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

The term psychosis is defined as:

1. Gross impairment in reality-testing (‘not in contact’ with reality).
2. Marked disturbance in personality, with impairment in social, interpersonal and occupational functioning.
3. Marked impairment in judgement and absent understanding of the current symptoms and behaviour (loss of insight).
4. Presence of the characteristic symptoms, like delusions and hallucinations.

Neurotic disorder (neurosis) is a less severe form of psychiatric disorder where patients show either excessive or
prolonged emotional reaction to any given stress.
These disorders are not caused by organic disease of the brain and,
however severe, do not involve hallucinations and delusions. They are classified under F40-F48 in ICD 10.

The term neurosis has been variously defined as meeting one or more of the following criteria:
1. The presence of a symptom or group of symptoms which cause subjective distress to the patient.
2. The symptom is recognised as undesirable (i.e. insight is present).
3. The personality and behaviour are relatively preserved and not usually grossly disturbed.
4. The contact with reality is preserved.
5. There is an absence of organic causative factors.
6. Reaction to severe stress, and adjustment disorders,
7. Dissociative ( conversion) disorders,
8. Somatoform disorders, and
9. Other neurotic disorders.

Neurotic, stress-related and somatoform disorders

F40 Phobic anxiety disorders
F41 Other anxiety disorders
F42 Obsessive - compulsive disorder
F43 Reaction to severe stress, and adjustment disorders
F44 Dissociative [conversion] disorders
F45 Somatoform disorders
F48 Other neurotic disorders

ANXIETY DISORDER
Anxiety is the commonest psychiatric symptom in clinical practice and anxiety disorders are one of the
commonest psychiatric disorders in general population.

Definition: Anxiety is a ‘normal’ phenomenon, which is characterised by a state of apprehension or unease arising
out of anticipation of danger.
OR
An emotional response (e.g., apprehension, tension, uneasiness) to anticipation of danger, the source of which is largely unknown
or unrecognized. Anxiety may be regarded as pathologic when it interferes with effectiveness in living, achievement of desired
goals or satisfaction, or reasonable emotional comfort.
 (Shahrokh & Hales, 2003).
 Anxiety is often differentiated from fear, as fear is an apprehension in response to an external danger while in
anxiety the danger is largely unknown (or internal).

Normal anxiety becomes pathological when it causes significant subjective distress and/or impairment
in functioning of an individual.
Some authors separate anxiety into two types:
1. Trait anxiety: This is a habitual tendency to be anxious in general (a trait) and is exemplified by
‘I often feel anxious’.
2. State anxiety: This is the anxiety felt at the present, cross-sectional moment (state) and is exemplified by ‘I feel
anxious now’.

Symptoms of Anxiety
The symptoms of anxiety can be broadly classified in two groups: physical and psycho logical (psychic)
1. Physical Symptoms
A. Motoric Symptoms: Tremors; Restlessness; Muscle twitches; Fearful facial expression
B. Autonomic and Visceral Symptoms: Palpitations; Tachycardia; Sweating; Flushes; Dyspnoea; Hyperventilation;
Constriction in the chest; Dry mouth; Frequency and hesitancy of mictu ri tion; Dizziness; Diarrhoea; Mydria sis
2. Psychological Symptoms
A. Cognitive Symptoms: Poor concentration; Distractibility; Hyperarousal; Vigilance or scanning; Negative automatic
thoughts
B. Perceptual Symptoms: Derealisation; Depersonalisation
C. Affective Symptoms: Diffuse, unpleasant, and vague sense of apprehension; Fearfulness; Inability
to relax; Irritability; Feeling of impending doom (when severe)
D. Other Symptoms: Insomnia (initial); Increased sensitivity to noise; Exaggerated startle response.

EPIDEMIOLOGICAL STATISTICS
Anxiety disorders are the most common of all psychiatric illnesses and result in considerable functional impairment
and distress .Statistics vary widely, but most are in agreement that anxiety disorders are more common in women
than in men by at least 2 to 1.
Prevalence rates for anxiety disorders within the general population have been given at 4 to 6 percent for generalized
anxiety disorder and panic disorder, 2 to 3 percent for OCD, 8 percent for PTSD, 13 percent for social anxiety
disorder, and 22 percent for phobias.
Studies of familial patterns suggest that a familial predisposition to anxiety disorders probably exists.

Generalised Anxiety Disorder

Generalized anxiety disorder is characterized by chronic, unrealistic, and excessive anxiety and worry. The
symptoms have existed for 6 months or longer and cannot be attributed to specific organic factors, such as caffeine
intoxication or hyperthyroidism.
OR
Generalized anxiety disorders are those in which anxiety is unvarying and persistent (unlike phobic anxiety
disorders where anxiety is intermittent and occurs only in the presence of a particular stimulus).

It is the most common neurotic disorder, and it occurs more frequently in women. The prevalence rate of
generalized anxiety disorders is about 2.5-8%.

Clinical Features
Generalized anxiety disorder (GAD) is manifested by the following signs of motor tension, autonomic hyperactivity,
apprehension and vigilence, which should last for at least 6 months in order to make a diagnosis:
Psychological: Fearful anticipation, irritability, sensitivity to noise, restlessness, poor concentration, worrying
thoughts and apprehension.
Physical:
• Gastrointestinal-dry mouth, difficulty in swallowing, epigastric discomfort, frequent or loose motions
• Respiratory=-constriction in the chest, difficulty inhaling, over-breathing
• Cardiovascular-palpitations, discomfort in chest
 • Genitourinary-frequency or urgent micturition, failure of erection, menstrual discomfort, amenorrhea
• Neuromuscular system-tremor, prickling sensations, tinnitus, dizziness, headache, aching muscles
• Sleep disturbances-insomnia, night terror
• Other symptoms: depression, obsessions, depersonalization, derealization
COURSE:
 This is characterised by an insidious onset in the third decade and a stable, usually chronic course which may
or may not be punctuated by repeated panic attacks (episodes of acute anxiety).
 The symptoms of anxiety should last for at least a period of 6 months for a diagnosis of generalised anxiety disorder
to be made.

PANIC DISORDER
Panic disorder is characterized by anxiety, which is intermittent and unrelated to particular circumstances (unlike
phobic anxiety disorders where, though anxiety is intermittent, it occurs only in particular situations).
OR
This disorder is characterized by recurrent panic attacks, the onset of which is unpredictable, and manifested by
intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense
physical discomfort.

 The central feature is the occurrence of panic attacks, i.e. sudden attacks of anxiety in which physical symptoms
predominate and are accompanied by fear of a serious consequence such as a heart attack.

PREVALENCE: The lifetime prevalence of panic disorder is 1.5 to 2 percent. It is seen 2 to 3 times more often in
females.

CLINICAL FEATURES:

 The symptoms come on unexpectedly; that is, they do not occur immediately before or on exposure to a situation
that usually causes anxiety (as in specific phobia). They are not triggered by situations in which the person is the focus
of others’ attention (as in social phobia). Organic factors in the role of etiology have been ruled out.
 At least four of the following symptoms must be present to identify the presence of a panic attack. When fewer than
four symptoms are present, the individual is diagnosed as having a limited-symptom attack.
● Palpitations, pounding heart, or accelerated heart rate
● Sweating
● Trembling or shaking
● Sensations of shortness of breath or smothering
● Feeling of choking
● Chest pain or discomfort
● Nausea or abdominal distress
● Feeling dizzy, unsteady, lightheaded, or faint
● Derealization (feelings of unreality) or depersonalization (being detached from oneself)
● Fear of losing control or going crazy
● Fear of dying
● Paresthesias (numbness or tingling sensations)
● Chills or hot flashes

Course
The onset is usually in early third decade with often a chronic course. It occurs recurrently every few days. The
episode is usually sudden in onset and lasts for a few minutes.

Panic Disorder with Agoraphobia:

 Panic disorder with agoraphobia is characterized by the symptoms described for panic disorder. In addition, the
individual experiences a fear of being in places or situations from which escape might be difficult (or
embarrassing) or in which help might not be available in the event that a panic attack should occur.
 This fear severely restricts travel and the individual may become nearly or completely housebound or unable to
leave the house unaccompanied.
 Common agoraphobic situations include being outside the home alone; being in a crowd or standing in a line; being
on a bridge; and traveling in a bus, train, or car.

Etiology of Anxiety Disorders (both GAD and panic disorder)

• Genetic theory: Anxiety disorder is most frequent among relatives of patients with this condition. About 15to 20%
of the first-degree relatives of patients with anxiety disorder exhibit anxiety disorders themselves. The concordance
rate in monozygotic twins of patients with panic disorder is 80 percent.
• Biochemical factors: Alteration in GABA levels may lead to production of clinical anxiety.