# 236 - 6E40.Z Psychological or behavioural factor af # 6E40.Z Psychological or behavioural factor affecting disorders and diseases classified... 647 Psychological or behavioural factors affecting disorders and diseases classified elsewhere Stress-related physiological response affecting disorders and diseases classified elsewhere • The presence of stress-related physiological responses that adversely affect the manifestation, treatment or course of a disorder or disease classified in another chapter is required for diagnosis (e.g. stress-related exacerbation of ulcer, hypertension, arrhythmia or tension headache). Other specified psychological or behavioural factor affecting disorders and diseases classified elsewhere • 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 is required for diagnosis (e.g. interpersonal, cultural, or religious factors). Psychological or behavioural factor affecting disorders and diseases classified elsewhere, unspecified 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) and idiopathic symptoms (e.g. dizziness, tinnitus). Developmental presentations • Psychological or behavioural factors affecting disorders and 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). 6E40.Y 6E40.Z Psychological or behavioural factors affecting disorders and diseases classified elsewhere 6E40.4 Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders 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 and 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 they leave the house because they are 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 they become anxious would be diagnosed with psychological or behavioural factors affecting disorders and 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 and 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 and diseases classified elsewhere, the psychological or behavioural factors themselves adversely affect the Psychological or behavioural factors affecting disorders and diseases classified elsewhere 649 Psychological or behavioural factors affecting disorders and diseases classified elsewhere 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 and diseases classified elsewhere In secondary mental or behavioural syndromes associated with disorders and 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 and 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 in each. 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 and 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, longstanding 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 6E40.2 Personality traits or coping style affecting disorders and 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. Psychological or behavioural factors affecting disorders and diseases classified elsewhere Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders