The ICD-10 Classification of Mental and Behavioural
Disorders: Clinical Descriptions and Diagnostic Guidelines
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The ICD-10 classification of mental and behavioural
disorders : clinical descriptions and diagnostic guidelines.
1.Mental disorders — classification 2.Mental disorders — diagnosis
ISBN 92 4 154422 8 (NLM Classification: WM 15)
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Contents
Preface v
Acknowledgements ix
Introduction 1
Notes on selected categories in the classification
of mental and behavioural disorders in ICD-10 8
List of categories 22
Clinical descriptions and diagnostic guidelines 41
Annex. Other conditions from ICD-10 often
associated with mental and behavioural disorders 292
List of principal investigators 312
Index 326
in
Preface
In the early 1960s, the Mental Health Programme of the World Health Organiza-
tion (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 draf-
ting 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 (7, 2).
The 1970s saw further growth of interest in improving psychiatric classifica-
tion 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, aim-
ing to facilitate further improvements in the classification and diagnosis of
mental disorders, and alcohol- and drug-related problems (5). 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).
v
MENTAL AND BEHAVIOURAL DISORDERS
Several major research efforts were undertaken to implement the recommen-
dations of the Copenhagen conference. One of them, involving centres
in 17 countries, had as its aim the development of the Composite Inter-
national 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 (ICD-10) (9). Converting diagnostic criteria into diagnostic
algorithms incorporated in the assessment instruments was useful in uncover-
ing 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 dif-
ferent 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 ex-
perts, 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 its 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 ver-
sion for use by general health care workers, a multiaxial presentation, and
vi
PREFACE
'"crosswalks" — allowing cross-reference between corresponding terms in
ICD-10, ICD-9 and ICD-8.
Use of this publication is described in the Introduction, and a subsequent sec-
tion 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 classifica-
tion 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
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 perspec-
tives on their diagnosis and classification. Amsterdam, Excerpta Medica,
1985 (International Congress Series, No. 669).
vii
MENTAL AND BEHAVIOURAL DISORDERS
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 neuro-
psychiatry. 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, 1994. 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 ac-
companying the WHO Classification of Mental and Behavioural Disorders
in ICD-10. Archives of general psychiatry, 1993, 50: 115-124.
vin
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 pro-
posals. 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 ac-
companying 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
ix
MENTAL AND BEHAVIOURAL DISORDERS
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. Lopez-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. Stromgren; and the
World Psychiatric Association which, through its President, Dr 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, Ger-
many, 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 contribu-
tions 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 coun-
tries. 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.
x
ACKNOWLEDGEMENTS
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 classifica-
tion. Their addresses are listed below because it is hoped that they will con-
tinue 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 Neuro-
sciences, Bangalore, India
Dr H. Dilling, Psychiatric Clinic of the Medical School, Liibeck, Germany
Dr M. Gelder, Department of Psychiatry, Oxford University Hospital,
Warneford Hospital, Headington, England
Dr D. Kemali, University of Naples, First Faculty of Medicine and Surgery,
Institute of Medical Psychology and Psychiatry, Naples, Italy
Dr J.J. Lopez-Ibor Jr, Lopez-Ibor Clinic, Pierto de Hierro, Madrid, Spain
Dr G. Mellsop, The Wellington Clinical School, Wellington Hospital, Wel-
lington, New Zealand
Dr Y. Nakane, Department of Neuropsychiatry, Nagasaki University, School
of Medicine, Nagasaki, Japan
xi
MENTAL AND BEHAVIOURAL DISORDERS
Dr A. Okasha, Department of Psychiatry, Ain-Shams University, Cairo, Egypt
Dr C. Pull, Department of Neuropsychiatry, Centre Hospitalier de Lux-
embourg, 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 Univer-
sity, 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
Xll
Introduction
Chapter V, Mental and behavioural disorders, of ICD-10 is to be available
in several different versions for different purposes. This version, Clinical descrip-
tions 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 care-
fully 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
1
MENTAL AND BEHAVIOURAL DISORDERS
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 pur-
poses. 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 "provi-
sional" 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 judge-
ment 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 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.
2
INTRODUCTION
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.
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 assump-
tions about psychodynamic mechanisms, but simply indicates the presence of
hallucinations, delusions, or a limited number of severe abnormalities of
3
MENTAL AND BEHAVIOURAL DISORDERS
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 intoxi-
cation 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 common-
ly 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)).
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 tradi-
tional disorders of personality. Disorders of sexual preference are clearly dif-
ferentiated from disorders of gender identity, and homosexuality in itself is
no longer included as a category.
4
INTRODUCTION
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 de-
viance 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 specify-
ing 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.
5
MENTAL AND BEHAVIOURAL DISORDERS
Impairment, disability, handicap and related terms
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 record-
ing 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
1
International classification of impairments, disabilities and handicaps. Geneva, World
Health Organization, 1980.
6
INTRODUCTION
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 informa-
tion 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.
7
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 demen-
tia, 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 na-
tionalities 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 handicap1. 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, atten-
tion, 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
1
International classification of impairments, disabilities and handicaps. Geneva, World
Health Organization, 1980.
8
NOTES ON SELECTED CATEGORIES
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.
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 oversen-
sitive). 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
9
MENTAL AND BEHAVIOURAL DISORDERS
is the extent to which such prodromes can be distinguished from schizoid and
paranoid personality disorders.
Separation of acute and transient psychotic disorders
( F 2 3 . - ) 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 "bouffee delirante", "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 symp-
toms may occur with these disorders, and whether they are usually or always
associated with acute psychological stress (bouffee delirante, at least, was
originally described as not usually associated with an obvious psychological
precipitant).
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 per-
sist 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
(amfetamine psychosis is the best example) are considered. Withdrawal of the
10
NOTES ON SELECTED CATEGORIES
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 disorders1, the second of which was epidemi-
ologically 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 unsatisfac-
tory, since to delay 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.
1
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).
11
