Mohammed T. Abou-Saleh

538 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYTable 97.1Relative positions of neurotic disorders in the diagnostic schemataICD-10DSM-IVF0 Organic mental disorders Disorders usually first evident in infancy, childhood or adolescenceF1 Mental and behavioral disorders due to psychoactive substance uses Delirium; dementia and amnestic and other cognitive disordersF2 Schizophrenia, schizotypal states and delusional disorders Mental disorders due to a general medical condition not elsewhereF3 Mood disorders classifiedF4 NEUROTIC, STRESS-RELATED Substance-related disordersAND SOMATOFORM DISORDERSSchizophrenia and other psychotic disordersF5 Behavioral syndromes and mental disorders associated with Mood disordersphysiological dysfunction and hormonal changesANXIETY DISORDERSF6 Abnormalities of adult personality and behavior SOMATOFORM DISORDERSF7 Mental retardation DISSOCIATIVE DISORDERSF8 Developmental disorders Factitious disordersF9 Behavioral and emotional disorders with onset usually occurring Sexual and gender identity disordersin childhood or adolescenceEating disordersSleep disordersImpulse-control disorders not elsewhere classifieddisorders, rather than with anxiety disorders. It does, however,retain the historical commonality that traces to Freud’s originalstress on the etiologic similarity of the psychoneuroses, acknowledgingthe current state of scientific knowledge that is, at best,ambiguous concerning the etiology of these disorders 12,13 .Table 97.1 compares the relative positions of the neuroticdisorders in ICD-10 and Axis I of DSM-IV. The alphanumericorganization of the International Classification requires theconstraint of all mental disorders to 10 major categories. DSM-IV, under no such limitation, separates out anxiety, somatoformand dissociative disorders but keeps them within the samegradient of severity between mood disorders and sexual disorders.Adjustment disorders are removed to a position implying lessseverity, as well as an implied direction that higher-rankingdiagnoses are to be made or eliminated first. Personality disorders,of course, are assigned to Axis II.Under the category of the neurotic disorders, the internationaland American systems differ in their organization, as outlined inTable 97.2. DSM-IV groups the phobic disorders, obsessivecompulsivedisorder, post-traumatic stress disorder and generalizedanxiety disorder together as anxiety disorders. ICD-10separates phobic disorders, anxiety disorders, and obsessivecompulsivedisorders. Post-traumatic stress disorders are classifiedwith adjustment disorders. Both schemes separate dissociative andsomatoform disorders. ICD-10 groups conversion disorder withdissociative states, consistent with the historical, etiologicallybasedclassification of the hysterias. DSM-IV combines it with thesomatoform disorders, based on their phenomenological similarities.ICD-10 retains the diagnosis of neurasthenia; while DSM-III-R refers the clinician to dysthymia, categorized unequivocallyas a mood disorder, DSM-IV eliminates the term entirely 8,9,11 .DIAGNOSTIC FEATURES OF NEUROTICDISORDERSWhile each of the major categories of neurotic disorders isdescribed in the chapters that follow, the clinical features of theseven ICD-10 groupings are presented here for overview andcomparison 11 .Phobic disorders are a set of disorders in which anxiety isinvoked only, or predominantly, by well-defined situations thatare not in themselves dangerous. By definition, the object of thefear is external to the individual, so that fears of bodily processesare more appropriately relegated to the category of somatoformdisorders. The feared objects are characteristically avoided, andanticipatory anxiety is common.Other anxiety disorders are those in which anxiety is the majorsymptom but which are not restricted to specific situations. Theyinclude panic disorder, generalized anxiety disorder, and mixedanxiety and depressive disorder. The latter is reserved for caseswhere symptoms of both are present, neither is predominant, andthe depression is not severe enough to be classified under milddepressive disorder.Obsessive-compulsive disorder is characterized by recurrentobsessional thoughts or compulsive acts, or both. These thoughtsand acts are subjectively distressing. Subjective anxiety is usuallypresent and depressive features are common.Reactions to severe stress and adjustment disorders represent aunique category, in that the component disorders are identified onthe grounds of both symptomatology and causation. In thesedisorders, anxiety follows an exceptionally stressful life event or asignificant life change. While psychosocial stressors may precipitatea wide variety of psychiatric syndromes, they areelsewhere neither necessary nor sufficient to explain the occurrenceand form of the disorder. The stress and adjustmentdisorders, however, are seen as arising as a direct consequence ofthe trauma or life change.Dissociative disorder is a group of entities that share a partial orcomplete loss of the normal integration between memory of thepast, awareness of identity and immediate sensations, and controlof bodily movements. It is presumed that, in these disorders, theability to exert conscious and selective control over memory,sensation or bodily function is impaired.Somatoform disorders are those in which physical symptoms arerepeatedly presented with requests for investigation or treatment,in spite of the absence of physical findings to substantiate theperception. Compared with patients who suffer from psychogenicmovement or sensory disorders, those with somatoform disorderswill demand attention and usually resent physicians who fail tobelieve in the physical nature of their illnesses. Even when theonset of symptoms is temporally related to a stressful life event, orwhen external manifestations of depression or anxiety are obviousto others, these patients will frequently resist speculation aboutpsychological causation.Other neurotic disorders feature two clinical entities, neurastheniaand depersonalization–derealization syndrome. Theformer, recalling the pre-Freudian nomenclature, is a controversialcategory in contemporary psychiatry. Its main feature isfatigue, which may occur upon either mental or physical exercise.The diagnosis is to be made only after depressive and anxiety