Istanbul Protocol Model Medical Curriculum

Includes: single episodes of:

• depressive reaction
• psychogenic depression
• reactive depression

Excludes: adjustment disorder (F43.2 [4])

• recurrent depressive disorder (F33 [3])
• when associated with conduct disorders in F91.- (F92.0 [1])

F32.0 Mild depressive episode

Two or three of the above symptoms are usually present. The patient is usually distressed by these but will probably be able to continue with most activities.

F32.1 Moderate depressive episode

Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities.

F32.2 Severe depressive episode without psychotic symptoms

An episode of depression in which several of the above symptoms are marked and distressing, typically with loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of “somatic” symptoms are usually present.

Agitated depression / Major depression / Vital depression: single episode without psychotic symptoms

F32.3 Severe depressive episode with psychotic symptoms

An episode of depression as described in F32.2, but with the presence of hallucinations, delusions, psychomotor retardation, or stupor so severe that ordinary social activities are impossible; there may be danger to life from suicide, dehydration, or starvation. The hallucinations and delusions may or may not be mood-congruent.

Single episodes of:

• major depression with psychotic symptoms
• psychogenic depressive psychosis
• psychotic depression
• reactive depressive psychosis

F32.8 Other depressive episodes

F32.9 Depressive episode, unspecified

Under “Mood [affective] disorders (F30-F39)” see also:

• F30 Manic episode
• F31 Bipolar affective disorder
• F33 Recurrent depressive disorder
• F34 Persistent mood [affective] disorders
• F38 Other mood [affective] disorders

Neurotic, stress-related and somatoform disorders (F40-F48)

F43 Reaction to Severe Stress and Adjustment Disorders

This category differs from others in that it includes disorders identifiable on the basis of not only symptoms and course but also the existence of one or other of two causative influences: an exceptionally stressful life event producing an acute stress reaction, or a significant life change leading to continued unpleasant circumstances that result in an adjustment disorder. Although less severe psychosocial stress (“life events”) may precipitate the onset or contribute to the presentation of a very wide range of disorders classified elsewhere in this chapter, its etiological importance is not always clear and in each case will be found to depend on individual, often idiosyncratic, vulnerability, i.e. the life events are neither necessary nor sufficient to explain the occurrence and form of the disorder. In contrast, the disorders brought together here are thought to arise always as a direct consequence of acute severe stress or continued trauma. The stressful events or the continuing unpleasant circumstances are the primary and overriding causal factor and the disorder would not have occurred without their impact. The disorders in this section can thus be regarded as maladaptive responses to severe or continued stress, in that they interfere with successful coping mechanisms and therefore lead to problems of social functioning.

F43.0 Acute Stress Reaction

A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions. The symptoms show a typically mixed and changing picture and include an initial state of “daze” with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation (to the extent of a dissociative stupor – F44.2), or by agitation and over-activity (flight reaction or fugue). Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days (often within hours). Partial or complete amnesia (F44.0) for the episode may be present. If the symptoms persist, a change in diagnosis should be considered.

• Acute:
  • crisis reaction
  • reaction to stress
• Combat fatigue
• Crisis state
• Psychic shock

F43.1 Post-Traumatic Stress Disorder

Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories (“flashbacks”), dreams or nightmares, occurring against the persisting background of a sense of “numbness” and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change (F62.0)

• Traumatic neurosis

F43.2 Adjustment Disorders

States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event. The stressor may have affected the integrity of an individual’s social network (bereavement, separation experiences) or the wider system of social supports and values (migration, refugee status), or represented a major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement). Individual predisposition or vulnerability plays an important role in the risk of occurrence and the shaping of the manifestations of adjustment disorders, but it is nevertheless assumed that the condition would not have arisen without the stressor. The manifestations vary and include depressed mood, anxiety or worry (or mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, as well as some degree of disability in the performance of daily routine. Conduct disorders may be an associated feature, particularly in adolescents. The predominant feature may be a brief or prolonged depressive reaction, or a disturbance of other emotions and conduct.

• Culture shock
• Grief reaction
• Hospitalism in children

F43.8 Other reactions to severe stress

F43.9 Reaction to severe stress, unspecified

F44 Dissociative [Conversion] Disorders

The common themes that are shared by dissociative or conversion disorders are 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. All types of dissociative disorders tend to remit after a few weeks or months, particularly if their onset is associated with a traumatic life event. More chronic disorders, particularly paralyses and anaesthesias, may develop if the onset is associated with insoluble problems or interpersonal difficulties. These disorders have previously been classified as various types of “conversion hysteria”. They are presumed to be psychogenic in origin, being associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. The symptoms often represent the patient’s concept of how a physical illness would be manifest. Medical examination and investigation do not reveal the presence of any known physical or neurological disorder. In addition, there is evidence that the loss of function is an expression of emotional conflicts or needs. The symptoms may develop in close relationship to psychological stress, and often appear suddenly. Only disorders of physical functions normally under voluntary control and loss of sensations are included here. Disorders involving pain and other complex physical sensations mediated by the autonomic nervous system are classified under somatization disorder (F45.0). The possibility of the later appearance of serious physical or psychiatric disorders should always be kept in mind.

Includes:

• conversion:
  • hysteria
  • reaction
• hysteria
• hysterical psychosis

F44.0 Dissociative Amnesia

The main feature is loss of memory, usually of important recent events, that is not due to organic mental disorder, and is too great to be explained by ordinary forgetfulness or fatigue. The amnesia is usually centred on traumatic events, such as accidents or unexpected bereavements, and is usually partial and selective. Complete and generalized amnesia is rare, and is usually part of a fugue (F44.1). If this is the case, the disorder should be classified as such. The diagnosis should not be made in the presence of organic brain disorders, intoxication, or excessive fatigue.

Under dissociative [conversion] disorder see also:

• 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

F45 Somatoform Disorders

The main feature is repeated presentation of physical symptoms together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis. If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient.

F45.0 Somatization Disorder

The main features are multiple, recurrent and frequently changing physical symptoms of at least two years’ duration. Most patients have a long and complicated history of contact with both primary and specialist medical care services, during which many negative investigations or fruitless exploratory operations may have been carried out. Symptoms may be referred to any part or system of the body. The course of the disorder is chronic and fluctuating, and is often associated with disruption of social, interpersonal, and family behaviour. Short-lived (less than two years) and less striking symptom patterns should be classified under undifferentiated somatoform disorder (F45.1).

• Briquet’s disorder
• Multiple psychosomatic disorder
• Excludes: malingering [conscious simulation] (Z76.5 [2])

F45.4 Persistent Somatoform Pain Disorder

The predominant complaint is of persistent, severe, and distressing pain, which cannot be explained fully by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion that they are the main causative influences. The result is usually a marked increase in support and attention, either personal or medical. Pain presumed to be of psychogenic origin occurring during the course of depressive disorders or schizophrenia should not be included here.

• Psychalgia
• Psychogenic:
  • backache
  • headache
• Somatoform pain disorder
• Excludes: backache NOS (M54.9 [6])
• pain:
  • NOS (R52.9 [7])
  • acute (R52.0 [11])
  • chronic (R52.2 [10])
  • intractable (R52.1 [9])
  • tension headache (G44.2 [8])

Under F45 Somatoform disorders, See also:

• F45.1 Undifferentiated somatoform disorder
• F45.2 Hypochondriacal disorder
• F45.3 Somatoform autonomic dysfunction
• F45.8 Other somatoform disorders

Under “Neurotic, stress-related and somatoform disorders (F40-F48)” see also:

• F40 Phobic 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
• F42 Obsessive-compulsive disorder

Disorders of adult personality and behaviour (F60-F69)

F62 Enduring Personality Changes, not Attributable to Brain Damage and Disease

Disorders of adult personality and behaviour that have developed in persons with no previous personality disorder following exposure to catastrophic or excessive prolonged stress, or following a severe psychiatric illness. These diagnoses should be made only when there is evidence of a definite and enduring change in a person’s pattern of perceiving, relating to, or thinking about the environment and himself or herself. The personality change should be significant and be associated with inflexible and maladaptive behaviour not present before the pathogenic experience. The change should not be a direct manifestation of another mental disorder or a residual symptom of any antecedent mental disorder.

Excludes: personality and behavioural disorder due to brain disease, damage and dysfunction (F07.- [12])

F62.0 Enduring Personality Change After Catastrophic Experience

Enduring personality change, present for at least two years, following exposure to catastrophic stress. The stress must be so extreme that it is not necessary to consider personal vulnerability in order to explain its profound effect on the personality. The disorder is characterized by a hostile or distrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of “being on edge” as if constantly threatened, and estrangement. Post-traumatic stress disorder (F43.1) may precede this type of personality change.

Personality change after:

• concentration camp experiences
• disasters
• prolonged:
• captivity with an imminent possibility of being killed
• exposure to life-threatening situations such as being a victim of terrorism
• torture
• Excludes: post-traumatic stress disorder (F43.1)

Behavioural syndromes associated with physiological disturbances and physical factors (F50-F59)

F52 Sexual dysfunction, not caused by organic disorder or disease

Sexual dysfunction covers the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish. Sexual response is a psychosomatic process and both psychological and somatic processes are usually involved in the causation of sexual dysfunction.

Under “F52-Sexual dysfunction, not caused by organic disorder or disease” see:

• F52.0 Lack of loss of sexual desire
• F52.1 Sexual aversion and lack of sexual enjoyment
• F52.2 Failure of genital response
• F52.3 Organic dysfunction
• F52.4 Premature ejaculation
• F52.5 Nonorganic vaginismus
• F52.6 Nonorganic dyspareunia

Under “Behavioural syndromes associated with physiological disturbances and physical factors (F50-59)”, see also:

• F50 Eating disorders
• F51 Non organic sleep disorders

Organic, including symptomatic, mental disorders (F00-F09)

F07 Personality and behavioural disorders due to brain disease, damage and dysfunction

Alteration of personality and behaviour can be a residual or concomitant disorder of brain disease, damage or dysfunction.

F07.2 Postconcussional Syndrome

A syndrome that occurs following head trauma (usually sufficiently severe to result in loss of consciousness) and includes a number of disparate symptoms such as headache, dizziness, fatigue, irritability, difficulty in concentration and performing mental tasks, impairment of memory, insomnia, and reduced tolerance to stress, emotional excitement, or alcohol.

Postcontusional syndrome (encephalopathy)
Post-traumatic brain syndrome, nonpsychotic

Schizophrenia, schizotypal and delusional disorders (F20-F29)

F23 Acute and Transient Psychotic Disorders

A heterogeneous group of disorders characterized by the acute onset of psychotic symptoms such as delusions, hallucinations, and perceptual disturbances, and by the severe disruption of ordinary behaviour. Acute onset is defined as a crescendo development of a clearly abnormal clinical picture in about two weeks or less. For these disorders there is no evidence of organic causation. Perplexity and puzzlement are often present but disorientation for time, place and person is not persistent or severe enough to justify a diagnosis of organically caused delirium (F05.-). Complete recovery usually occurs within a few months, often within a few weeks or even days. If the disorder persists, a change in classification will be necessary. The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks.

Under “F 23 Acute and Transient Psychotic Disorders” see:

• F23.0 Acute polymorphic psychotic disorder without symptoms of schizophrenia
• F23.1 Acute polymorphic psychotic disorder with symptoms of schizophrenia
• F 23.2 Acute schizophrenia-like psychotic disorder
• F 23.3 Other acute predominantly delusional psychotic disorders
• F 23.8 Other acute and transient psychotic disorders
• F 23.9 Acute and transient psychotic disorder, unspecified
  Brief reactive psychosis NOS
  Reactive psychosis