cases, it may be shown by a
strong reluctance to share, a lack of positive regard, and a paucity of friendly
interactions.
The emotional disturbance may take any of several forms, often including some
regression with loss of previously acquired skills (such as bowel or bladder
control) and a tendency to babyish behaviour. Frequently, too, the child wants to
copy the baby in activities that provide for parental attention, such as feeding.
There is usually an increase in confrontational or oppositional behaviour with the
parents, temper tantrums, and dysphoria exhibited in the form of anxiety, misery,
or social withdrawal. Sleep may become disturbed and there is frequently
increased pressure for parental attention, such as at bedtime.
Includes: sibling jealousy
Excludes: peer rivalries (non-sibling) (F93.8)
F93.8 Other childhood emotional disorders
Includes: identity disorder
overanxious disorder
peer rivalries (non-sibling)
Excludes: gender identity disorder of childhood (F64.2)
F93.9 Childhood emotional disorder, unspecified
Includes: childhood emotional disorder NOS
F94Disorders of social functioning with onset specific to childhood and
adolescence
- 218 This
is a somewhat heterogeneous group of disorders, which have in common
abnormalities in social functioning that begin during the developmental period,
but that (unlike the pervasive developmental disorders) are not primarily
characterized by an apparently constitutional social incapacity or deficit that
pervades all areas of functioning. Serious environmental distortions or privations
are commonly associated and are thought to play a crucial etiological role in many
instances. There is no marked sex differential. The existence of this group of
disorders of social functioning is well recognized, but there is uncertainty
regarding the defining diagnostic criteria, and also disagreement regarding the
most appropriate subdivision and classification.
F94.0 Elective mutism
The condition is characterized by a marked, emotionally determined selectivity in
speaking, such that the child demonstrates his or her language competence in
some situations but fails to speak in other (definable) situations. Most frequently,
the disorder is first manifest in early childhood; it occurs with approximately the
same frequency in the two sexes, and it is usual for the mutism to be associated
with marked personality features involving social anxiety, withdrawal, sensitivity,
or resistance. Typically, the child speaks at home or with close friends and is
mute at school or with strangers, but other patterns (including the converse) can
occur.
Diagnostic guidelines
The diagnosis presupposes:
(a)a normal, or near-normal, level of language comprehension;
(b)a level of competence in language expression that is sufficient for social
communication;
(c)demonstrable evidence that the individual can and does speak normally or
almost normally in some situations.
However, a substantial minority of children with elective mutism have a history of
either some speech delay or articulation problems. The diagnosis may be made in
the presence of such problems provided that there is adequate language for
effective communication and a gross disparity in language usage according to the
social context, such that the child speaks fluently in some situations but is mute or
near-mute in others. There should also be demonstrable failure to speak in some
social situations but not in others. The diagnosis requires that the failure to speak
is persistent over time and that there is a consistency and predictability with
respect to the situations in which speech does and does not occur.
Other socio-emotional disturbances are present in the great majority of cases but
they do not constitute part of the necessary features for diagnosis. Such
disturbances do not follow a consistent pattern, but abnormal temperamental
features (especially social sensitivity, social anxiety, and social withdrawal) are
usual and oppositional behaviour is common.
- 219 Includes:
selective mutism
Excludes: pervasive developmental disorders (F84.-)
schizophrenia (F20.-)
specific developmental disorders of speech and language (F80.-)
transient mutism as part of separation anxiety in young children
(F93.0)
F94.1 Reactive attachment disorder of childhood
This disorder, occurring in infants and young children, is characterized by
persistent abnormalities in the child's pattern of social relationships, which are
associated with emotional disturbance and reactive to changes in environmental
circumstances. Fearfulness and hypervigilance that do not respond to comforting
are characteristic, poor social interaction with peers is typical, aggression towards
the self and others is very frequent, misery is usual, and growth failure occurs in
some cases. The syndrome probably occurs as a direct result of severe parental
neglect, abuse, or serious mishandling. The existence of this behavioural pattern
is well recognized and accepted, but there is continuing uncertainty regarding the
diagnostic criteria to be applied, the boundaries of the syndrome, and whether the
syndrome constitutes a valid nosological entity. However, the category is
included here because of the public health importance of the syndrome, because
there is no doubt of its existence, and because the behavioural pattern clearly does
not fit the criteria of other diagnostic categories.
Diagnostic guidelines
The key feature is an abnormal pattern of relationships with care-givers that
developed before the age of 5 years, that involves maladaptive features not
ordinarily seen in normal children, and that is persistent yet reactive to sufficiently
marked changes in patterns of rearing.
Young children with this syndrome show strongly contradictory or ambivalent
social responses that may be most evident at times of partings and reunions.
Thus, infants may approach with averted look, gaze strongly away while being
held, or respond to care-givers with a mixture of approach, avoidance, and
resistance to comforting. The emotional disturbance may be evident in apparent
misery, a lack of emotional responsiveness, withdrawal reactions such as huddling
on the floor, and/or aggressive responses to their own or others' distress.
Fearfulness and hypervigilance (sometimes described as "frozen watchfulness")
that are unresponsive to comforting occur in some cases. In most cases, the
children show interest in peer interactions but social play is impeded by negative
emotional responses. The attachment disorder may also be accompanied by a
failure to thrive physically and by impaired physical growth (which should be
coded according to the appropriate somatic category (R62)).
Many normal children show insecurity in the pattern of their selective attachment
to one or other parent, but this should not be confused with the reactive
attachment disorder which differs in several crucial respects. The disorder is
characterized by an abnormal type of insecurity shown in markedly contradictory
- 220 social
responses not ordinarily seen in normal children. The abnormal responses
extend across different social situations and are not confined to a dyadic
relationship with a particular care-giver; there is a lack of responsiveness to
comforting; and there is associated emotional disturbance in the form of apathy,
misery, or fearfulness.
Five main features differentiate this condition from pervasive developmental
disorders. First, children with a reactive attachment disorder have a normal
capacity for social reciprocity and responsiveness, whereas those with a pervasive
developmental disorder do not. Second, although the abnormal patterns of social
responses in a reactive attachment disorder are initially a general feature of the
child's behaviour in a variety of situations, they remit to a major degree if the child
is placed in a normal rearing environment that provides continuity in responsive
care-giving. This does not occur with pervasive developmental disorders. Third,
although children with reactive attachment disorders may show impaired
language development (of the type described under F80.1), they do not exhibit the
abnormal qualities of communication characteristic of autism. Fourth, unlike
autism, reactive attachment disorder is not associated with persistent and severe
cognitive deficits that do not respond appreciably to environmental change. Fifth,
persistently restricted, repetitive, and stereotyped patterns of behaviour, interests
and activities are not a feature of reactive attachment disorders.
Reactive attachment disorders nearly always arise in relation to grossly inadequate
child care. This may take the form of psychological abuse or neglect (as evidenced
by harsh punishment, persistent failure to respond to the child's overtures, or
grossly inept parenting), or of physical abuse or neglect (as evidenced by persistent
disregard of the child's basic physical needs, repeated deliberate injury, or
inadequate provision of nutrition). Because there is insufficient knowledge of the
consistency of association between inadequate child care and the disorder, the
presence of environmental privation and distortion is not a diagnostic
requirement. However, there should be caution in making the diagnosis in the
absence of evidence of abuse or neglect. Conversely, the diagnosis should not be
made automatically on the basis of abuse or neglect: not all abused or neglected
children manifest the disorder.
Excludes: Asperger's syndrome (F84.5)
disinhibited attachment disorder of childhood (F94.2)
maltreatment syndromes, resulting in physical problems (T74)
normal variation in pattern of selective attachment
sexual or physical abuse in childhood, resulting in psychosocial
problems (Z61.4-Z61.6)
F94.2 Disinhibited attachment disorder of childhood
A particular pattern of abnormal social functioning that arises during the first 5
years of life and that, having become established, shows a tendency to persist
despite marked changes in environmental circumstances. At age about 2 years it
is usually manifest by clinging and diffuse, non-selectively focused attachment
behaviour. By age 4 years, diffuse attachments remain but clinging tends to be
replaced by attention-seeking and indiscriminately friendly behaviour. In middle
- 221 and
later childhood, individuals may or may not have developed selective
attachments but attention-seeking behaviour often persists, and poorly modulated
peer interactions are usual; depending on circumstances, there may also be
associated emotional or behavioural disturbance. The syndrome has been most
clearly identified in children reared in institutions from infancy but it also occurs
in other situations; it is thought to be due in part to a persistent failure of
opportunity to develop selective attachments as a consequence of extremely
frequent changes in care-givers. The conceptual unity of the syndrome depends
on the early onset of diffuse attachments, continuing poor social interactions, and
lack of situation-specificity.
Diagnostic guidelines
Diagnosis should be based on evidence that the child showed an unusual degree
of diffuseness in selective attachments during the first 5 years and that this was
associated with generally clinging behaviour in infancy and/or indiscriminately
friendly, attention-seeking behaviour in early or middle childhood. Usually there
is difficulty in forming close, confiding relationships with peers. There may or
may not be associated emotional or behavioural disturbance (depending in part on
the child's current circumstances). In most cases there will be a clear history of
rearing in the first years that involved marked discontinuities in care-givers or
multiple changes in family placements (as with multiple foster family
placements).
Includes: affectionless psychopathy
institutional syndrome
Excludes: Asperger's syndrome (F84.5)
hospitalism in children (F43.2)
hyperkinetic or attention deficit disorder (F90.-)
reactive attachment disorder of childhood (F94.1)
F94.8 Other childhood disorders of social functioning
Includes: disorders of social functioning with withdrawal and shyness due to
social competence deficiencies
F94.9 Childhood disorder of social functioning, unspecified
F95 Tic disorders
The predominant manifestation in these syndromes is some form of tic. A tic is
an involuntary, rapid, recurrent, non-rhythmic motor movement (usually
involving circumscribed muscle groups), or vocal production, that is of sudden
onset and serves no apparent purpose. Tics tend to be experienced as irresistible
but they can usually be suppressed for varying periods of time. Both motor and
vocal tics may be classified as either simple or complex, although the boundaries
are not well defined. Common simple motor tics include eye-blinking,
- 222 neck-jerking,
shoulder-shrugging, and facial grimacing. Common simple vocal
tics include throat-clearing, barking, sniffing, and hissing. Common complex tics
include hitting one's self, jumping, and hopping. Common complex vocal tics
include the repetition of particular words, and sometimes the use of socially
unacceptable (often obscene) words (coprolalia), and the repetition of one's own
sounds or words (palilalia).
There is immense variation in the severity of tics. At the one extreme the
phenomenon is near-normal, with perhaps 1 in 5 to 1 in 10 children showing
transient tics at some time. At the other extreme, Tourette's syndrome is an
uncommon, chronic, incapacitating disorder. There is uncertainty about whether
these extremes represent different conditions or are opposite ends of the same
continuum; many authorities regard the latter as more likely. Tic disorders are
substantially more frequent in boys than in girls and a family history of tics is
common.
Diagnostic guidelines
The major features distinguishing tics from other motor disorders are the sudden,
rapid, transient, and circumscribed nature of the movements, together with the
lack of evidence of underlying neurological disorder; their repetitiveness; (usually)
their disappearance during sleep; and the ease with which they may be voluntarily
reproduced or suppressed. The lack of rhythmicity differentiates tics from the
stereotyped repetitive movements seen in some cases of autism or of mental
retardation. Manneristic motor activities seen in the same disorders tend to
comprise more complex and variable movements than those usually seen with
tics. Obsessive- compulsive activities sometimes resemble complex tics but differ
in that their form tends to be defined by their purpose (such as touching some
object or turning a number of times) rather than by the muscle groups involved;
however, the differentiation is sometimes difficult.
Tics often occur as an isolated phenomenon but not infrequently they are
associated with a wide variety of emotional disturbances, especially, perhaps,
obsessional and hypochondriacal phenomena. However, specific developmental
delays are also associated with tics.
There is no clear dividing line between tic disorder with some associated
emotional disturbance and an emotional disorder with some associated tics.
However, the diagnosis should represent the major type of abnormality.
F95.0 Transient tic disorder
Meets the general criteria for a tic disorder, but tics do not persist for longer than
12 months. This is the commonest form of tic and is most frequent about the age
of 4 or 5 years; the tics usually take the form of eye-blinking, facial grimacing, or
head-jerking. In some cases the tics occur as a single episode but in other cases
there are remissions and relapses over a period of months.
F95.1 Chronic motor or vocal tic disorder
- 223 Meets
the general criteria for a tic disorder, in which there are motor or vocal tics
(but not both); tics may be either single or multiple (but usually multiple), and
last for more than a year.
F95.2 Combined vocal and multiple motor tic disorder [de la Tourette's syndrome]
A form of tic disorder in which there are, or have been, multiple motor tics and
one or more vocal tics, although these need not have occurred concurrently.
Onset is almost always in childhood or adolescence. A history of motor tics before
development of vocal tics is common; the symptoms frequently worsen during
adolescence, and it is common for the disorder to persist into adult life.
The vocal tics are often multiple with explosive repetitive vocalizations,
throat-clearing, and grunting, and there may be the use of obscene words or
phrases. Sometimes there is associated gestural echopraxia, which also may be of
an obscene nature (copropraxia). As with motor tics, the vocal tics may be
voluntarily suppressed for short periods, be exacerbated by stress, and disappear
during sleep.
F95.8 Other tic disorders
F95.9 Tic disorder, unspecified
A non-recommended residual category for a disorder that fulfils the general
criteria for a tic disorder but in which the specific subcategory is not specified or
in which the features do not fulfil the criteria for F95.0, F95.1 or F95.2.
F98Other behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
This rubric comprises a heterogeneous group of disorders that share the
characteristic of onset in childhood but otherwise differ in many respects. Some
of the conditions represent well defined syndromes, but others are no more than
symptom complexes which lack nosological validity, but which are included
because of their frequency and association with psychosocial problems, and
because they cannot be incorporated into other syndromes.
Excludes: breath-holding attacks (R06.8)
gender identity disorder of childhood (F64.2)
hypersomnolence and megaphagia (Kleine-Levin syndrome) (G47.8)
obsessive-compulsive disorder (F42.-)
sleep disorders (F51.-)
F98.0 Nonorganic enuresis
A disorder characterized by involuntary voiding of urine, by day and/or by night,
which is abnormal in relation to the individual's mental age and which is not a
consequence of a lack of bladder control due to any neurological disorder, to
epileptic attacks, or to any structural abnormality of the urinary tract. The
enuresis may have been present from birth (i.e. an abnormal extension of the
normal infantile incontinence) or it may have arisen following a period of acquired
- 224 bladder
control. The later onset (or secondary) variety usually begins about the
age of 5 to 7 years. The enuresis may constitute a monosymptomatic condition or
it may be associated with a more widespread emotional or behavioural disorder.
In the latter case there is uncertainty over the mechanisms involved in the
association. Emotional problems may arise as a secondary consequence of the
distress or stigma that results from enuresis, the enuresis may form part of some
other psychiatric disorder, or both the enuresis and the emotional/behavioural
disturbance may arise in parallel from related etiological factors. There is no
straightforward, unambiguous way of deciding between these alternatives in the
individual case, and the diagnosis should be made on the basis of which type of
disturbance (i.e. enuresis or emotional/ behavioural disorder) constitutes the main
problem.
Diagnostic guidelines
There is no clear-cut demarcation between an enuresis disorder and the normal
variations in the age of acquisition of bladder control. However, enuresis would
not ordinarily be diagnosed in a child under the age of 5 years or with a mental
age under 4 years. If the enuresis is associated with some (other) emotional or
behavioural disorder, enuresis would normally constitute the primary diagnosis
only if the involuntary voiding of urine occurred at least several times per week
and if the other symptoms showed some temporal covariation with the enuresis.
Enuresis sometimes occurs in conjunction with encopresis; when this is the case,
encopresis should be diagnosed.
Occasionally, children develop transient enuresis as a result of cystitis or polyuria
(as from diabetes). However, these do not constitute a sufficient explanation for
enuresis that persists after the infection has been cured or after the polyuria has
been brought under control. Not infrequently, the cystitis may be secondary to an
enuresis that has arisen by ascending infection up the urinary tract as a result of
persistent wetness (especially in girls).
Includes: enuresis (primary) (secondary) of nonorganic origin
functional or psychogenic enuresis
urinary incontinence of nonorganic origin
Excludes: enuresis NOS (R32)
F98.1 Nonorganic encopresis
Repeated voluntary or involuntary passage of faeces, usually of normal or
near-normal consistency, in places not appropriate for that purpose in the
individual's own sociocultural setting. The condition may represent an abnormal
continuation of normal infantile incontinence, it may involve a loss of continence
following the acquisition of bowel control, or it may involve the deliberate
deposition of faeces in inappropriate places in spite of normal physiological bowel
control. The condition may occur as a monosymptomatic disorder, or it may
form part of a wider disorder, especially an emotional disorder (F93.-) or a
conduct disorder (F91.-).
- 225 Diagnostic
guidelines
The crucial diagnostic feature is the inappropriate placement of faeces. The
condition may arise in several different ways. First, it may represent a lack of
adequate toilet-training or of adequate response to training, with the history being
one of continuous failure ever to acquire adequate bowel control. Second, it may
reflect a psychologically determined disorder in which there is normal
physiological control over defecation but, for some reason, a reluctance, resistance,
or failure to conform to social norms in defecating in acceptable places. Third, it
may stem from physiological retention, involving impaction of faeces, with
secondary overflow and deposition of faeces in inappropriate places. Such
retention may arise from parent/child battles over bowel-training, from
withholding of faeces because of painful defecation (e.g. as a consequence of anal
fissure), or for other reasons.
In some instances, the encopresis may be accompanied by smearing of faeces over
the body or over the external environment and, less commonly, there may be anal
fingering or masturbation. There is usually some degree of associated
emotional/behavioural disturbance. There is no clear-cut demarcation between
encopresis with associated emotional/behavioural disturbance and some other
psychiatric disorder which includes encopresis as a subsidiary symptom. The
recommended guideline is to code encopresis if that is the predominant
phenomenon and the other disorder if it is not (or if the frequency of the
encopresis is less than once a month). Encopresis and enuresis are not
infrequently associated and, when this is the case, the coding of encopresis should
have precedence. Encopresis may sometimes follow an organic condition such as
anal fissure or a gastrointestinal infection; the organic condition should be the sole
coding if it constitutes a sufficient explanation for the faecal soiling but, if it serves
as precipitant but not a sufficient cause, encopresis should be coded (in addition to
the somatic condition).
Differential diagnosis. It is important to consider the following:
(a)encopresis due to organic disease such as aganglionic megacolon (Q43.1) or
spina bifida (Q05.-) (note, however, that encopresis may accompany or
follow conditions such as anal fissure or gastrointestinal infection);
(b)constipation involving faecal blockage resulting in "overflow" faecal soiling of
liquid or semiliquid faeces (K59.0); if, as happens in some cases, encopresis
and constipation coexist, encopresis should be coded (with an additional
code, if appropriate, to identify the cause of the constipation).
F98.2 Feeding disorder of infancy and childhood
A feeding disorder of varying manifestations, usually specific to infancy and early
childhood. It generally involves refusal of food and extreme faddiness in the
presence of an adequate food supply and a reasonably competent care-giver, and
the absence of organic disease. There may or may not be associated rumination
(repeated regurgitation without nausea or gastrointestinal illness).
Diagnostic guidelines
- 226 Minor
difficulties in eating are very common in infancy and childhood (in the
form of faddiness, supposed undereating, or supposed overeating). In themselves,
these should not be considered as indicative of disorder. Disorder should be
diagnosed only if the difficulties are clearly beyond the normal range, if the nature
of the eating problem is qualitatively abnormal in character, or if the child fails to
gain weight or loses weight over a period of at least 1 month.
Includes: rumination disorder of infancy
Differential diagnosis. It is important to differentiate this disorder from:
(a)conditions where the child readily takes food from adults other than the usual
care-giver;
(b)organic disease sufficient to explain the food refusal;
(c)anorexia nervosa and other eating disorders (F50.-);
(d)broader psychiatric disorder;
(e)pica (F98.3);
(f)feeding difficulties and mismanagement (R63.3).
F98.3 Pica of infancy and childhood
Persistent eating of non-nutritive substances (soil, paint chippings, etc). Pica may
occur as one of many symptoms of a more widespread psychiatric disorder (such
as autism), or as a relatively isolated psychopathological behaviour; only in the
latter case should this code be used. The phenomenon is most common in
mentally retarded children; if mental retardation is also present, it should be coded
(F70-79). However, pica may also occur in children (usually young children) of
normal intelligence.
F98.4 Stereotyped movement disorders
Voluntary, repetitive, stereotyped, nonfunctional (and often rhythmic)
movements that do not form part of any recognized psychiatric or neurological
condition. When such movements occur as symptoms of some other disorder,
only the overall disorder should be coded (i.e. F98.4 should not be used). The
movements that are noninjurious include: body-rocking, head-rocking,
hair-plucking, hair-twisting, finger-flicking mannerisms, and hand-flapping.
(Nail-biting, thumb-sucking, and nose-picking should not be included as they are
not good indicators of psychopathology, and are not of sufficient public health
importance to warrant classification.) Stereotyped self-injurious behaviour
includes repetitive head-banging, face-slapping, eye-poking, and biting of hands,
lips or other body parts. All the stereotyped movement disorders occur most
frequently in association with mental retardation; when this is the case, both
disorders should be coded.
Eye-poking is particularly common in children with visual impairment.
However, the visual disability does not constitute a sufficient explanation, and
when both eye-poking and blindness (or partial blindness) occur, both should be
coded: eye-poking under F98.4 and the visual condition under the appropriate
somatic disorder code.
- 227 Excludes:
abnormal involuntary movements (R25.-)
movement disorders of organic origin (G20-G26)
nail-biting, nose-picking, thumb-sucking (F98.8)
obsessive-compulsive disorder (F42.-)
stereotypies that are part of a broader psychiatric condition (such as
pervasive developmental disorder)
tic disorders (F95.-)
trichotillomania (F63.3)
F98.5 Stuttering [stammering]
Speech that is characterized by frequent repetition or prolongation of sounds or
syllables or words, or by frequent hesitations or pauses that disrupt the rhythmic
flow of speech. Minor dysrhythmias of this type are quite common as a transient
phase in early childhood, or as a minor but persistent speech feature in later
childhood and adult life. They should be classified as a disorder only if their
severity is such as markedly to disturb the fluency of speech. There may be
associated movements of the face and/or other parts of the body that coincide in
time with the repetitions, prolongations, or pauses in speech flow. Stuttering
should be differentiated from cluttering (see below) and from tics. In some cases
there may be an associated developmental disorder of speech or language, in
which case this should be separately coded under F80.-.
Excludes: cluttering (F98.6)
neurological disorder giving rise to speech dysrhythmias (Chapter VI
of ICD-10)
obsessive-compulsive disorder (F42.-)
tic disorders (F95.-)
F98.6 Cluttering
A rapid rate of speech with breakdown in fluency, but no repetitions or
hesitations, of a severity to give rise to reduced speech intelligibility. Speech is
erratic and dysrhythmic, with rapid, jerky spurts that usually involve faulty
phrasing patterns (e.g. alternating pauses and bursts of speech, producing groups
of words unrelated to the grammatical structure of the sentence).
Excludes: neurological disorder giving rise to speech dysrhythmias (Chapter VI
of ICD-10)
obsessive-compulsive disorder (F42.-)
stuttering (F98.5)
tic disorders (F95.-)
F98.8 Other specified behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
Includes: attention deficit disorder without hyperactivity
(excessive) masturbation
nail-biting
nose-picking
- 228 -
thumb-sucking
F98.9Unspecified behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
F99 Mental disorder, not otherwise specified
Non-recommended residual category, when no other code from F00-F98 can be used.
- 229 -
ANNEX
OTHER CONDITIONS FROM ICD-10 OFTEN ASSOCIATED WITH
MENTAL AND BEHAVIOURAL DISORDERS
This appendix contains a list of conditions in other chapters of ICD-10 that are
often found in association with the disorders in Chapter V(F) itself. They are
provided here so that psychiatrists recording diagnoses by means of the Clinical
Descriptions and Diagnostic Guidelines have immediately to hand the ICD terms
and codes that cover the associated diagnoses most likely to be encountered in
ordinary clinical practice. The majority of the conditions covered are given only
at the three-character level, but four-character codes are given for a selection of
those diagnoses that will be used most frequently.
Chapter I
Certain infectious and parasitic diseases (A00-B99)
A50 Congenital syphilis
A50.4 Late congenital neurosyphilis [juvenile neurosyphilis]
A52 Late syphilis
A52.1 Symptomatic neurosyphilis
Includes: tabes dorsalis
A81 Slow virus infections of central nervous system
A81.0 Creutzfeldt-Jakob disease
A81.1 Subacute sclerosing panencephalitis
A81.2 Progressive multifocal leukoencephalopathy
B22Human immunodeficiency virus (HIV) disease resulting in other specified diseases
B22.0 HIV disease resulting in encephalopathy
Includes: HIV dementia
Chapter II
Neoplasms (C00-D48)
C70.- Malignant neoplasm of meninges
C71.- Malignant neoplasm of brain
C72.-Malignant neoplasm of spinal cord, cranial nerves and other parts of central
nervous system
D33.-Benign neoplasm of brain and other parts of central nervous system
- 230 D42.-Neoplasm
of uncertain and unknown behaviour of meninges
D43.-Neoplasm of uncertain and unknown behaviour of brain and central nervous
system
Chapter IV
Endocrine, nutritional and metabolic diseases (E00-E90)
E00.- Congenital iodine-deficiency syndrome
E01.- Iodine-deficiency-related thyroid disorders and allied conditions
E02 Subclinical iodine-deficiency hypothyroidism
E03 Other hypothyroidism
E03.2 Hypothyroidism due to medicaments and other exogenous
substances
E03.5 Myxoedema coma
E05.- Thyrotoxicosis [hyperthyroidism]
E15 Nondiabetic hypoglycaemic coma
E22 Hyperfunction of pituitary gland
E22.0 Acromegaly and pituitary gigantism
E22.1 Hyperprolactinaemia
Includes: drug-induced hyperprolactinaemia
E23.- Hypofunction and other disorders of pituitary gland
E24.- Cushing's syndrome
E30 Disorders of puberty, not elsewhere classified
E30.0 Delayed puberty
E30.1 Precocious puberty
E34 Other endocrine disorders
E34.3 Short stature, not elsewhere classified
E51 Thiamine deficiency
E51.2 Wernicke's encephalopathy
E64.- Sequelae of malnutrition and other nutritional deficiencies
E66.- Obesity
E70 Disorders of aromatic amino-acid metabolism
E70.0 Classical phenylketonuria
E71Disorders of branched-chain amino-acid metabolism and fatty-acid metabolism
- 231 E71.0
Maple-syrup-urine disease
E74.- Other disorders of carbohydrate metabolism
E80.- Disorders of porphyrin and bilirubin metabolism
Chapter VI
Diseases of the nervous system (G00-G99)
G00.- Bacterial meningitis, not elsewhere classified
Includes: haemophilus, pneumococcal, streptococcal, staphylococcal and
other
bacterial meningitis
G02.- Meningitis in other infectious and parasitic diseases classified elsewhere
G03.- Meningitis due to other and unspecified causes
G04.- Encephalitis, myelitis and encephalomyelitis
G06 Intracranial and intraspinal abscess and granuloma
G06.2 Extradural and subdural abscess, unspecified
G10 Huntington's disease
G11.- Hereditary ataxia
G20 Parkinson's disease
G21 Secondary parkinsonism
G21.0 Malignant neuroleptic syndrome
G21.1 Other drug-induced secondary parkinsonism
G21.2 Secondary parkinsonism due to other external agents
G21.3 Postencephalitic parkinsonism
G24 Dystonia
Includes: dyskinesia
G24.0 Drug-induced dystonia
G24.3 Spasmodic torticollis
G24.8 Other dystonia
Includes: tardive dyskinesia
G25.- Other extrapyramidal and movement disorders
Includes:restless legs syndrome, drug-induced tremor, myoclonus, chorea,
tics
- 232 G30
Alzheimer's disease
G30.0 Alzheimer's disease with early onset
G30.1 Alzheimer's disease with late onset
G30.8 Other Alzheimer's disease
G30.9 Alzheimer's disease, unspecified
G31 Other degenerative diseases of nervous system, not elsewhere classified
G31.0 Circumscribed brain atrophy
Includes: Pick's disease
G31.1 Senile degeneration of brain, not elsewhere classified
G31.2 Degeneration of nervous system due to alcohol
Includes: alcoholic cerebellar ataxia and degeneration, cerebral
degeneration
and encephalopathy; dysfunction of the autonomic nervous
system due to alcohol
G31.8 Other specified degenerative diseases of the nervous system
Includes: Subacute necrotizing encephalopathy [Leigh] grey-matter
degeneration [Alpers]
G31.9 Degenerative disease of nervous system, unspecified
G32.-Other degenerative disorders of nervous system in diseases classified elsewhere
G35 Multiple sclerosis
G37 Other demyelinating diseases of central nervous system
G37.0 Diffuse sclerosis
Includes: periaxial encephalitis; Schilder's disease
G40 Epilepsy
G40.0Localization-related (focal) (partial) idiopathic epilepsy and epileptic
syndromes with seizures of localized onset
Includes: benign childhood epilepsy with centrotemporal EEG spikes or
occipital EEG paroxysms
G40.1Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with simple partial seizures
Includes: attacks without alteration of consciousness
G40.2Localization-related (focal) (partial) symptomatic epilepsy and
epileptic syndromes with complex partial seizures
- 233 Includes:
attacks with alteration of consciousness, often with automatisms
G40.3Generalized idiopathic epilepsy and epileptic syndromes
G40.4Other generalized epilepsy and epileptic syndromes
Includes: salaam attacks
G40.5 Special epileptic syndromes
Includes: epileptic seizures related to alcohol, drugs and sleep deprivation
G40.6 Grand mal seizures, unspecified (with or without petit mal)
G40.7 Petit mal, unspecified, without grand mal seizures
G41.- Status epilepticus
G43.- Migraine
G44.- Other headache syndromes
G45.- Transient cerebral ischaemic attacks and related syndromes
G47 Sleep disorders
G47.2 Disorders of the sleep-wake schedule
G47.3 Sleep apnoea
G47.4 Narcolepsy and cataplexy
G70 Myasthenia gravis and other myoneural disorders
G70.0 Myasthenia gravis
G91.- Hydrocephalus
G92 Toxic encephalopathy
G93 Other disorders of brain
G93.1 Anoxic brain damage, not elsewhere classified
G93.3 Postviral fatigue syndrome
Includes: benign myalgic encephomyelitis
G93.4 Encephalopathy, unspecified
G97 Postprocedural disorders of nervous system, not elsewhere classified
G97.0 Cerebrospinal fluid leak from spinal puncture
Chapter VII
Diseases of the eye and adnexa (H00-H59)
H40 Glaucoma
H40.6 Glaucoma secondary to drugs
- 234 Chapter
VIII
Diseases of the ear and mastoid process (H60-H95)
H93 Other disorders of ear, not elsewhere classified
H93.1 Tinnitus
Chapter IX
Diseases of the circulatory system (I00-I99)
I10 Essential (primary) hypertension
I60.- Subarachnoid haemorrhage
I61.- Intracerebral haemorrhage
I62 Other nontraumatic intracranial haemorrhage
I62.0 Subdural haemorrhage (acute) (nontraumatic)
I62.1 Nontraumatic extradural haemorrhage
I63.- Cerebral infarction
I64 Stroke, not specified as haemorrhage or infarction
I65.- Occlusion and stenosis of precerebral arteries, not resulting in cerebral
infarction
I66.- Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction
I67 Other cerebrovascular diseases
I67.2 Cerebral atherosclerosis
I67.3 Progressive vascular leukoencephalopathy
Includes: Binswanger's disease
I67.4 Hypertensive encephalopathy
I69.- Sequelae of cerebrovascular disease
I95 Hypotension
I95.2 Hypotension due to drugs
Chapter X
Diseases of the respiratory system (J00-J99)
J10 Influenza due to identified influenza virus
J10.8 Influenza with other manifestations, influenza virus identified
J11 Influenza, virus not identified
- 235 J11.8
Influenza with other manifestations, virus not identified
J42 Unspecified chronic bronchitis
J43.- Emphysema
J45.- Asthma
Chapter XI
Diseases of the digestive system (K00-K93)
K25 Gastric ulcer
K26 Duodenal ulcer
K27 Peptic ulcer, site unspecified
K29 Gastritis and duodenitis
K29.2 Alcoholic gastritis
K30 Dyspepsia
K58.- Irritable bowel syndrome
K59.- Other functional intestinal disorders
K70.- Alcoholic liver disease
K71.- Toxic liver disease
Includes: drug-induced liver disease
K86 Other diseases of pancreas
K86.0 Alcohol-induced chronic pancreatitis
Chapter XII
Diseases of the skin and subcutaneous tissue (L00-L99)
L20.- Atopic dermatitis
L98 Other disorders of skin and subcutaneous tissue, not elsewhere classified
L98.1 Factitial dermatitis
Includes: neurotic excoriation
Chapter XIII
Diseases of the musculoskeletal system and connective tissue
(M00-M99)
- 236 M32.-
Systemic lupus erythematosus
M54.- Dorsalgia
Chapter XIV
Diseases of the genitourinary system (N00-N99)
N48 Other disorders of penis
N48.3 Priapism
N48.4 Impotence of organic origin
N91.- Absent, scanty and rare menstruation
N94Pain and other conditions associated with female genital organs and menstrual
cycle
N94.3 Premenstrual tension syndrome
N94.4 Primary dysmenorrhoea
N94.5 Secondary dysmenorrhoea
N94.6 Dysmenorrhoea, unspecified
N95 Menopausal and other perimenopausal disorders
N95.1 Menopausal and female climacteric states
N95.3 States associated with artificial menopause
Chapter XV
Pregnancy, childbirth and the puerperium (O00-O99)
O04 Medical abortion
O35 Maternal care for known or suspected fetal abnormality and damage
O35.4Maternal care for (suspected) damage to fetus from alcohol
O35.5 Maternal care for (suspected) damage to fetus by drugs
O99Other maternal diseases classifiable elsewhere but complicating pregnancy,
childbirth and puerperium
O99.3Mental disorders and diseases of the nervous system complicating
pregnancy, childbirth and the puerperium
Includes: conditions in F00-F99 and G00-G99
Chapter XVII
Congenital malformations, deformations, and chromosomal
abnormalities (Q00-Q99)
Q02 Microcephaly
Q03.- Congenital hydrocephalus
- 237 Q04.-
Other congenital malformations of brain
Q05.- Spina bifida
Q75.- Other congenital malformations of skull and face bones
Q85 Phakomatoses, not elsewhere classified
Q85.0 Neurofibromatosis (nonmalignant)
Q85.1 Tuberous sclerosis
Q86Congenital malformation syndromes due to known exogenous causes, not
elsewhere classified
Q86.0 Fetal alcohol syndrome (dysmorphic)
Q90 Down's syndrome
Q90.0 Trisomy 21, meiotic nondisjunction
Q90.1 Trisomy 21, mosaicism (mitotic nondisjunction)
Q90.2 Trisomy 21, translocation
Q90.9 Down's syndrome, unspecified
Q91.- Edwards' syndrome and Patau's syndrome
Q93 Monosomies and deletions from the autosomes, not elsewhere classified
Q93.4 Deletion of short arm of chromosome 5
Includes: cri-du-chat syndrome
Q96.- Turner's syndrome
Q97.-Other sex chromosome abnormalities, female phenotype, not elsewhere
classified
Q98Other sex chromosome abnormalities, male phenotype, not elsewhere classified
Q98.0 Klinefelter's syndrome karyotype 47, XXY
Q98.1 Klinefelter's syndrome, male with more than two X chromosomes
Q98.2 Klinefelter's syndrome, male with 46, XX karyotype
Q98.4 Klinefelter's syndrome, unspecified
Q99.- Other chromosome abnormalities, not elsewhere classified
Chapter XVIII
Symptoms, signs and abnormal clinical and laboratory findings, not
elsewhere classified (R00-R99)
R55 Syncope and collapse
R56 Convulsions, not elsewhere classified
R56.0 Febrile convulsions
R56.8 Other and unspecified convulsions
- 238 R62
Lack of expected normal physiological development
R62.0 Delayed milestone
R62.8 Other lack of expected normal physiological development
R62.9Lack of expected normal physiological development, unspecified
R63 Symptoms and signs concerning food and fluid intake
R63.0 Anorexia
R63.1 Polydipsia
R63.4 Abnormal weight loss
R63.5 Abnormal weight gain
R78.- Findings of drugs and other substances, normally not found in blood
Includes: alcohol (R78.0); opiate drug (R78.1); cocaine (R78.2);
hallucinogen (R78.3); other drugs of addictive
potential (R78.4);
psychotropic drug (R78.5); abnormal level of lithium (R78.8)
R83 Abnormal findings in cerebrospinal fluid
R90.- Abnormal findings on diagnostic imaging of central nervous system
R94 Abnormal results of function studies
R94.0 Abnormal results of function studies of central nervous system
Includes: abnormal electroencephalogram [EEG]
Chapter XIX
Injury, poisoning and certain other consequences of external causes
(S00-T98)
S06 Intracranial injury
S06.0 Concussion
S06.1 Traumatic cerebral oedema
S06.2 Diffuse brain injury
S06.3 Focal brain injury
S06.4 Epidural haemorrhage
S06.5 Traumatic subdural haemorrhage
S06.6 Traumatic subarachnoid haemorrhage
S06.7 Intracranial injury with prolonged coma
Chapter XX
External causes of morbidity and mortality (V0I-Y98)
Intentional self-harm (X60-X84)
Includes: purposely self-inflicted poisoning or injury; suicide
- 239 X60Intentional
self-poisoning by and exposure to nonopioid analgesics, antipyretics
and antirheumatics
X61Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic,
antiparkinsonism and psychotropic drugs, not elsewhere classified
Includes: antidepressants, barbiturates, neuroleptics, psychostimulants
X62Intentional self-poisoning by and exposure to narcotics and psychodysleptics
[hallucinogens], not elsewhere classified
Includes: cannabis (derivatives), cocaine, codeine, heroin, lysergide
[LSD],
mescaline, methadone, morphine, opium (alkaloids)
X63Intentional self-poisoning by and exposure to other drugs acting on the
autonomic nervous systems
X64Intentional self-poisoning by and exposure to other and unspecified drugs and
biological substances
X65Intentional self-poisoning by and exposure to alcohol
X66Intentional self-poisoning by and exposure to organic solvents and halogenated
hydrocarbons and their vapours
X67Intentional self-poisoning by and exposure to other gases and vapours
Includes: carbon monoxide; utility gas
X68 Intentional self-poisoning by and exposure to pesticides
X69Intentional self-poisoning by and exposure to other and unspecified chemicals
and noxious substances
Includes: corrosive aromatics, acids and caustic alkalis
X70 Intentional self-harm by hanging, strangulation and suffocation
X71 Intentional self-harm by drowning and submersion
X72 Intentional self-harm by handgun discharge
X73 Intentional self-harm by rifle, shotgun and larger firearm discharge
X74 Intentional self-harm by other and unspecified firearm discharge
X75 Intentional self-harm by explosive material
X76 Intentional self-harm by fire and flames
X77 Intentional self-harm by steam, hot vapours and hot objects
X78 Intentional self-harm by sharp object
- 240 X79
Intentional self-harm by blunt object
X80 Intentional self-harm by jumping from a high place
X81 Intentional self-harm by jumping or lying before moving object
X82 Intentional self-harm by crashing of motor vehicle
X83 Intentional self-harm by other specified means
Includes: crashing of aircraft, electrocution, caustic substances
(except poisoning)
X84 Intentional self-harm by unspecified means
Assault (X85-Y09)
Includes: homicide; injuries inflicted by another person with intent to
injure or kill, by any means
X93 Assault by handgun discharge
X99 Assault by sharp object
Y00 Assault by blunt object
Y04 Assault by bodily force
Y05 Sexual assault by bodily force
Y06.- Neglect and abandonment
Y07.- Other maltreatment syndromes
Includes: mental cruelty; physical abuse; sexual abuse; torture
Drugs, medicaments and biological substances causing adverse
effects in therapeutic use (Y40-Y59)
Y46 Antiepileptics and antiparkinsonism drugs
Y46.7 Antiparkinsonism drugs
Y47.- Sedatives, hypnotics and antianxiety drugs
Y49 Psychotropic drugs, not elsewhere classified
Y49.0 Tricyclic and tetracyclic antidepressants
Y49.1 Monoamine-oxidase-inhibitor antidepressants
Y49.2 Other and unspecified antidepressants
Y49.3 Phenothiazine antipsychotics and neuroleptics
- 241 Y49.4
Butyrophenone and thioxanthene neuroleptics
Y49.5 Other antipsychotics and neuroleptics
Y49.6 Psychodysleptics [hallucinogens]
Y49.7 Psychostimulants with abuse potential
Y49.8 Other psychotropic drugs, not elsewhere classified
Y49.9 Psychotropic drug, unspecified
Y50.- Central nervous system stimulants, not elsewhere classified
Y51.- Drugs primarily affecting the autonomic nervous system
Y57.- Other and unspecified drugs and medicaments
Chapter XXI
Factors influencing health status and contact with health services (Z00-Z99)
Z00General examination and investigation of persons without complaint and
reported diagnosis
Z00.4General psychiatric examination, not elsewhere classified
Z02Examination and encounter for administrative purposes
Z02.3Examination for recruitment to armed forces
Z02.4Examination for driving licence
Z02.6Examination for insurance purposes
Z02.7Issue of medical certificate
Z03Medical observation and evaluation for suspected diseases and conditions
Z03.2Observation for suspected mental and behavioural disorders
Includes:observation for dissocial behaviour, fire-setting, gang activity, and
shoplifting, without manifest psychiatric disorder
Z04Examination and observation for other reasons
Includes:examination for medicolegal reasons
Z04.6General psychiatric examination, requested by authority
Z50Care involving use of rehabilitation procedures
Z50.2Alcohol rehabilitation
Z50.3Drug rehabilitation
Z50.4Psychotherapy, not elsewhere classified
Z50.7Occupational therapy and vocational rehabilitation, not elsewhere classified
Z50.8Care involving use of other specified rehabilitation procedures
Includes: tobacco abuse rehabilitation
- 242 training
in activities of daily living [ADL]
Z54Convalescence
Z54.3Convalescence following psychotherapy
Z55.-Problems related to education and literacy
Z56.-Problems related to employment and unemployment
Z59.-Problems related to housing and economic circumstances
Z60Problems related to social environment
Z60.0Problems of adjustment to life-cycle transitions
Z60.1Atypical parenting situation
Z60.2Living alone
Z60.3Acculturation difficulty
Z60.4Social exclusion and rejection
Z60.5Target of perceived adverse discrimination and persecution
Z60.8Other specified problems related to social environment
Z61Problems related to negative life events in childhood
Z61.0Loss of love relationship in childhood
Z61.1Removal from home in childhood
Z61.2Altered pattern of family relationships in childhood
Z61.3Events resulting in loss of self-esteem in childhood
Z61.4Problems related to alleged sexual abuse of child by person within primary
support group
Z61.5Problems related to alleged sexual abuse of child by person outside primary
support group
Z61.6Problems related to alleged physical abuse of child
Z61.7Personal frightening experience in childhood
Z61.8Other negative life events in childhood
Z62Other problems related to upbringing
Z62.0Inadequate parental supervision and control
Z62.1Parental overprotection
Z62.2Institutional upbringing
Z62.3Hostility towards and scapegoating of child
Z62.4Emotional neglect of child
Z62.5Other problems related to neglect in upbringing
Z62.6Inappropriate parental pressure and other abnormal qualities of upbringing
Z62.8Other specified problems related to upbringing
Z63Other problems related to primary support group, including family
circumstances
Z63.0Problems in relationship with spouse or partner
Z63.1Problems in relationship with parents and in-laws
Z63.2Inadequate family support
Z63.3Absence of family member
- 243 Z63.4Disappearance
and death of family member
Z63.5Disruption of family by separation and divorce
Z63.6Dependent relative needing care at home
Z63.7Other stressful life events affecting family and household
Z63.8Other specified problems related to primary support group
Z64Problems related to certain psychosocial circumstances
Z64.0Problems related to unwanted pregnancy
Z64.2Seeking and accepting physical, nutritional and chemical interventions
known to be hazardous and harmful
Z64.3Seeking and accepting behavioural and psychological interventions known
to be hazardous and harmful
Z64.4Discord with counsellors
Includes: probation officer; social worker
Z65Problems related to other psychosocial circumstances
Z65.0Conviction in civil and criminal proceedings without imprisonment
Z65.1Imprisonment and other incarceration
Z65.2Problems related to release from prison
Z65.3Problems related to other legal circumstances
Includes: arrest
child custody or support proceedings
Z65.4Victim of crime and terrorism (including torture)
Z65.5Exposure to disaster, war and other hostilities
Z70.-Counselling related to sexual attitude, behaviour and orientation
Z71Persons encountering health services for other counselling and medical
advice, not elsewhere classified
Z71.4Alcohol abuse counselling and surveillance
Z71.5Drug abuse counselling and surveillance
Z71.6Tobacco abuse counselling
Z72Problems relating to lifestyle
Z72.0Tobacco use
Z72.1Alcohol use
Z72.2Drug use
Z72.3Lack of physical exercise
Z72.4Inappropriate diet and eating habits
Z72.5High-risk sexual behaviour
Z72.6Gambling and betting
Z72.8Other problems related to lifestyle
Includes: self-damaging behaviour
- 244 Z73Problems
related to life-management difficulty
Z73.0Burn-out
Z73.1Accentuation of personality traits
Includes:type A behaviour pattern
Z73.2Lack of relaxation or leisure
Z73.3Stress, not elsewhere classified
Z73.4Inadequate social skills, not elsewhere classified
Z73.5Social role conflict, not elsewhere classified
Z75Problems related to medical facilities and other health care
Z75.1Person awaiting admission to adequate facility elsewhere
Z75.2Other waiting period for an investigation and treatment
Z75.5Holiday relief care
Z76Persons encountering health services in other circumstances
Z76.0Issue of repeat prescription
Z76.5Malingerer [conscious simulation]
Includes: persons feigning illness with obvious motivation
Z81Family history of mental and behavioural disorders
Z81.0Family history of mental retardation
Z81.1Family history of alcohol abuse
Z81.3Family history of other psychoactive substance abuse
Z81.8Family history of other mental and behavioural disorders
Z82Family history of certain disabilities and chronic diseases leading to
disablement
Z82.0Family history of epilepsy and other diseases of the nervous system
Z85.-Personal history of malignant neoplasm
Z86Personal history of certain other diseases
Z86.0Personal history of other neoplasms
Z86.4Personal history of psychoactive substance abuse
Z86.5Personal history of other mental and behavioural disorders
Z86.6Personal history of diseases of the nervous system and sense organs
Z87Personal history of other diseases and conditions
Z87.7Personal history of congenital malformations, deformations and
chromosomal abnormalities
Z91Personal history of risk-factors, not elsewhere classified
Z91.1Personal history of noncompliance with medical treatment and regimen
Z91.4Personal history of psychological trauma, not elsewhere classified
Z91.5Personal history of self-harm
- 245 Includes:
parasuicide; self-poisoning; suicide attempt
- 246 List
of principal investigators
Field trials of the ICD-10 proposals involved researchers and clinicians in some 110
institutes in 40 countries. Their efforts and comments were of great importance for the
successive revisions of the first draft of the classification and the clinical descriptions
and diagnostic guidelines. All principal investigators are named below. The individuals
who produced the initial drafts of the classification and guidelines are marked with an
asterisk.
Australia
Dr P.J.V. Beumont (Sydney)
Dr E. Blackmore (Nedlands)
Dr R. Davidson (Nedlands)
Ms C.R. Dossetor (Melbourne)
Dr G.A. German (Nedlands)
*Dr A.S. Henderson (Canberra)
Dr H.E. Herrman (Melbourne)
Dr G. Johnson (Perth)
Dr A.F. Jorm (Canberra)
Dr S.D. Joshua (Melbourne)
Dr S. Kisely (Perth)
Dr T. Lambert (Nedlands)
Dr P.D. McGorry (Melbourne)
Dr I. Pilowski (Adelaide)
Dr J. Saunders (Camperdown)
Dr B. Singh (Melbourne)
Austria
Dr P. Berner (Vienna)
Dr H. Katschnig (Vienna)
Dr G. Koinig (Vienna)
Dr K. Meszaros (Vienna)
Dr P. Schuster (Vienna)
*Dr H. Strotzka (Vienna)
Bahrain
Dr M.K. Al-Haddad
Dr C.A. Kamel
Dr M.A. Mawgoud
Belgium
Dr D. Bobon (Liège)
Dr C. Mormont (Liège)
Dr W. Vandereyken (Louvain)
Brazil
- 247 Dr
P.B. Abreu (Porto Alegre)
Dr N. Bezerra (Porto Alegre)
Dr M. Bugallo (Pelotas)
Dr E. Busnello (Porto Alegre)
Dr D. Caetano (Campinas)
Dr C. Castellarin (Porto Alegre)
Dr M.L.F. Chaves (Porto Alegre)
Dr D. Coniberti (Pelotas)
Dr V. Damiani (Pelotas)
Dr M.P.A. Fleck (Porto Alegre)
Dr M.K. Gehlen (Porto Alegre)
Dr D. Hilton Post (Pelotas)
Dr L. Knijnik (Porto Alegre)
Dr M. Knobel (Campinas)
Dr P.S.P. Lima (Porto Alegre)
Dr S. Olivé Leite (Pelotas)
Dr C.M.S. Osorio (Porto Alegre)
Dr F. Resmini (Pelotas)
Dr G. Soares (Porto Alegre)
Dr A.P. Santin (Porto Alegre)
Dr S.B. Zimmer (Porto Alegre)
Bulgaria
Dr M. Boyadjieva (Sofia)
Dr A. Jablensky (Sofia)
Dr K. Kirov (Sofia)
Dr V. Milanova (Sofia)
Dr V. Nikolov (Sofia)
Dr I. Temkov (Sofia)
Dr K. Zaimov (Sofia)
Canada
Dr J. Beitchman (London)
Dr D. Bendjilali (Baie-Comeau)
Dr D. Berube (Baie-Comeau)
Dr D. Bloom (Verdun)
Dr D. Boisvert (Baie-Comeau)
Dr R. Cooke (London)
Dr A.J. Cooper (St Thomas)
Dr J.J. Curtin (London)
Dr J.L. Deinum (London)
Dr M.L.D. Fernando (St Thomas)
Dr P. Flor-Henry (Edmonton)
Dr L. Gaborit (Baie-Comeau)
Dr P.D. Gatfield (London)
Dr A. Gordon (Edmonton)
- 248 Dr
J.A. Hamilton (Toronto)
Dr G.P. Harnois (Verdun)
Dr G. Hasey (London)
Dr W.-T. Hwang (Toronto)
Dr H. Iskandar (Verdun)
Dr B. Jean (Verdun)
Dr W. Jilek (Vancouver)
Dr D.L. Keshav (London)
Dr M. Koilpillai (Edmonton)
Dr M. Konstantareas (London)
Dr T. Lawrence (Toronto)
Dr M. Lalinec (Verdun)
Dr G. Lefebvre (Edmonton)
Dr H. Lehmann (Montreal)
*Dr Z. Lipowski (Toronto)
Dr B.L. Malhotra (London)
Dr R. Manchanda (St Thomas)
Dr H. Merskey (London)
Dr J. Morin (Verdun)
Dr N.P.V. Nair (Verdun)
Dr J. Peachey (Toronto)
Dr B. Pedersen (Toronto)
Dr E. Persad (London)
Dr G. Remington (London)
Dr P. Roper (Verdun)
Dr C. Ross (Winnipeg)
Dr S.S. Sandhu (St Thomas)
Dr M. Sharma (Verdun)
Dr M. Subak (Verdun)
Dr R.S. Swaminath (St Thomas)
Dr G.N. Swamy (St Thomas)
Dr V.R. Velamoor (St Thomas)
Dr K. Zukowska (Baie-Comeau)
China
Dr He Wei (Chengdu)
Dr Huang Zong-mei (Shanghai)
Dr Liu Pei-yi (Chengdu)
Dr Liu Xie-he (Chengdu)
*Dr Shen Yu-cun (Beijing)
Dr Song Wei-sheng (Chengdu)
Dr Xu Tao-yuan (Shanghai)
Dr Xu Yi-feng (Shanghai)
*Dr Xu You-xin (Beijing)
Dr Yang De-sen (Changsha)
Dr Yang Quan (Chengdu)
Dr Zhang Lian-di (Shanghai)
- 249 -
Colombia
Dr A. Acosta (Cali)
Dr W. Arevalo (Cali)
Dr A. Calvo (Cali)
Dr E. Castrillon (Cali)
Dr C.E. Climent (Cali)
Dr L.V. de Aragon (Cali)
Dr M.V. de Arango (Cali)
Dr G. Escobar (Cali)
Dr L.F. Gaviria (Cali)
Dr C.H. Gonzalez (Cali)
Dr C.A. Léon (Cali)
Dr S. Martinez (Cali)
Dr R. Perdomo (Cali)
Dr E. Zambrano (Cali)
Costa Rica
Dr E. Madrigal-Segura (San José)
Côte d'Ivoire
Dr B. Claver (Abidjan)
Cuba
Dr C. Acosta Nodal (Havana)
Dr C. Acosta Rabassa (Manzanillo)
Dr O. Ares Freijo (Havana)
Dr A. Castro Gonzalez (Manzanillo)
Dr J. Cueria Basulto (Manzanillo)
Dr C. Dominguez Abreu (Havana)
Dr F. Duarte Castaneda (Havana)
Dr O.A. Freijo (Havana)
Dr F. Galan Rubi (Havana)
Dr A.C. Gonzalez (Manzanillo)
Dr R. Gonzalez Menendez (Havana)
Dr M. Guevara Machado (Havana)
Dr H. Hernandez Elias (Pinar del Rio)
Dr R. Hernandez Rios (Havana)
Dr M. Leyva Concepcion (Havana)
Dr M. Ochoa Cortina (Havana)
Dr A. Otero Ojeda (Havana)
Dr L. de la Parte Perez (Havana)
Dr V. Ravelo Perez (Havana)
Dr M. Ravelo Salazar (Havana)
Dr R.H. Rios (Havana)
Dr J. Rodriguez Garcia (Havana)
Dr T. Rodriguez Lopez (Pinar del Rio)
- 250 Dr
E. Sabas Moraleda (Havana)
Dr M.R. Salazar (Havana)
Dr H. Suarez Ramos (Havana)
Dr I. Valdes Hidalgo (Havana)
Dr C. Vasallo Mantilla (Havana)
Czechoslovakia
Dr P. Baudis (Prague)
Dr V. Filip (Prague)
Dr D. Seifertova (Prague)
Dr D. Taussigova (Prague)
Denmark
Dr J. Aagaard (Aarhus)
Dr J. Achton (Aarhus)
Dr E. Andersen (Odense)
Dr T. Arngrim (Aarhus)
Dr E. Bach Jensen (Aarhus)
Dr U. Bartels (Aarhus)
Dr P. Bech (Hillerod)
Dr A. Bertelsen (Aarhus)
Dr B. Butler (Hillerod)
Dr L. Clemmesen (Hillerod)
Dr H. Faber (Aarhus)
Dr O. Falk Madsen (Aarhus)
Dr T. Fjord-Larsen (Aalborg)
Dr F. Gerholt (Odense)
Dr J. Hoffmeyer (Odense)
Dr S. Jensen (Aarhus)
Dr. P.W. Jepsen (Hillerod)
Dr P. Jorgensen (Aarhus)
Dr M. Kastrup (Hillerod)
Dr P. Kleist (Aarhus)
Dr A. Korner (Copenhagen)
Dr P. Kragh-Sorensen (Odense)
Dr K. Kristensen (Odense)
Dr I. Kyst (Aarhus)
Dr M. Lajer (Aarhus)
Dr J.K. Larsen (Copenhagen)
Dr P. Liisberg (Aarhus)
Dr H. Lund (Aarhus)
Dr J. Lund (Aarhus)
Dr S. Moller-Madsen (Copenhagen)
Dr I. Moulvad (Aarhus)
Dr B. Nielsen (Odense)
Dr B.M. Nielsen (Copenhagen)
Dr C. Norregard (Copenhagen)
- 251 Dr
P. Pedersen (Odense)
Dr L. Poulsen (Odense)
Dr K. Raben Pedersen (Aarhus)
Dr P. Rask (Odense)
Dr N. Reisby (Aarhus)
Dr K. Retboll (Aarhus)
Dr F. Schulsinger (Copenhagen)
Dr C. Simonsen (Aarhus)
Dr E. Simonsen (Copenhagen)
Dr H. Stockmar (Aarhus)
Dr S.E. Straarup (Aarhus)
*Dr E. Strömgren (Aarhus)
Dr L.S. Strömgren (Aarhus)
Dr J.S. Thomsen (Aalborg)
Dr P. Vestergaard (Aarhus)
Dr T. Videbech (Aarhus)
Dr T. Vilmar (Hillerod)
Dr A. Weeke (Aarhus)
Egypt
Dr M. Sami Abdel-Gawad (Cairo)
Dr A.S. Eldawla (Cairo)
Dr K. El Fawal (Alexandria)
Dr A.H. Khalil (Cairo)
Dr S.S. Nicolas (Alexandria)
Dr A. Okasha (Cairo)
Dr M.A. Shohdy (Cairo)
Dr H. El Shoubashi (Alexandria)
Dr M.I. Soueif (Cairo)
Dr N.N. Wig (Alexandria)
Germany
Dr M. Albus (Munich)
Dr H. Amorosa (Munich)
Dr O. Benkert (Mainz)
Dr M. Berger (Freiburg)
Dr B. Blanz (Mannheim)
Dr M. von Bose (Munich)
Dr B. Cooper (Mannheim)
Dr M. von Cranach (Kaufbeuren)
Mr T. Degener (Essen)
Dr H. Dilling (Lübeck)
Dr R.R. Engel (Munich)
Dr K. Foerster (Tübingen)
Dr H. Freyberger (Lübeck)
Dr G. Fuchs (Ottobrunn)
Dr M. Gastpar (Essen)
- 252 *Dr
J. Glatzel (Mainz)
Dr H. Gutzmann (Berlin)
Dr H. Häfner (Mannheim)
Dr H. Helmchen (Berlin)
Dr S. Herdemerten (Essen)
Dr W. Hiller (Munich)
Dr A. Hillig (Mannheim)
Dr H. Hippius (Munich)
Dr P. Hoff (Munich)
Dr S.O. Hoffmann (Mainz)
Dr K. Koehler (Bonn)
Dr R. Kuhlmann (Essen)
*Dr G.-E. Kühne (Jena)
Dr E. Lomb (Essen)
Dr W. Maier (Mainz)
Dr E. Markwort (Lübeck)
Dr K. Maurer (Mannheim)
Dr J. Mittelhammer (Munich)
Dr H.-J. Moller (Bonn)
Dr W. Mombour (Munich)
Dr J. Niemeyer (Mannheim)
Dr R. Olbrich (Mannheim)
Dr M. Philipp (Mainz)
Dr K. Quaschner (Mannheim)
Dr H. Remschmidt (Marburg)
Dr G. Rother (Essen)
Dr R. Rummler (Munich)
Dr H. Sass (Aachen)
Dr H.W. Schaffert (Essen)
Dr H. Schepank (Mannheim)
Dr M.H. Schmidt (Mannheim)
Dr R.-D. Stieglitz (Berlin)
Dr M. Strockens (Essen)
Dr W. Trabert (Homburg)
Dr W. Tress (Mannheim)
Dr H.-U. Wittchen (Munich)
Dr M. Zaudig (Munich)
France
Dr J. F. Allilaire (Paris)
Dr J.M. Azorin (Marseilles)
Dr Baier (Strasbourg)
Dr M. Bouvard (Paris)
Dr C. Bursztejn (Strasbourg)
Dr P.F. Chanoit (Paris)
Dr M.-A. Crocq (Rouffach)
Dr J.M. Danion (Strasbourg)
Dr A. Des Lauriers (Paris)
Dr M. Dugas (Paris)
- 253 Dr
B. Favre (Paris)
Dr C. Gerard (Paris)
Dr S. Giudicelli (Marseilles)
Dr J.D. Guelfi (Paris)
Dr M.F. Le Heuzey (Paris)
Dr V. Kapsambelis (Paris)
Dr Koriche (Strasbourg)
Dr S. Lebovici (Bobigny)
Dr J.P. Lepine (Paris)
Dr C. Lermuzeaux (Paris)
*Dr R. Misès (Paris)
Dr J. Oules (Montauban)
Dr P. Pichot (Paris)
Dr. D. Roume (Paris)
Dr L. Singer (Strasbourg)
Dr M. Triantafyllou (Paris)
Dr D. Widlocher (Paris)
Greece
*Dr C.R. Soldatos (Athens)
Dr C. Stefanis (Athens)
Hungary
Dr J. Szilard (Szeged)
India
Dr A.K. Agarwal (Lucknow)
Dr N. Ahuja (New Delhi)
Dr A. Avasthi (Chandigarh)
Dr G. Bandopaday (Calcutta)
Dr P.B. Behere (Varanasi)
Dr P.K. Chaturvedi (Lucknow)
Dr H.M. Chawla (New Delhi)
Dr H.M. Chowla (New Delhi)
Dr P.K. Dalal (Lucknow)
Dr P. Das (New Delhi)
Dr R. Gupta (Ludhiana)
Dr S.K. Khandelwal (New Delhi)
Dr S. Kumar (Lucknow)
Dr N. Lal (Lucknow)
Dr S. Malhotra (Chandigarh)
Dr D. Mohan (New Delhi)
Dr S. Murthy (Bangalore)
Dr P.S. Nandi (Calcutta)
Dr R.L. Narang (Ludhiana)
Dr J. Paul (Vellore)
- 254 Dr
M. Prasad (Lucknow)
Dr R. Raghuram (Bangalore)
Dr G.N.N. Reddy (Bangalore)
Dr S. Saxena (New Delhi)
Dr B. Sen (Calcutta)
Dr C. Shamasundar (Bangalore)
Dr H. Singh (Lucknow)
Dr P. Sitholey (Lucknow)
Dr S.C. Tiwari (Lucknow)
Dr B.M. Tripathi (Varanasi)
Dr J.K. Trivedi (Lucknow)
Dr V.K. Varma (Chandigarh)
Dr A. Venkoba Rao (Madurai)
Dr A. Verghese (Vellore)
Dr K.R. Verma (Varanasi)
Indonesia
Dr R. Kusumanto Setyonegoro
(Jakarta)
Dr D.B. Lubis (Jakarta)
Dr L. Mangendaan (Jakarta)
Dr W.M. Roan (Jakarta)
Dr K.B. Tun (Jakarta)
Islamic Republic of Iran
Dr H. Davidian (Tehran)
Ireland
Dr A. O'Grady-Walshe (Dublin)
Dr D. Walsh (Dublin)
Israel
Dr R. Blumensohn (Petach-Tikua)
Dr H. Hermesh (Petach-Tikua)
Dr H. Munitz (Petach-Tikua)
Dr S. Tyano (Petach-Tikua)
Italy
Dr M.G. Ariano (Naples)
Dr F. Catapano (Naples)
Dr A. Cerreta (Naples)
Dr S. Galderisi (Naples)
Dr M. Guazzelli (Pisa)
Dr D. Kemali (Naples)
- 255 Dr
S. Lobrace (Naples)
Dr C. Maggini (Pisa)
Dr M. Maj (Naples)
Dr A. Mucci (Naples)
Dr M. Mauri (Pisa)
Dr P. Sarteschi (Pisa)
Dr M.R. Solla (Naples)
Dr F. Veltro (Naples)
Japan
Dr Y. Atsumi (Tokyo)
Dr T. Chiba (Sapporo)
Dr T. Doi (Tokyo)
Dr F. Fukamauchi (Tokyo)
Dr J. Fukushima (Sapporo)
Dr T. Gotohda (Sapporo)
Dr R. Hayashi (Ichikawa)
Dr I. Hironaka (Nagasaki)
Dr H. Hotta (Fukuoka)
Dr J. Ichikawa (Sapporo)
Dr T. Inoue (Sapporo)
Dr K. Kadota (Fukuoka)
Dr R. Kanena (Tokyo)
Dr T. Kasahara (Sapporo)
Dr M. Kato (Tokyo)
Dr D. Kawatani (Fukuoka)
Dr R. Kobayashi (Fukuoka)
Dr M. Kohsaka (Sapporo)
Dr T. Kojima (Tokyo)
Dr M. Komiyama (Tokyo)
Dr T. Koyama (Sapporo)
Dr A. Kuroda (Tokyo)
Dr H. Machizawa (Ichikawa)
Dr R. Masui (Fukuoka)
Dr R. Matsubara (Sapporo)
Dr M. Matsumori (Ichikawa)
Dr E. Matsushima (Tokyo)
Dr M. Matsuura (Tokyo)
Dr M. S. Michituji (Nagasaki)
Dr H. Mori (Sapporo)
Dr N. Morita (Sapporo)
Dr I. Nakama (Nagasaki)
Dr Y. Nakane (Nagasaki)
Dr M. Nakayama (Sapporo)
Dr M. Nankai (Tokyo)
Dr R. Nishimura (Fukuoka)
Dr M. Nishizono (Fukuoka)
Dr Y. Nonaka (Fukuoka)
- 256 Dr
T. Obara (Sapporo)
Dr Y. Odagaki (Sapporo)
Dr U.Y. Ohta (Nagasaki)
Dr K. Ohya (Tokyo)
Dr S. Okada (Ichikawa)
Dr Y. Okubo (Tokyo)
Dr J. Semba (Tokyo)
Dr H. Shibuya (Tokyo)
Dr N. Shinfuku (Tokyo)
Dr M. Shintani (Tokyo)
Dr K. Shoda (Tokyo)
Dr T. Sumi (Sapporo)
Dr R. Takahashi (Tokyo)
Dr T. Takahashi (Ichikawa)
Dr T. Takeuchi (Ichikawa)
Dr S. Tanaka (Sapporo)
Dr G. Tomiyama (Ichikawa)
Dr S. Tsutsumi (Fukuoka)
Dr J. Uchino (Nagasaki)
Dr H. Uesugi (Tokyo)
Dr S. Ushijima (Fukuoka)
Dr M. Wada (Sapporo)
Dr T. Watanabe (Tokyo)
Dr Y. Yamashita (Sapporo)
Dr N. Yamanouchi (Ichikawa)
Dr H. Yasuoka (Fukuoka)
Kuwait
Dr F. El-Islam (Kuwait)
Liberia
Dr B.L. Harris (Monrovia)
Luxembourg
Dr G. Chaillet (Luxembourg)
*Dr C.B. Pull (Luxembourg)
Dr M.C. Pull (Luxembourg)
Mexico
Dr S. Altamirano (Mexico D.F.)
Dr G. Barajas (Mexico D.F.)
Dr C. Berlanga (Mexico D.F.)
Dr J. Cravioto (Mexico D.F.)
Dr G. Enriquez (Mexico D.F.)
Dr R. de la Fuente (Mexico D.F.)
Dr G. Heinze (Mexico D.F.)
- 257 Dr
J. Hernandez (Mexico D.F.)
Dr M. Hernandez (Mexico D.F.)
Dr M. Ruiz (Mexico D.F.)
Dr M. Solano (Mexico D.F.)
Dr A. Sosa (Mexico D.F.)
Dr D. Urdapileta (Mexico D.F.)
Dr L.E. de la Vega (Mexico D.F.)
Netherlands
Dr V.D. Bosch (Groningen)
Dr R.F.W. Diekstra (Leiden)
*Dr R. Giel (Groningen)
Dr O. Van der Hart (Amsterdam)
Dr W. Heuves (Leiden)
Dr Y. Poortinga (Tilburg)
Dr C. Slooff (Groningen)
New Zealand
Dr C.M. Braganza (Tokanui)
Dr J. Crawshaw (Wellington)
Dr P. Ellis (Wellington)
Dr P. Hay (Wellington)
Dr G. Mellsop (Wellington)
Dr J.R.B. Saxby (Tokanui)
Dr G.S. Ungvari (Tokanui)
Nigeria
*Dr R. Jegede (Ibadan)
Dr K. Ogunremi (Ilorin)
Dr J.U. Ohaeri (Ibadan)
Dr M. Olatawura (Ibadan)
Dr B.O. Osuntokun (Ibadan)
Norway
Dr M. Bergem (Oslo)
Dr A.A. Dahl (Oslo)
Dr L. Eitinger (Oslo)
Dr C. Guldberg (Oslo)
Dr H. Hansen (Oslo)
*Dr U. Malt (Oslo)
Pakistan
Dr S. Afgan (Rawalpindi)
Dr A.R. Ahmed (Rawalpindi)
Dr M.M. Ahmed (Rawalpindi)
- 258 Dr
S.H. Ahmed (Karachi)
Dr M. Arif (Karachi)
Dr S. Baksh (Rawalpindi)
Dr T. Baluch (Karachi)
Dr K.Z. Hasan (Karachi)
Dr I. Haq (Karachi)
Dr S. Hussain (Rawalpindi)
Dr S. Kalamat (Rawalpindi)
Dr K. Lal (Karachi)
Dr F. Malik (Rawalpindi)
Dr M.H. Mubbashar (Rawalpindi)
Dr Q. Nazar (Rawalpindi)
Dr T. Qamar (Rawalpindi)
Dr T.Y. Saraf (Rawalpindi)
Dr Sirajuddin (Karachi)
Dr I.A.K. Tareen (Lahore)
Dr K. Tareen (Lahore)
Dr M.A. Zahid (Lahore)
Peru
Dr J. Marietegui (Lima)
Dr A. Perales (Lima)
Dr C. Sogi (Lima)
Dr D. Worton (Lima)
Dr H. Rotondo (Lima)
Poland
Dr M. Anczewska (Warsaw)
Dr E. Bogdanowicz (Warsaw)
Dr A. Chojnowska (Warsaw)
Dr K. Gren (Warsaw)
Dr J. Jaroszynski (Warsaw)
Dr A. Kiljan (Warsaw)
Dr E. Kobrzynska (Warsaw)
Dr L. Kowalski (Warsaw)
Dr S. Leder (Warsaw)
Dr E. Lutynska (Warsaw)
Dr B. Machowska (Warsaw)
Dr A. Piotrowski (Warsaw)
Dr S. Puzynski (Warsaw)
Dr M. Rzewuska (Warsaw)
Dr I. Stanikowska (Warsaw)
Dr K. Tarczynska (Warsaw)
Dr I. Wald (Warsaw)
Dr J. Wciorka (Warsaw)
Republic of Korea
- 259 Dr
Young Ki Chung (Seoul)
Dr M.S. Kil (Seoul)
Dr B.W. Kim (Seoul)
Dr H.Y. Lee (Seoul)
Dr M.H. Lee (Seoul)
Dr S.K. Min (Seoul)
Dr B.H. Oh (Seoul)
Dr S.C. Shin (Seoul)
Romania
Dr M. Dehelean (Timisoara)
Dr P. Dehelean (Timisoara)
Dr M. Ienciu (Timisoara)
Dr M. Lazarescu (Timisoara)
Dr O. Nicoara (Timisoara)
Dr F. Romosan (Timisoara)
Dr D. Schrepler (Timisoara)
Russian Federation
Dr I. Anokhina (Moscow)
Dr V. Kovalev (Moscow)
Dr A. Lichko (St Petersburg)
*Dr R.A. Nadzharov (Moscow)
*Dr A.B. Smulevitch (Moscow)
Dr A.S. Tiganov (Moscow)
Dr V. Tsirkin (Moscow)
Dr M. Vartanian (Moscow)
Dr A.V. Vovin (St Petersburg)
Dr N.N. Zharikov (Moscow)
Saudi Arabia
Dr O.M. Al-Radi (Taif)
Dr H. Amin (Riyadh)
Dr W. Dodd (Riyadh)
Dr S.R.A. El Fadl (Riyadh)
Dr A.T. Ibrahim (Riyadh)
Dr M. Marasky (Riyadh)
Dr F.M.A. Rahim (Riyadh)
Spain
Dr A. Abrines (Madrid)
Dr J.L. Alcázar (Madrid)
Dr C. Alvarez (Bilbao)
Dr C. Ballús (Barcelona)
Dr P. Benjumea (Seville)
- 260 Dr
V. Beramendi (Bilbao)
Dr M. Bernardo (Barcelona)
Dr J. Blanco (Seville)
Dr J.M. Blazquez (Salamanca)
Dr E. Bodega (Madrid)
Dr I. Boulandier (Bilbao)
Dr A. Cabero (Granada)
Dr M. Camacho (Seville)
Dr A. Candina (Bilbao)
Dr J.L. Carrasco (Madrid)
Dr N. Casas (Seville)
Dr C. Caso (Bilbao)
Dr A. Castaño (Madrid)
Dr M.L. Cerceño (Salamanca)
Dr V. Corcés (Madrid)
Dr D. Crespo (Madrid)
Dr O. Cuenca (Madrid)
Dr E. Ensunza (Bilbao)
Dr A. Fernández (Madrid)
Dr P. Fernández-Argüelles (Seville)
Dr E. Gallego (Bilbao)
Dr García (Madrid)
Dr E. Giles (Seville)
Dr J. Giner (Seville)
Dr J. González (Saragossa)
Dr A. González-Pinto (Bilbao)
Dr C. Guaza (Madrid)
Dr J. Guerrero (Seville)
Dr C. Hernández (Madrid)
Dr A. Higueras (Granada)
Dr D. Huertas (Madrid)
Dr J.A. Izquierdo (Salamanca)
Dr J.L. Jimenez (Granada)
Dr L. Jordá (Madrid)
Dr J. Laforgue (Bilbao)
Dr F. Lana (Madrid)
Dr A. Lobo (Saragossa)
Dr J.J. López-Ibor Jr (Madrid)
Dr J. López-Plaza (Saragossa)
Dr C. Maestre (Granada)
Dr F. Marquínez (Bilbao)
Dr M. Martin (Madrid)
Dr T. Monsalve (Madrid)
Dr P. Morales (Madrid)
Dr P.E. Muñoz (Madrid)
Dr A. Nieto (Bilbao)
Dr P. Oronoz (Bilbao)
Dr A. Otero (Barcelona)
Dr A. Ozamiz (Bilbao)
- 261 Dr
J. Padierna (Bilbao)
Dr E. Palacios (Madrid)
Dr J. Pascual (Bilbao)
Dr M. Paz (Granada)
Dr J. Pérez de los Cobos (Madrid)
Dr J. Pérez-Arango (Madrid)
Dr A. Pérez-Torres (Granada)
Dr A. Pérez-Urdaniz (Salamanca)
Dr J. Perfecto (Salamanca)
Dr R. del Pino (Granada)
Dr J.M. Poveda (Madrid)
Dr A. Preciado (Salamanca)
Dr L. Prieto-Moreno (Madrid)
Dr J.L. Ramos (Salamanca)
Dr F. Rey (Salamanca)
Dr M.L. Rivera (Seville)
Dr P. Rodríguez (Madrid)
Dr P. Rodríguez-Sacristan (Seville)
Dr C. Rueda (Madrid)
Dr J. Ruiz (Granada)
Dr B. Salcedo (Bilbao)
Dr J. San Sebastián (Madrid)
Dr J. Sola (Granada)
Dr S. Tenorio (Madrid)
Dr R. Teruel (Bilbao)
Dr F. Torres (Granada)
Dr J. Vallejo (Barcelona)
Dr M. Vega (Madrid)
Dr B. Viar (Madrid)
Dr D. Vico (Granada)
Dr V. Zubeldia (Madrid)
Sudan
Dr M.B. Bashir (Khartoum)
Dr A.O. Sirag (Khartoum)
Sweden
Dr T. Bergmark (Danderyd)
Dr G. Dalfelt (Lund)
Dr G. Elofsson (Lund)
Dr E. Essen-Möller (Lysekil)
Dr L. Gustafson (Lund)
*Dr B. Hagberg (Gothenburg)
*Dr C. Perris (Umea)
Dr B. Wistedt (Danderyd)
Switzerland
- 262 Dr
N. Aapro (Geneva)
Dr J. Angst (Zurich)
Dr L. Barrelet (Perreux)
Dr L. Ciompi (Bern)
Dr V. Dittman (Basel)
Dr P. Kielholz (Basel)
Dr E. Kolatti (Geneva)
Dr D. Ladewig (Basel)
Dr C. Müller (Prilly)
Dr J. Press (Geneva)
Dr C. Quinto (Basel)
Dr B. Reith (Geneva)
*Dr C. Scharfetter (Zurich)
Dr M. Sieber (Zurich)
Dr H.-C. Steinhausen (Zurich)
Mr A. Tongue (Lausanne)
Thailand
Dr C. Krishna (Bangkok)
Dr S. Dejatiwongse (Bangkok)
Turkey
Dr I.F. Dereboy (Ankara)
Dr A. Gögü_ (Ankara)
Dr C. Güleç (Ankara)
Dr O. Öztürk (Ankara)
Dr D.B. Ulug (Ankara)
Dr N.A. Ulu_ahin (Ankara)
Dr T.B. Üstün (Ankara)
United Kingdom
Dr Adityanjee (London)
Dr P. Ainsworth (Manchester)
Dr T. Arie (Nottingham)
Dr J. Bancroft (Edinburgh)
Dr P. Bebbington (London)
Dr S. Benjamin (Manchester)
Dr I. Berg (Leeds)
Dr K. Bergman (London)
Dr I. Brockington (Birmingham)
Dr J. Brothwell (Nottingham)
Dr C. Burford (London)
Dr J. Carrick (London)
*Dr A. Clare (London)
Dr A.W. Clare (London)
- 263 Dr
D. Clarke (Birmingham)
*Dr J.E. Cooper (Nottingham)
Dr P. Coorey (Liverpool)
Dr S.J. Cope (London)
Dr J. Copeland (Liverpool)
Dr A. Coppen (Epsom)
*Dr J.A. Corbett (London)
Dr T.K.J. Craig (London)
Dr C. Darling (Nottingham)
Dr C. Dean (Birmingham)
Dr R. Dolan (London)
*Dr J. Griffith Edwards (London)
Dr D.M. Eminson (Manchester)
Dr A. Farmer (Cardiff)
Dr K. Fitzpatrick (Nottingham)
Dr T. Fryers (Manchester)
*Dr M. Gelder (Oxford)
*Dr D. Goldberg (Manchester)
Dr I.M. Goodyer (Manchester)
*Dr M. Gossop (London)
*Dr P. Graham (London)
Dr T. Hale (London)
Dr M. Harper (Cardiff)
Dr A. Higgitt (London)
Dr J. Higgs (Manchester)
Dr N. Holden (Nottingham)
Dr P. Howlin (London)
Dr C. Hyde (Manchester)
Dr R. Jacoby (London)
Dr I. Janota (London)
Dr P. Jenkins (Cardiff)
Dr R. Jenkins (London)
Dr G. Jones (Cardiff)
*Dr R.E. Kendell (Edinburgh)
Dr N. Kreitman (Edinburgh)
Dr R. Kumar (London)
Dr M.H. Lader (London)
Dr R. Levy (London)
Dr J.E.B. Lindesay (London)
Dr W.A. Lishman (London)
Dr A. McBride (Cardiff)
Dr A.D.J. MacDonald (London)
Dr C. McDonald (London)
Dr P. McGuffin (Cardiff)
Dr M. McKenzie (Manchester)
Dr J. McLaughlin (Leeds)
Dr A.H. Mann (London)
Dr S. Mann (London)
*Dr I. Marks (London)
- 264 Dr
D. Masters (London)
Dr M. Monaghan (Manchester)
Dr K.W. Moses (Manchester)
Dr J. Oswald (Edinburgh)
Dr E. Paykel (London)
Dr N. Richman (London)
Dr Sir Martin Roth (Cambridge)
*Dr G. Russell (London)
*Dr M. Rutter (London)
Dr N. Seivewright (Nottingham)
Dr D. Shaw (Cardiff)
*Dr M. Shepherd (London)
Dr A. Steptoe (London)
*Dr E. Taylor (London)
Dr D. Taylor (Manchester)
Dr R. Thomas (Cardiff)
Dr P. Tyrer (London)
*Dr D.J. West (Cambridge)
Dr P.D. White (London)
Dr A.O. Williams (Liverpool)
Dr P. Williams (London)
*Dr J. Wing (London)
*Dr L. Wing (London)
Dr S. Wolff (Edinburgh)
Dr S. Wood (London)
Dr W. Yule (London)
United Republic of Tanzania
*Dr J.S. Neki (Dar es Salaam)
United States of America
Dr T.M. Achenbach (Burlington)
Dr H.S. Akiskal (Memphis)
Dr N. Andreasen (Iowa City)
Dr T. Babor (Farmington)
Dr T. Ban (Nashville)
Dr G. Barker (Cincinnati)
Dr J. Bartko (Rockville)
Dr M. Bauer (Richmond)
Dr C. Beebe (Columbia)
Dr D. Beedle (Cambridge)
Dr B. Benson (Chicago)
*Dr F. Benson (Los Angeles)
Dr J. Blaine (Rockville)
Dr G. Boggs (Cincinnati)
Dr R. Boshes (Cambridge)
Dr J. Brown (Farmington)
- 265 Dr
J. Burke (Rockville)
Dr J. Cain (Dallas)
Dr M. Campbell (New York)
*Dr D. Cantwell (Los Angeles)
Dr R.C. Casper (Chicago)
Dr A. Conder (Richmond)
Dr P. Coons (Indianapolis)
Mrs W. Davis (Washington, DC)
Dr J. Deltito (White Plains)
Dr M. Diaz (Farmington)
Dr M. Dumaine (Cincinnati)
Dr C. DuRand (Cambridge)
Dr M.H. Ebert (Nashville)
Dr J.I. Escobar (Farmington)
Dr R. Falk (Richmond)
Dr M. First (New York)
Dr M.F. Folstein (Baltimore)
Dr S. Foster (Philadelphia)
Dr A. Frances (New York)
Dr S. Frazier (Belmont)
Dr S. Freeman (Cambridge)
Dr H.E. Genaidy (Hastings)
Dr P.M. Gillig (Cincinnati)
Dr M. Ginsburg (Cincinnati)
Dr F. Goodwin (Rockville)
Dr E. Gordis (Rockville)
Dr I.I. Gottesman (Charlottesville)
Dr B. Grant (Rockville)
*Dr S. Guze (St Louis)
Dr R. Hales (San Francisco)
Dr D. Haller (Richmond)
Dr J. Harris (Baltimore)
Dr R. Hart (Richmond)
*Dr J. Helzer (St Louis)
Dr L. Hersov (Worcester)
Dr J.R. Hillard (Cincinnati)
Dr R.M.A. Hirschfeld (Rockville)
Dr C.E. Holzer (Galveston)
*Dr P. Holzman (Cambridge)
Dr M.J. Horowitz (San Francisco)
Dr T.R. Insel (Bethesda)
Dr L.F. Jarvik (Los Angeles)
Dr V. Jethanandani (Philadelphia)
Dr L. Judd (Rockville)
Dr C. Kaelber (Rockville)
Dr I. Katz (Philadelphia)
Dr B. Kaup (Baltimore)
Dr S.A. Kelt (Dallas)
Dr P. Keck (Belmont)
- 266 Dr
K.S. Kendler (Richmond)
Dr D.F. Klein (New York)
*Dr A. Kleinman (Cambridge)
Dr G. Klerman (Boston)
Dr R. Kluft (Philadelphia)
Dr R.D. Kobes (Dallas)
Dr R. Kolodner (Dallas)
Dr J.S. Ku (Cincinnati)
*Dr D.J. Kupfer (Pittsburgh)
Dr M. Lambert (Dallas)
Dr M. Lebowitz (New York)
Dr B. Lee (Cambridge)
Dr L. Lettich (Cambridge)
Dr N. Liebowitz (Farmington)
Dr B.R. Lima (Baltimore)
Dr A.W. Loranger (New York)
Dr D. Mann (Cambridge)
Dr W.G. McPherson (Hastings)
Dr L. Meloy (Cincinnati)
Dr W. Mendel (Hastings)
Dr R. Meyer (Farmington)
*Dr J. Mezzich (Pittsburgh)
Dr C. Moran (Richmond)
Dr P. Nathan (Chicago)
Dr D. Neal (Ann Arbor)
Dr G. Nestadt (Baltimore)
Dr B. Orrok (Farmington)
Dr D. Orvin (Cambridge)
Dr H. Pardes (New York)
Dr J. Parks (Cincinnati)
Dr R. Pary (Pittsburgh)
Dr R. Peel (Washington, DC)
Dr M. Peszke (Farmington)
Dr R. Petry (Richmond)
Dr F. Petty (Dallas)
Dr R. Pickens (Rockville)
Dr H. Pincus (Washington, DC)
Dr M. Popkin (Long Lake)
Dr R. Poss Rosen (Bayside)
Dr H. van Praag (Bronx)
Mr D. Rae (Rockville)
Dr J. Rapoport (Bethesda)
Dr D. Regier (Rockville)
Dr R. Resnick (Richmond)
Dr R. Room (Berkeley)
Dr S. Rosenthal (Cambridge)
Dr B. Rounsaville (New Haven)
Dr A.J. Rush (Dallas)
Dr M. Sabshin (Washington, DC)
Dr R. Salomon (Farmington)
- 267 Dr
B. Schoenberg (Bethesda)
Dr E. Schopler (Chicago)
Dr M.A. Schuckit (San Diego)
Dr R. Schuster (Rockville)
Dr M. Schwab-Stone (New Haven)
Dr S. Schwartz (Richmond)
Dr D. Shaffer (New York)
Dr T. Shapiro (New York)
*Dr R. Spitzer (New York)
Dr T.S. Stein (East Lansing)
Dr R. Stewart (Dallas)
Dr G. Tarnoff (New Haven)
Dr J.R. Thomas (Richmond)
Dr K. Towbin (New Haven)
Mr L. Towle (Rockville)
Dr M.T. Tsuang (Iowa City)
Dr J. Wade (Richmond)
Dr J. Walkup (New Haven)
Dr M. Weissmann (New Haven)
Dr J. Williams (New York)
Dr R.W.Winchel (New York)
Dr K. Winters (St Paul)
Dr T.K. Wolff (Dallas)
Dr W.C. Young (Littleton)
Uruguay
Dr R. Almada (Montevideo)
Dr P. Alterwain (Montevideo)
Dr L. Bolognin (Montevideo)
Dr P. Bustelo (Montevideo)
Dr U. Casarotti (Montevideo)
Dr E. Dorfman (Montevideo)
Dr F. Leite Gastal (Montevideo)
Dr A.J. Montoya (Montevideo)
Dr A. Nogueira (Montevideo)
Dr E. Probst (Montevideo)
Dr C. Valino (Montevideo)
Yugoslavia
Dr N. Bohacek (Zagreb)
Dr M. Kocmur (Ljubljana)
*Dr J. Lokar (Ljubljana)
Dr B. Milac (Ljubljana)
Dr M. Tomori (Ljubljana)