Psychological or behavioural factors affecting disorders or diseases classified elsewhere

6E40 General Diagnostic Requirements for Psychological or Behavioural Factors Affecting Disorders or Diseases Classified Elsewhere

Essential (Required) Features:

• Psychological or behavioural factors are present that adversely affect the manifestation, treatment, or course of a disorder or disease classified in another chapter in one or more of the following ways:
• The factors interfere with the treatment of the disorder or disease by affecting treatment adherence or care seeking (e.g., avoidance of needed medical care in an individual with anxiety, non-adherence to a complex treatment regimen in an individual with Personality Disorder).
• The factors constitute an additional health risk for the person with the disorder or disease classified elsewhere (e.g., binge eating in a person with diabetes).
• The factors influence the underlying pathophysiology to precipitate or exacerbate symptoms or otherwise necessitate medical attention (e.g., stress response causing chest pain in an individual with coronary heart disease or anxiety causing bronchospasm in an individual with asthma).
• The factors increase the risk of suffering, disability, or death.
• The factors represent a focus of clinical attention.

Categories describing specific types of factors:

The following categories may be used to describe the specific types of psychological or behavioural factors that are adversely affecting the manifestation, treatment, or course of a disorder or disease classified in another chapter of the ICD. Multiple categories may be assigned as necessary to describe the clinical presentation.

• 6E40.0 Mental, Behavioural, or Neurodevelopmental Disorder affecting disorders or diseases classified elsewhere
• 6E40.1 Psychological symptoms affecting disorders or diseases classified elsewhere
• 6E40.2 Personality traits or coping style affecting disorders or diseases classified elsewhere
• 6E40.3 Maladaptive health behaviours affecting disorders or diseases classified elsewhere
• 6E40.4 Stress-related physiological response affecting disorders or diseases classified elsewhere
• 6E40.Y Other specified psychological or behavioural factor affecting disorders or diseases classified elsewhere

For presentations characterized by psychological or behavioural factors that adversely affect the manifestation, treatment, or course of a disorder or disease classified in another chapter but do not fulfil the diagnostic requirements for any other category in the Psychological or Behavioural Factors Affecting Disorders or Diseases Classified Elsewhere grouping, the following catogory may be appropriate:

6E40.Y Other specified psychological or behavioural factor affecting disorders or diseases classified elsewhere

• The general diagnostic requirements for Psychological or Behavioural Factors Affecting Disorders or Diseases Classified Elsewhere (6E40) are met.
• The presence of other psychological or behavioural factors that adversely affect the manifestation, treatment, or course of a disorder or disease classified in another chapter (e.g., interpersonal, cultural, or religious factors).

Additional Clinical Features:

• The adverse effects can range from acute, with immediate medical consequences (e.g., anxiety precipitating a cardiac arrhythmia) to chronic, occurring over a long period of time (e.g., chronic occupational stress aggravating diabetes). The adverse effects may be time-limited, episodic, or chronic and persistent. The disorders or diseases potentially affected by psychological or behavioural factors include those with clear pathophysiology (e.g., hypertension, HIV infection, coronary disease), functional syndromes (e.g., chronic fatigue syndrome, irritable bowel syndrome, fibromyalgia), or idiopathic symptoms (e.g., dizziness, tinnitus).

Developmental Presentations:

• Psychological or Behavioural Factors Affecting Disorders or Diseases Classified elsewhere can occur across the lifespan. Particularly with young children, collateral history from parents or school personnel can assist in diagnosis. Some psychological or behavioural factors are more prevalent at particular stages of life (e.g., body image concerns in adolescents).

Culture-Related Features:

• Differences between cultures may influence psychological or behavioural factors and their effects on other conditions, such as linguistic and verbal communication, explanatory models of illness, health care practices and delivery, provider-patient relationships, family and gender roles, and attitudes towards pain and death.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Adjustment Disorder: Stress associated with having a medical condition can cause psychological or behavioural symptoms that may meet the diagnostic requirements for Adjustment Disorder, specifically preoccupation with the stressor or its consequences, including excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its implications that results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. In Psychological or Behavioural Factors Affecting Disorders or Diseases Classified Elsewhere, the causality is in the opposite direction; that is, psychological or behavioural factors adversely affect an existing medical condition. For example, an individual who, in the weeks following a heart attack, develops severe anxiety whenever he leaves the house because he is afraid of experiencing cardiac symptoms when no help is available might be appropriately diagnosed as having Adjustment Disorder. In contrast, an individual with atherosclerotic heart disease who develops chest pain whenever she becomes anxious would be diagnosed with Psychological or Behavioural Factors Affecting Disorders or Diseases Classified Elsewhere. In clinical practice however, psychological factors and a medical condition are often mutually exacerbating, in which case both diagnoses may be assigned if it is clinically useful to do so.
• Boundary with Hypochondriasis (Health Anxiety Disorder): Hypochondriasis is characterized by persistent preoccupation with or fear about the possibility of having one or more serious, progressive or life-threatening diseases. The focus of clinical care is the individual’s worry about having a disease; in most cases, no serious medical disease is present. In Psychological or Behavioural Factors Affecting Disorders or Diseases Classified Elsewhere, anxiety may be a relevant psychological factor affecting a medical condition, but the clinical concern is the adverse effects of the anxiety on the manifestations, course, or treatment of the medical condition.
• Boundary with Bodily Distress Disorder occurring in an individual with an established medical condition: Bodily Distress Disorder occurring in an individual with an established medical condition is characterized by a combination of distressing bodily symptoms and a degree of attention related to the symptoms that is clearly excessive in relation to the nature and severity of the medical condition. In contrast, in Psychological or Behavioural Factors Affecting Disorders or Diseases Classified Elsewhere, the psychological or behavioural factors themselves adversely affect the manifestations, course, or treatment of the medical condition. In cases where the excessive attention paid to the bodily symptoms does adversely affect the medical condition (e.g., repeated contact with medical professionals that result in medically unwarranted investigative procedures that have made the medical condition worse), both diagnoses may be assigned if it is clinically useful to do so.
• Boundary with Secondary Mental or Behavioural Syndromes Associated with Disorders or Diseases Classified Elsewhere: In Secondary Mental or Behavioural Syndromes Associated with Disorders or Diseases Classified Elsewhere, a medical condition is judged to be causing mental or behavioural symptoms through a direct physiological mechanism. In contrast, in Psychological or Behavioural Factors Affecting Disorders or Diseases Classified Elsewhere, the psychological or behavioural factors are judged to affect the manifestations, course, or treatment of the medical condition. In both cases, there is a temporal relationship between the psychological and behavioural manifestations and the medical condition, but the presumed causal relationship is in the opposite direction.
• Boundary with other co-occurring mental disorders and medical conditions: Whereas co-occurrence of a Mental, Behavioural, or Neurodevelopmental Disorder and a medical condition may have an impact on the management of the medical condition (e.g., medications used in the treatment of the mental disorder interacting with medications used to treat the medical condition), Psychological or Behavioural Factors Affecting Disorders or Diseases Classified Elsewhere would only be diagnosed if the mental disorder itself is having a negative impact on the manifestations, course, or treatment of the medical condition.
• Boundary with Personality Difficulty: Personality Difficulty refers to pronounced, long-standing personality characteristics that may affect treatment or health services but do not rise to the level of severity to merit a diagnosis of Personality Disorder. In Personality Difficulty, there are difficulties in the individual’s way of experiencing and thinking about the self, others and the world that may be intermittently manifested in maladaptive patterns of cognitive and emotional experience and expression. The stress associated with being diagnosed or living with a serious medical condition is one factor that could potentially precipitate an exacerbation of Personality Difficulty. The category Personality traits or coping style affecting disorders or diseases classified elsewhere, on the other hand, would describe the situation in which Personality Difficulty has an adverse effect on the manifestations, course, or treatment of a medical condition. In clinical practice, however, Personality Difficulty and a medical condition may be mutually exacerbating, in which case both diagnoses may be assigned if it is clinically useful to do so.