Neurotic Disorders

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Neurotic Disorders

• Department of Psychiatry
• 1st Faculty of Medicine
• Charles University, Prague
• Head Prof. MUDr. Jirí Raboch, DrSc.

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Neurotic Disorders

• Neurotic, stress-related, and somatoform
  disorders have common historical origin with the
  concept of neurosis and association of a
  substantial proportion of these disorders with
  psychological causation.
• Mixtures of symptoms, especially anxiety and
  depressive ones are common in these disorders
• About one fourth of the population in developed
  countries will suffer from neurotic disorders
  during its lifetime course.
• With the exception of social phobia their
  frequency is higher in women than in men.

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Neurotic, Stress-Related and Somatoform Disorders
(F40-F48)

• 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

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F40 Phobic anxiety disorders

• F40 Phobic anxiety disorders
• F40.0 Agoraphobia
• F40.1 Social phobias
• F40.2 Specific (isolated) phobias
• F40.8 Other phobic anxiety disorders
• F40.9 Phobic anxiety disorder, unspecified

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Phobic Anxiety Disorders

• In agoraphobia, social and specific phobias,
  anxiety is evoked predominantly by certain
  well-defined situations or objects, which are
  external to the individual and are not currently
  dangerous.
• As a result, these situations or objects are
  characteristically avoided or endured with dread.
• Phobic anxiety fluctuates from mild uneasy to
  terror. The individuals 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.

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Agoraphobia

• Agoraphobia - the fear from marketplace.
• Agoraphobia includes various phobias embracing
  fears of leaving home fears of entering shops,
  crowds, and public places, or of traveling alone
  in trains, buses, underground or planes.
• The lack of an immediately available exit is one
  of the key features of many agoraphobic
  situations.
• The avoidance behaviour causes sometimes that the
  sufferer becomes completely housebound.
• Most sufferers are women. Onset - early adult
  life.
• The lifetime prevalence - between 57.
• High co-morbidity with panic disorder depressive
  and obsessional symptoms and social phobias may
  be also present.

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Agoraphobia
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Social Phobias

• Clinical picture - fear of scrutiny by other
  people in comparatively small groups leading to
  avoidance of social situations
• The fears may be
• discrete - restricted to eating in public, to be
  introduced to other people, to public speaking,
  or to encounters with the opposite sex
• diffuse - social situations outside the family
  circle.
• Direct eye-to-eye confrontation may be stressful.
• Low self-esteem and fear of criticism.
• Symptoms may progress to panic attacks.
• Avoidance - almost complete social isolation.
• Usually start in childhood or adolescence.
• Estimation of lifetime prevalence - between 10-13
  .
• It is equally common in both sexes.
• Secondary alcoholism.

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Social Phobias
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Specific (Isolated) Phobias

• Fears of proximity to particular animals
• spiders (arachnophobia)
• insects (entomophobia)
• snakes (ophidiophobia)
• Fears of specific situations such as
• heights (acrophobia)
• thunder (keraunophobia)
• darkness (nyctophobia)
• closed spaces (claustrophobia)
• Fears of diseases, injuries or medical
  examinations
• visiting a dentist
• the sight of blood (hemophobia) or injury (pain
  odynophobia)
• the fear of exposure to venereal diseases
  (syphilidophobia) or AIDS-phobia.
• Usually arise in childhood or early adult life
  and can persist for decades if they remain
  untreated.
• Lifetime prevalence - between 10-20.

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F41 Other Anxiety Disorders

• 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

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Other Anxiety Disorders

• Manifestations of anxiety are also the major
  symptoms of these disorders, however, it is not
  restricted to any particular environmental
  situation.

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Panic Disorder

• The essential features are recurrent attacks of
  severe anxiety (panic attacks) which are not
  restricted to any particular situation or set of
  circumstances.
• Typical symptoms are palpitations, chest pain,
  choking sensations, dizziness, and feelings of
  unreality (depersonalisation or derealization).
• Individual attacks usually last for minutes only.
  The frequency of attacks varies substantially.
• Frequent and predictable panic attacks produce
  fear of being alone or going into public places.
• The afflicted persons used to think that they got
  a serious somatic disease.
• The course of panic disorder is long-lasting and
  is complicated with various comorbidities, in
  half of the cases with agoraphobia.
• The estimation of lifetime prevalence moves
  between 1-3.

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Panic Disorder
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General Anxiety Disorder

• The essential feature is anxiety lasting more
  than 6 months, which is generalized and
  persistent but not restricted to, or even
  strongly predominating in, any particular
  environmental circumstances.
• Symptoms continuous feelings of nervousness,
  trembling, muscular tension, sweating,
  lightheadedness, palpitations, dizziness, and
  epigastric discomfort.
• Fears that the patient or a relative will shortly
  become ill or have an accident are often
  expressed, together with a variety of other
  worries and forebodings.
• The estimation of lifetime prevalence moves
  between 4-6 .
• This disorder is more common in women, and often
  related to chronic environmental stress.
• Its course uses to be fluctuating and chronic
  connected with symptoms of frustration, sadness
  and complicated with abuse of alcohol and other
  illicit drugs.

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Mixed Anxiety and Depressive Disorder

• Symptoms of both anxiety and depression are
  present, but neither of symptoms, considered
  separately, is sufficiently severe to justify a
  diagnosis of depressive episode or specific
  anxiety disorder.
• Some autonomic symptoms, such as tremor,
  palpitations, dry mouth, stomach churning, must
  be present.
• Individuals with this mixture of comparatively
  mild symptoms are frequently seen in primary care.

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Etiology of Anxiety Disorders

• The etiology of anxiety disorders is not exactly
  known.
• Genetic factors were found to play a role.
• Nongenetic factors, such as various stressful
  life events during early or later stages of
  ontogenesis were thought to be even more
  important.
• Several different neurotransmitter systems have
  been implicated in these disorders, including the
  noradrenergic, GABA, and serotoninergic systems
  in some parts of the brain.
• The role of CO2 in the etiology of panic disorder
  is seriously discussed.

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Clinical Management of Anxiety Disorders

• Treatment of anxiety disorders
• various psychotherapeutic techniques
• cognitive-behavioural therapy (CBT)
• psychodynamic approaches
• psychopharmacotherapy
• benzodiazepines (alprazolam, clonazepam) - for
  several weeks (potential for abuse, development
  of tolerance and addiction)
• Buspirone - little abusive potential especially
  GAD, not effective in panic disorder longer use
  is necessary
• beta-blocking drugs - for the short treatment of
  performance anxiety, especially somatic symptoms
  like tremor
• antihistaminics
• various types of antidepressants - SRIs
  (clomipramine, citalopram, fluoxetine,
  fluvoxamine, paroxetitle, sertraline), MOAIs
  (tranylcypromifle), RIMA (moclobemide) and SNRI
  (venlafaxine) well tolerated, no abuse potential
• Recommendation to start the treatment with a
  brief course of benzodiazepines as well as with
  antidepressants for a longer period and to
  combine the drug treatment with various types of
  psychotherapy.

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Commonly Used Anxiolytics
Drug Commonly used dosage (mg) Elimination halftime (hours)
Alprazolam 0,5-6 12-15
Bromazepam 3-15 12
Diazepam 5-30 24-72
Chfordiazepoxied 10-50 24-100
Clobazam 20-30 20
Clonazepam 1-8 34
Clorazepate 15-60 60
Lorazepam 1-4 11-13
Medazepam 10-30 29
Oxazepam 30-90 4-20
Tofizopam 50-300 6
Buspirone 20-30 2-11
Hydroxyzine 300-400 12-20
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F42 Obsessive-Compulsive Disorder (OCD)

• 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

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Obsessive-Compulsive Disorder (OCD)

• Obsessional thought are ideas, images or impulses
  that enter the individuals mind again and again
  in a stereotyped form.
• They are recognized as the individuals own
  thoughts, even though they are involuntary and
  often repugnant. Common obsessions include fears
  of contamination, of harming other persons or
  sinning against God.
• Compulsions are repetitive, purposeful, and
  intentional behaviours or mental acts performed
  in response to obsessions or according to certain
  rule that must be applied rigidly. Compulsions
  are meant to neutralize or reduce discomfort or
  to prevent a dreaded event or situation.
• Autonomic anxiety symptoms are often present.
• There is very frequent comorbidity with
  depression (about 80) - suicidal thoughts.
  Obsessive-compulsory symptoms may appear in early
  stages of schizophrenia.
• The life time prevalence 2 - 3. Equally common
  in men and women. The course is variable and more
  likely to be chronic.

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Etiology of OCD

• The neurobiological model has received widespread
  support in the past decade. OCD occurs more often
  in persons who have various neurological
  disorders, including cases of head trauma,
  epilepsy, Sydenhams and Huntingtons chorea. OCD
  has also been linked to birth injury, abnormal
  EEG findings, abnormal auditory evoked
  potentials, growth delays, and abnormalities in
  neuropsychological test results. Recently, a type
  of OCD has been identified in children after a
  group A beta-streptococcal infection.
• The most widely studied biochemical model has
  focused on the neurotransmitter serotonin because
  SRIs are effective in treating patients with OCD.
  
• Brain imaging studies have provided some evidence
  of basal ganglia involvement in persons with OCD.

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Clinical Management

• The treatment of OCD has traditionally been
  viewed as difficult and unsatisfactory. Recent
  developments have changed this picture
  substantially.
• Pharmacotherapy
• antidepressants influencing the central
  serotoninergic system (clomipramine and SSRIs)
  higher doses of the drugs are required to treat
  OCD than depression, and response is often
  delayed.
• Cognitive-behaviour therapy
• Family therapy
• Patient support groups
• Psychosurgery (e.g. stereotactic cingulotomy)

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Epidemiology
Kessler et al., 1995
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F44 Dissociative (Conversion) Disorders

• 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
• F44.9 Dissociative (conversion) disorder,
  unspecified

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Dissociative (Conversion) Disorders

• The common theme shared by dissociative disorders
  is a partial or complete loss of the normal
  integration between memories of the past,
  awareness of identity and 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.
• The term conversion hysteria should be avoided,
  because it is confusing and stigmatizing.
• The prevalence is not exactly known (up to 10) .
• Sudden onset and termination of dissociative
  states.
• There are several forms of dissociative syndromes.

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Dissociative Amnesia

• The main feature is loss of memory, usually of
  important recent event, which is not due to
  organic mental disorder and is too extensive to
  be explained by ordinary forgetfulness or
  fatigue.
• The amnesia is usually centered on traumatic
  events, such as accidents, combat experiences, or
  unexpected bereavements, and used to be partial
  and selective.
• The amnesia typically develops suddenly and can
  last from minutes to days.
• Differential diagnosis complicated it is
  necessary to rule out all organic brain disorders
  as well as various intoxications. The most
  difficult differentiation is from conscious
  simulation - malingering.

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Dissociative Stupor

• The individual suffers from diminution or absence
  of voluntary movement and normal responsiveness
  to external stimuli such as light, noise, and
  touch.
• The person lies or sits largely motionless for
  long periods of time.
• Speech and spontaneous and purposeful movement
  are completely absent.
• 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.
• Positive evidence of psychogenic causation in the
  form of either recent stressful events or
  prominent interpersonal or social problems.

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Trance and Possession Disorders

• There is a temporary loss of both the sense of
  personal identity and full awareness of the
  surroundings. The individual can act as if taken
  over by another personality, spirit, deity, or
  force. Repeated sets of extraordinary
  movements, postures, and utterances can be
  observed.

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Dissociative Disorders of Movement and Sensation

• There is a loss of or interference with movements
  or loss of sensations (usually cutaneous). 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.
• Dissociative motor disorders
• Dissociative convulsions
• Dissociative anaesthesia
• Gansers syndrome approximate or grossly
  incorrect answers
• Multiple personality disorder means the apparent
  existence of two or more distinct personalities
  within an individual, with only one of them being
  evident at a time (Mr. Jekyl and Mr. Hyde). Each
  personality is complete, with its own memories,
  behaviours, and preferences, but neither has
  access to the memories of the other and the two
  are almost always unaware of each others
  existence. Change from one personality to another
  is in the first instance usually sudden and
  closely associated with traumatic events.

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Clinical Management

• Psychotherapy is a method of choice of treatment
  of dissociative disorders (e.g. psychodynamic
  programs, hypnosis).
• Medications have no proven value with exception
  of sodium amobarbital interview.

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F43 Reaction to Severe Stress, and Adjustment
Disorders

• F43 Reaction to severe stress, and adjustment
  disorders
• F43.0 Acute stress reaction
• F43.1 Post-traumatic stress disorder
• F43.2 Adjustment disorders
• F43.8 Other reactions to severe stress
• F43.9 Reaction to severe stress, unspecified

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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 (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) producing an acute stress
  reaction
• significant life change leading to continued
  unpleasant circumstances that result in an
  adjustment disorder
• Stressful event is thought to be the primary and
  overriding causal factor, and the disorder would
  not have occurred without its impact.

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Acute Stress Reaction

• A transient disorder of significant severity,
  which develops in an individual without any
  previous mental disorder in response to
  exceptional physical and/or psychological stress.
  
• Not all people exposed to the same stressful
  event develop the disorder.
• The symptoms 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
  (extreme variant - dissociative stupor), or by
  agitation and overactivity.
• Autonomic signs - tachycardia, sweating or
  flushing, as well as other anxiety or depressive
  symptoms.
• The symptoms usually appear within minutes of the
  impact of the stressful event, and disappear
  within several hours, maximally 23 days.

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Post-traumatic Stress Disorder (PTSD)

• PTSD is a delayed and/or protracted response to a
  stressful event of an exceptionally threatening
  or catastrophic nature.
• The three major elements of PTSD include
• reexperiencing the trauma through dreams or
  recurrent and intrusive thoughts (flashbacks)
• showing emotional numbing such as feeling
  detached from others
• having symptoms of autonomic hyperarousal such as
  irritability and exaggerated startle response,
  insomnia
• Commonly there is fear and avoidance of cues that
  remind the sufferer of the original trauma.
  Anxiety and depression are commonly associated
  with the above symptoms. Excessive use of alcohol
  and drugs may be a complicating factor.
• The onset follows the trauma with a latency
  period, which may range from several weeks to
  months, but rarely more than half a year.
• The lifetime prevalence is estimated at about
  0.5 in men and 1.2 in women.

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Post-traumatic Stress Disorder (PTSD)
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Clinical Management

• Pharmacological approach
• antidepressant medication
• short-term benzodiazepines trials
• mood stabilizers (carbamazepine, valproate)
• antipsychotics
• Psychotherapy is also of importance - CBT using
  education and exposure techniques
• Group therapy, family therapy and self-help
  groups are widely recommended.

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Adjustment Disorders

• Adjustment disorder comprises states of
  subjective distress and emotional disturbance
  arising in the period of adaptation to a
  significant life change or to the consequences of
  a stressful life event, such as serious physical
  illness, bereavement or separation, migration or
  refugee status.
• The clinical picture depressed mood, anxiety,
  worry, a feeling of inability to cope, plan
  ahead, or continue in the present situation, and
  some degress of disability in the performance of
  daily routine.
• Onset - within 1 month duration - below 6
  months.
• More frequently women, unmarried and young
  persons.
• Psychotherapy is the first line treatment of this
  disorder. Symptomatic treatment may comprise
  short trial of hypnotics or benzodiazepines.

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F45 Somatoform Disorders

• F45 Somatoform disorders
• F45.0 Somatization disorder
• F45.1 Undifferentiated somatoform disorder
• F45.2 Hypochondriacal disorder
• F45.3 Somatoform autonomic dysfunction
• F45.4 Persistent somatoform pain disorder
• F45.8 Other somatoform disorders
• F45.9 Somatoform disorder, unspecified

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F45 Somatoform Disorders

• Somatoform disorders - multiple, recurrent and
  frequent somatic complaints requiring medical
  attention without association with any physical
  disorder are prominent.
• The medical history of multiple contacts with
  primary care and specialized health services is
  typical before the patient is referred to
  psychiatric care.
• Characteristics of somatoform disorders
• somatic complains of many medical maladies
  without association with serious demonstrable
  peripheral organ disorder
• psychological problems and conflicts that are
  important in initiating, exacerbating and
  maintaining the disturbance

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F45.0 Somatization DisorderDiagnostic Guidelines

• A definite diagnosis requires the presence of all
  of the following
• at least 2 years of multiple and variable
  physical symptoms for which no adequate physical
  explanation has been found,
• persistent refusal to accept the advice or
  reassurance of several doctors that there is no
  physical explanation for the symptoms,
• some degree of impairment of social and family
  functioning attributable to the nature of
  symptoms and resulting behavior.

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F45.0 Somatization DisorderDifferential Diagnosis

• Medical conditions may be confused with
  somatoform disorder especially early in their
  course (multiple sclerosis, brain tumor,
  hyperparathyroidism, hyperthyroidism, lupus
  erythematosus).
• Further investigation or consultation should be
  considered in long-term somatization disorder if
  there is a shift in the emphasis or stability of
  the physical complaints. This change in symptoms
  suggests possible development of physical
  disease.
• Affective (depressive) and anxiety disorders
  accompany somatization disorders but need not be
  specified separately unless they are sufficiently
  marked and persistent.

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F45.0 Somatization DisorderTherapy and Prognosis

• Chronic relapsing condition starting in
  adolescence or even as late as the third decade
  of life.
• New symptoms during the emotional distress.
• Typical episodes last 6 to 9 months quiescent
  time of 9 to 12 months.
• Management strategies
• the trusting relationship between the patient and
  one (if possible) primary care physician
• set up regularly scheduled visits every 4 or 6
  weeks
• keep outpatient visits brief-perform at least a
  partial physical examination during each visit
  directed at the organ system of complaint
• understand symptoms as emotional message rather
  than a sing of new disease, look for signs of
  disease rather than focus on symptom
• avoid diagnostic tests, laboratory evaluations
  and operative procedures unless clearly indicated
  
• set a goal to get selected somatization patients
  referral- ready for mental health care
• Group therapy (time limited, behavior oriented
  and structured group).

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F45.1 Undifferentiated Somatoform Disorder

• The diagnosis should be considered if the
  complete and typical clinical picture of
  somatization disorders has not been fulfilled.
• No physical basis of the symptoms presented
  remains the basis for the diagnosis.
• Differential diagnosis
• frequently occur in major depression and
  schizophrenia.
• chronic history of multiple somatic complaints
• begin before the age of 30
• adjustment disorder with unexplained somatic
  complaints should last by definition less than 6
  moths
• Therapy and prognosis
• chronic and relapsing but some cases experience
  only one episode
• treatment approaches as in somatization disorder

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F45.2 Hypochondriacal Disorder

• The disorder is characterized by a persistent
  preoccupation and a fear of developing or having
  one or more serious and progressive physical
  disorders.
• Patients persistently complain of physical
  problems or are persistently preoccupied with
  their physical appearance.
• The fear is based on the misinterpretation of
  physical signs and sensations.
• Physician physical examination does not reveal
  any physical disorder, but the fear and
  convictions persist despite the reassurance.

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F45.2 Hypochondriacal DisorderDiagnostic
Guidelines

• Presence of both of the following criteria
• persistent belief in the presence of at least one
  serious physical illness underlying the
  presenting symptom or symptoms, even thought
  repeated investigations and examinations have not
  identified any adequate physical explanation, or
  a persistent preoccupation with presumed
  deformity or disfigurement
• persistent refusal to accept the advice and
  reassurance of several different doctors that
  there is no physical illness or abnormity
  underlying the symptoms
• Includes Body dysmorphic disorder,
  Dysmorphophobia (non delusional), Hypochondriacal
  neurosis, Hypochondriasis, Nosophobia

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F45.2 Hypochondriacal Disorder Differential
Diagnosis

• Basic - ruling out underlying organic disease.
• The main somatoform disorder that need to be
  differentiated from hypochondriasis is
  somatization disorder.
• Hypochondriasis needs to be distinguished from
  factitious disorder with predominantly physical
  signs and from malingering.

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F45.2 Hypochondriacal Disorder Therapy and
Prognosis

• The illness is usually long-standing, with
  episodes lasting months or years. Recurrences
  occur frequently after psychosocial distress.
• Higher socio-economic status, presence of other
  treatable condition, anxiety and depression, an
  acute onset, absence of personality disorder or
  comorbid organic disease predict better outcome.
• No evidence-based treatment has been described.
• Patients strongly refuse the mental health care
  professionals and remain in primary health care.
• Similar management and group therapy strategy as
  in somatization disorder may be useful.

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F45.3 Somatoform Autonomic Dysfunction

• The symptoms are presented as physical disorder
  of system or organ largely or completely under
  controlled by autonomic innervation, i.e. the
  cardiovascular, gastrointestinal, or respiratory
  system and some aspects of genitourinary system.
• The symptoms are usually of two types
• complaints based on objective signs of autonomic
  arousal (palpitation, sweating, flushing, tremor)
• idiosyncratic, subjective, non-specific (fleeting
  aches and pains, burning, heaviness, tightness,
  sensation of being bloated or distended)
• These symptoms patients refer to a specific organ
  or system.
• In many cases there is evidence of psychological
  stress or current problems related to the
  disorder.

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F45.3 Somatoform Autonomic Dysfunction
Diagnostic Guidelines

• Symptoms of autonomic arousal such as
  palpitations, sweating, tremor, flushing which
  are troublesome and persistent
• Additional subjective symptoms referred to
  specific organ or system
• Preoccupation with the symptoms and possibility
  of serious (often non specified disorder). It
  does not respond to repeated explanations and
  reassurance of physicians
• No evidence of a significant disturbance of
  structure or function of the system or organ

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F45.3 Somatoform Autonomic Dysfunction
Differential Diagnosis

• In comparison with generalized anxiety there is
  predominance of psychological component of
  autonomic arousal. In somatization disorders
  autonomic symptoms when they are present they are
  nor prominent nor persistent and symptoms are not
  so persistently attributed to one organ or
  system.
• Excludes psychological and behavioural factors
  associated with disorders or diseases classified
  elsewhere (F54).
• The individual disorder may be classified by
  fifth character indicating the organ or system
  affected

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F45.3 Somatoform Autonomic Dysfunction Therapy
and Prognosis

• Similar chronic relapsing condition as the
  somatization disorder.
• Patients report worse health than do those with
  chronic medical condition and their report of
  specific symptoms if they meet the severity
  criteria is sufficient and need not to be
  considered legitimate by the clinician.
• Treatment strategies will be similar stressing
  the importance of the interdisciplinary
  collaboration.

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F45.4 Persistent Somatoform Pain Disorder

• The predominant symptom is a persistent severe
  and distressing pain that cannot be explained
  fully by a physiological process of physical
  illness.
• Pain occurs in association with emotional
  conflicts or psychosocial problems.
• The expression of chronic pain may vary with
  different personalities and cultures.
• The patient is not malingering and the complaints
  about the intensity of the pain are to be
  believed.

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F45.4 Persistent Somatoform Pain Diagnostic
Guidelines

• The clinical examination should focus on
• the extend the patient is disabled by the pain
• the degree of complicating emotional factors and
  comorbid psychiatric conditions
• Includes psychalgia, psychogenic backache or
  headache, somatoform pain disorder.

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F45.4 Persistent Somatoform PainDifferential
Diagnosis

• Not included
• pain presumed to be of psychological origin
  occurring during the course of depression or
  schizophrenia
• pain due to known or inferred physiological
  mechanism such as muscle tension pain or migraine
  but still believed to have psychological cause
  are coded as P54
• the somatoform pain disorder has to be
  differentiated from histrionic behaviour in
  reaction to organic pain
• Excluded backache NOS (M54.9), pain NOS (acute,
  chronic) (R52.-), tension type headache (G44.2).

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F45.4 Persistent Somatoform PainTherapy and
prognosis

• Once diagnosis is completed the outpatient
  treatment on regular basis by one interested
  physician has to be carried out.
• Patients have to be reassured that the treatment
  continues if there is some improvement.
• Those with pain-prone reaction to distress are
  described to have poor or transient improvement.
• Patients with comorbid depression may improve
  with antidepressant medication.
• Treatment with any type of the pain disorder
  subtypes needs to be multidisciplinary and
  multidimensional from the onset.

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F45.8 Other Somatoform Disorders

• In these disorders the presented complaints are
  not mediated through the autonomic nervous, and
  are limited to specific system of body part.
• Any other disorders of sensation not due to
  physical disorders which are closely associated
  in time with stressful event or problem and which
  results in significant increase of attention for
  the patient, personal or medical care should also
  be classified here.
• Swelling, movement on the skin and paraesthesias
  (tingling or/and numbness) are common.
• Disorders included in this category
• globus hystericus
• psychogenic torticollis and other disorders of
  spasmodic movement (excluding Tourettes
  syndrome)
• psychogenic pruritus but excluding specific skin
  lesions such as alopecia, dermatitis eczema, or
  urticaria of psychogenic origin

58
F45.9 Somatoform Disorder, Unspecified

• Includes unspecified physiological or
  psychosomatic disorder in patients whose symptoms
  and associated disability do not fit the full
  criteria for other somatoform disorders. The
  treatment and the outcome however do not
  considerably differ.

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Other Neurotic Disorders

• F48 Other neurotic disorders
• F48.0 Neurasthenia
• F48.1 Depersonalization-derealization syndrome
• F48.8 Other specified neurotic disorders
• F48.9 Neurotic disorder, unspecified