by

Chatidjah Satriyo Wibowo dr. Sp.KJ.
] Introduction

] F.40 Phobic Anxiety disorders

+ Anxiety is evoked only or predominantly by
certain well defined situation or objects
+ These situation or objects are characteristically
avoided or endured with dead
+ Indistinguishable subjectively, physiologically,
behaviorally from other types of anxiety
+ The individual’s concern may focus on individual
symptoms
Phobic anxiety disorder
w The anxiety is not relieved by the
knowledge that other people do not
regard the situation
w Contemplation of entry to the phobic
situation.
w Phobic anxiety often coexist with the
depression.
w Invariably gets worse during an
inter current depressive episode.
w More common in woman than in men .
F. 40.0 Agoraphobia

6 Fears of open space and of
related aspect
6 Mostly woman , the onset is in
adult life
6 Without effective treatment 
chronic , fluctuating
Agoraphobia
Diagnosis guidelines
All of the following criteria :
+ psychological or autonomic symptoms as
the primarily manifestation of anxiety
+ the anxiety occur mainly in at least 2 of the
following situations : crowds, public
places , traveling
+ avoidance of the phobic situation as
prominent feature
Agora phobia
Differential diagnosis

[ depression
[ depersonalization
[ obsessional disorder
[ social phobia
The fifth characters

F. 40.0 without panic disorder
F. 40.1 with panic disorder

Includes :
panic disorder with agora phobia
F. 40.1 Social phobias

¬ Often start in adolescence
¬ equally common in men and woman
¬ direct eye to eye confrontation  stressful
¬ low self esteem & fear of criticism
¬ blushing, hand tremor , nausea etc.
¬ progress to panic attacks
¬ avoidance is often marked complete social
isolation

Social phobias
Diagnosis guidelines
All of the following criteria :
+ the psychological , behavioral , or autonomic
symptoms must be primarily manifestations
of anxiety
+ the anxiety must be restricted to or
predominate in social situations
+ avoidance of the phobic situations
Social phobias

Includes : anthropophobia
social neurosis

differential diagnosis
• depressive disorders
• agoraphobia
F 40.2 Specific (isolated) phobias

[ Restricted to highly specific situations
[ Usually arise in childhood or early adult
life.
[ Radiation sickness and veneral infection
AIDS are common subjects
Specific phobias
Diagnosis guidelines
All of the following criteria :
a) the psychological or autonomic symptoms
must be primary manifestations of anxiety.
b) The anxiety must be restricted to the
presence of the particular phobic object or
situation
c) the phobic situation is avoided whenever
possible.
Specific phobia
Includes :

+ acrophobia
+ animal phobia
+ claustrophobia
+ examination phobia
+ simple phobia
Specific phobias

Differential diagnosis

+ agoraphobia
+ social phobia
F. 40.8 Other phobic anxiety disorder
F. 40.9 Phobic Anxiety disorder ,
unspecific

Includes :
• phobia NOS
• phobic status NOS
F. 41.0 Other anxiety disorders

+ Manifestations of anxiety are not
restricted to any particular
environmental situation

+ Depressive and obsessional
symptoms are clearly secondary
or less severe
F. 41.0 Panic disorder
( episodic paroxysmal anxiety)

+ Recurrent attacks of severe anxiety (panic)
+ Are not restricted to any particular situation.
+ Symptoms vary from person to person
+ Palpitations, chest pain , choking sensation ,
dizziness, feelings of unreality , etc.
+ Fear of dying , losing control , going mad.
+ Fear of being alone , or going to public places.
Panic disorder
Diagnosis guidelines
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.
c). With comparative freedom from anxiety
symptoms between attacks
Panic disorder
Includes :
+ panic attacks
+ panic state

Differential diagnosis
+ Depressive disorders
F. 41 1 Generalized anxiety disorder

+ The essential feature is anxiety ,
generalized, persistent.
+ Continuous feelings of nervousness.
+ More common in woman
+ Tends to be fluctuating and chronic


Generalized anxiety disorder
Diagnostic guidelines
The primary symptoms of anxiety mot days for at
least several weeks at a time , usually for several
months.
Involve elements of :
+ apprehension
+ motor tension
+ autonomic over activity
Generalized anxiety disorder
Includes :
+ Anxiety neurosis
+ Anxiety reaction
+ Anxiety state
F. 41.2 Mixed anxiety and depressive
disorder
+ Symptoms of both anxiety and depression are
present
+ Some autonomic symptoms must be present even if
only intermittently .

Includes : anxiety , depression .
Excludes : persistent anxiety depression
( dysthimia F. 34.1 )
F. 41.3 Other mixed anxiety disorders

Disorders that meet the criteria for
generalized anxiety disorders ( F.41.1)
and that also have prominent feature of
the other disorders in F. 40. -- F. 49.

F. 41.8 Other specified anxiety
disorder
Includes : anxiety hysteria

F. 41.9 Anxiety disorder unspecified
Includes : anxiety NOS
F. 42 Obsessive - compulsive
disorder

+ The essential feature is recurrent
obsessional thought or conpulsive acts .
+ Equally common in men and women

Obsessive - compulsive disorder
Diagnostic guidelines
must be present on most days for at least 2
successive week .
Characteristies :
+ They must be recognized as the individual’s own
thoughts or impulses .
+ There must be at least one thought or act that is
still resisted unsuccessfully.
+ The thought of carrying out the act must not in
itself be pleasurable
+ The thoughts , images, or impulses must be
unpleasantly repetitive

Obsessive - compulsve disorder

Includes : anankastic neurosis
obsessional neurosis
obsessive - compulsive neurosis
Differential diagnosis :
• depressive disorder
• schizophrenia
• tourett’s syndrome
• organic mental disorder
42. 0 Predominantly obsessional
thought or ruminations

+ May take the form of ideas , mental images or
impulses to act
+ Variable in content but nearly always distressing
to the individual .
+ The ideas are merely futile.

Differential diagnosis :  depressive neurosis
F. 42.1 Predominantly compulsive act
( obsessional rituals )

+ The majority of compulsive act are concerned
with cleaning.
+ Underlying the overt behavior is a fear .
+ Compulsive ritual acts may occupy many
hours every day
+ Equally common in the two sexes
Predominantly compulsive acts

+ Hand - washing rituals are more common
in
women
+ Slowness without repetition is more
common in men
+ Less closely associated with depression
than obsessional thought .
+ More readily amenable to behavioral
therapies
F. 42.2 Mixed obsessional thoughts
and acts

+ Most obsessive - compulsive individuals
have elements of both obsessional
thinking and compulsive behavior

+ Since thought and acts may respond to
different treatment , it is useful to specify
only one if it is clearly predominant.

F. 42.8
Other obsessive - compulsive disorder

F. 42.9
Obsessive - compulsive disorder
unspecified
F. 43. Reaction to severe stress and
adjustment disorders

+ Identifiable on ground of symptomatology and
course but also on the basis of one or other
of two causative influences
+ The disorders are to arise always as a direct
consequence of the acute severe stress or
continued trauma
+ Reaction to severe stress and adjustment
disorders in all age groups.
F. 43.0 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 or mental stress

+ the stressor may be an overwhelming traumatic
experience involving serious threat to the
security or physical integrity of the individual
or of a loved persons
Acute stress reaction
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

Acute stress reaction
the symptoms

O Show a mixed and usually changing picture ,
in addition to the initial state of “ daze “

O resolve rapidly in those case where removal
from the stressful environment is possible .
Acute stress reaction
Includes :
+ acute crisis reaction
+ combat fatigue
+ crisis state
+ psychic shock
F. 43.1 Post - traumatic stress
disorder

6 Arises as a delayed and / or protracted response to
a stressful event or situation
6 typical symptoms include episodes of repeated
reliving of the trauma in intrusive memories.
6 Commonly there is fear and avoidance of cues that
remind the sufferer of the original trauma
6 dramatic, acute burst of fear , triggered by stimuli
arousing a sudden recollection and/or re
enactment of the trauma

Post - traumatic stress disorder
+ autonomic hyper arousal with hyper vigilance an
enhanced startle reaction and insomnia
+ anxiety and depression
+ suicidal ideation is not infrequent
+ excessive use of alcohol or drugs may be a
complicating factor
+ the onset may range a few weeks to months , but
rarely exceed 6 months
+ the course is fluctuating but recovery can be
expected in majority of cases
+ small cases may show a chronic course over many
years
Post traumatic stress disorder
Diagnostic guidelines
6 it arose within 6 month of a traumatic event
of exceptional severity
6 there must be a repetitive , intrusive
recollection or reenactment of the event in
memories , day time imagery or dreams

includes : traumatic neurosis
F. 43.2 Adjustment disorders

[ State of subjective distress and emotional
disturbance
[ Interfering with social functioning and
performance
[ Arising in the period of adaptation to a live
change or stressful live event.
[ The stressor may involve only the individual or
community
[ The onset within 1 month not usually exceed 6
months
Adjustment disorders
Diagnostic guidelines

Relationship between :
+ form , content, severity of symptoms
+ previous history and personality
+ stressful event , situation , live crisis
Adjustment disorder
Includes :

^ culture shock
^ grief reaction
^ hospitalism in children
F. 43.20 Brief depression reaction
• transient , mild depressive
• duration not exceeding 1 months
F. 43.21 Prolonged depressive reaction
• mild depressive state
• prolonged exposure to a stressful situation
• duration not exceeding 2 years .
F. 43.22 Mixed anxiety and depressive reaction
• anxiety and depressive symptoms are prominent
• at levels no greater than F. 41.2 or F. 41.3
F. 43.23 With predominant disturbance of
other emotions
^ The symptoms are several type of emotion :
anxiety, depression ,worry, tension, anger.
F. 43.24 With predominant disturbance of
conduct
¬ One involving conduct i.e. Grief reaction
resulting in aggressive or dissocial
behavior

F. 43.28 With other specified predominant
symptoms

F. 43.8 Other reactions to severe stress

F. 43.9 Reaction to severe stress ,
unspecified
F. 44 dissociative (conversion) disorders
e A partial / complete loss of the normal
- integration between memories of the past
- awareness of identity & immediate sensations
- control of bodily movement .
e In the dissociative disorders the ability to exercise
a conscious and selective control is impaired

e In conversion the unpleasant affect , engendered
by the problems & conflict that the individual
cannot solve
Dissociative disorder
Diagnostic guidelines
a). the clinical feature as in F . 44 .
b). No evidence of a physical disorder
c). evidence for psychological causation

Inccludes : conversion hysteria
conversion reaction
hysteria
hysterical psychosis
F. 44.0 Dissociative amnesia

+ loss of recent memory
+ not due to organic mental disorder

Diagnostic guidelines
a). Amnesia , partial / complete , recent events
b). Absence of organic brain disorder intoxication ,
excessive fatigue
Dissociative amnesia
Excludes :
+ alcohol/psychoactive substance - induced amnestic
disorder ( F. 10 - F. 19 with 4
th.
character .6 )
+ amnesia NOS ( R. 41.3)
+ anterograde amnesia (R.41.1)
+ non alcoholic organic amnestic syndrome ( F. 04 )
+ post ictal amnesia in epilepsy ( G. 40 )
+ retrograde amnesia ( R 41.2 )
F. 44.1 Dissociative fugue
Diagnostic guidelines
a). The features of dissociative amnesia ( F. 44.0 )
b). Purposeful travel beyond the usual every day range.
c). Maintenance of basic self - care and social
interaction with stranger

Differential diagnosis : - temporal lobe epilepsy
- conscious simulation

F. 44.2 Dissociative stupor

+ Profound diminution or absence of voluntary
movement and normal responsiveness to
external stimuli ( light, noise , touch )
+ The individual lies or sits largely motionless
for long periods of time .
Dissociative stupor
Diagnostic guidelines
a). Stupor
b). Absence of a physical or other psychiatric
disorder that might explain the stupor
c). Evidence of recent stressful event or current
problems
Differential diagnosis :
- depressive / manic stupor
- catatonic schizophrenia
F. 44.3 Trance & possession disorders

] a temporary loss of both sense of personal
identity and full awareness of the surroundings .
] Acts as if taken over by another personality , spirit
deity or force

differential diagnosis :
) schizophrenia ) acute psychosis
) multiple personality ) head injury
) temporal lobe epilepsy
) psychoactive substance intoxication



F. 44.4 - F. 44.7
Dissociative disorder of movement
and sensation

Diagnostic guidelines
a). There should be no evidence of physical disorder
b). Be known about psychological , social setting and
personal relationships to formulate the reason
for the appearance of the disorder.
F. 44.4 Dissociative motor disorder

) loss of ability to more the whole or part of a
limb(s)
) paralysis may be partial with movements being
weak /slow / complete

includes - psychogenic aphonia
- psychogenic dysphonia
F. 44.5 Dissociative convulsions

- pseudo seizures may mimic epileptic
seizures
- absent of tongue - biting , serious
bruising due to falling incontinence
urine, loss of consciousness


F.44.6
Dissociative anaesthesia and
sensory loss

´ anaesthetic areas of skin boundaries
´ sensory loss may be accompanied by
complaints of paraesthesia
´ visual disturbance
´ psychogenic deafness
F. 44.7
Mixed dissociative (conversion) disorder
• mixture of disorder specified above
( F. 44.0 - F. 44.6 )

F. 44.8
Other dissociative (conversion) disorders
F. 44.80 - ganser’s syndrome
characterized by “approximate answer”
F. 44.81 Multiple personality disorder
• the apparent existence of two or more distinct
personalities within an individual
• one of them being evident at a time
• each personality is complete

F. 44 82
Transient dissociative (conversion) disorder
• occurring in childhood and adolescence

F. 44.88
Other specified dissociative
(conversion) disorder
Includes : - psychogenic confusion
- twilight state

F. 44. 9
Dissociative (conversion) disorder,
unspecified
F. 45 Somatoform disorder

) Repeated presentation of physical
symptoms
) Persistent request for medical
investigations
) The symptoms have no physical basis
) There is often a degree of attention -
seeking

Differential diagnosis : hypochondriacal delusions
F. 45.0 Somatization disorder
Diagnostic guidelines
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 doctors that there is no
physical explanation for the symptoms
c). Impairment of social and family functioning
attributable to the nature of the symptoms
& resulting behavior
Somatization disorder
includes :
• multiple complaint syndrome
• multiple psychosomatic disorder
Differential diagnosis :
• physical disorders
• affective (depressive) and anxiety disorder
• hypochondriacal disorder
• delusional disorders
F. 45.1
undifferentiated
somatoform disorder

+ physical complaints are multiple
+ varying and persistent
+ the complete and typical clinical picture
of somatoform disorder is not fulfilled .
F. 45.2 Hypochondriacal disorder

Diagnostic guidelines
a). Persistent belief in the presence serious
physical illness underlying the presenting
symptoms.
b) persistent refusal to accept the advice and
reassurance of doctors that there is no
physical illness or abnormality underlying
the symptoms
Hypochondriacal disorder
Includes : ) body dysmorphic disorder
) dysmorphophobia
) hypochondriacal neurosis
) hypochondriasis
) nosophobia

Differential diagnosis : - somatization disorder
- depressive disorder
- delusional disorder
- anxiety and panic disorder
F. 45.3 Somatoform autonomic
dysfunction
diagnostic guidelines
) autonomic arousal, palpitation, sweating,tremor,
flushing which are persistent and troblesome .
) additional subjective symptoms referred to a
specific organ or system
) preoccupation with and distress about the
possibility of a serious disorder of the stated
organ or system.
) No evidence of a significant disturbance of structure
or function of the stated system or organ .
Somatoform autonomic dysfunction


Differential diagnosis
) general anxiety disorder
) somatization disorder
F. 45.30
Heart and cardiovascular system
w cardiac neurosis
w da Costa’s syndrome
w neurocirculatory asthenia

F. 45.31 Upper gastrointestinal tract
w gastric neurosis
w psychogenic aerophagy ,
hiccough dyspepsia, pylorospasm
F. 45.32 Lower gastrointestinal tract
• psychogenic flatulence , irritable bowel
syndrome , diarrhoea gas syndrome
F. 45.33 Respiratory system
• psychogenic form of cough and
hyperventilation
F. 45.34 Genitourinary system
• Psychogenic increase of frequency of
micturition and dysuria
F. 45.38 Other organ or system
F. 45.4
Persistent somatoform pain disorder

) The predominant complaint is of persistent
severe distressing pain . Cannot be
explain by a physiological process or
physical disorder
) Pain occurs in association with emotional
conflict or psychosocial problems .
Persistent somatoform pain disorder
Includes :
+ psychalgia
+ psychogenic backache or headache
+ somatoform pain disorder

Differential diagnosis
+ histrionic elaboration of organically
caused pain
F. 45.8 Other somatoform disorders
• The presenting complaints are not mediated
through the autonomic nervous system
• Limited to specific system or part of the body
Includes :
+ “globus hystericus “ dysphagia
+ psychogenic torticollis
+ psychogenic pruritus
+ psychogenic dysmenorrhoea
+ teeth - grinding
F. 48.0 Neurasthenia
Diagnostic guidelines
a). Persistent and distressing complaints of increased
fatigue after mental effort, or bodily weakness
and exhaustion after minimal effort
b). at least two of the following
+ feelings of muscular aches and pain
+ dizziness + tensions headaches
+ sleep disturbance + inability to relax
+ irritability + dyspepsia

Neurasthenia


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.
F. 48.1
Depersonalization - derealization syndrome
Diagnostic guidelines
a). Depersonalization symptoms, feel that his or her own
feelings and for experiences are detached ,
distant, not his or her own , lost ,etc.
b). Derealization symptoms , object, people, surrounding
seem unreal ,distant, artificial , colorless , etc.
c). An acceptance that this is a subjective and
spontaneous change , not imposed by outside
forces or other people .
d). A clear sensorium and absence of toxic confusional
state or epilepsy.
Depersonalization - derealization syndrome

Differential diagnosis
+ schizophrenia
+ dissociative disorder.
+ Early dementia
+ temporal lobe epilepsy

F. 48.8 Other specified neurotic disorders
] mixed disorders of behavior , belief, emotion.
] Uncertain etiology and nosological status
] occur with particular frequency in certain cultures

Includes :
+ Briquet’s disorder + koro
+ Dhat syndrome + latah
+ occupational neurosis + psychasthenic neurosis
+ psychogenic syncope
F. 48.9
Neurotic disorder , unspecified

Includes : neurosis NOS