The Comorbidity of Daydreaming Disorder (Maladaptive Daydreaming).

To determine the comorbidity profile of individuals meeting criteria for a proposed new disorder, daydreaming disorder (more commonly known as maladaptive daydreaming [MD]), the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the Structured Clinical Interview for DSM-IV Dissociative Disorders were administered to 39 participants who met criteria for MD on a structured interview. We determined high rates of comorbidity: 74.4% met criteria for more than three additional disorders, and 41.1% met criteria for more than four. The most frequent comorbid disorder was attention deficit hyperactivity disorder (76.9%); 71.8% met criteria for an anxiety disorder, 66.7% for a depressive disorder, and 53.9% for an obsessive-compulsive or related disorder. Notably, 28.2% have attempted suicide. Individuals meeting criteria for MD have complex psychiatric problems spanning a range of DSM-5 disorders. This finding provides evidence that MD is different than normal daydreaming and that these individuals experience considerable distress and impairment.

[Psychotraumatology : Differentiation, extension and public discourse]. / Psychotraumatologie : Differenzierung, Erweiterung und öffentlicher Diskurs.

The first description of posttraumatic stress disorder (PTSD) in the 1980s marked the origin of psychotraumatology. Based on the variety of developments in the meantime and being relevant for basic research and clinical application, a differentiation of diagnoses according to the new International Classification of Diseases (ICD-11) are presented including PTSD, complex PTSD, prolonged grief disorder and adjustment disorder. In addition, extension towards traumatic and adverse childhood experiences and their significance for lifetime mental and somatic morbidity are described. Concerning these childhood traumata and adversities, distinct biological and epigenetic factors have been extensively investigated. Also, research groups have postulated that important psychological disorders should be differentiated according to those with and those without reference to pathogenetic trauma. Lastly, regarding relevant public discourses, societal dimensions of victimhood and compensation are discussed as well as a global perspective with respect to continuous and historical traumatization.

Psychopathological characteristics of adjustment disorder among outpatients with and without work related stress.

OBJECTIVES: Study's objective is to assess psychopathological profiles in outpatients with a diagnosis of Adjustment Disorder (AD) who had positive evaluations of work related stress (AD-W) versus those exposed to other stressful life events (AD-O). METHODS: The participants were 70 outpatients with AD-W, compared to 71 outpatients with AD-O, admitted at the Unit of Psychiatry and Occupational Medicine, Sant'Andrea Hospital, Rome. Patients completed the Hamilton Rating Scale for Depression (HRSD), the Hamilton Anxiety Rating Scale (HAM-A), the Minnesota Multiphasic Personality Inventory - 2 (MMPI-2), and the Rorschach test. RESULTS: The emerged data underline that patients with AD-W scored significantly higher than patients with AD-O in the MMPI-2 scales D, Pd, Pa, FAM, and in the Rorschach anxiety scale (Sum Y). CONCLUSIONS: Finally patients with AD-W showed greater levels of psychopathology compared to patients with AD-O. Further studies assessing the harm associated with stress might allow a better understanding of the diagnosis and therapeutic implications of AD.

STRESSORS, SYMPTOM PROFILE, AND PREDICTORS OF ADJUSTMENT DISORDER IN CANCER PATIENTS. RESULTS FROM AN EPIDEMIOLOGICAL STUDY WITH THE COMPOSITE INTERNATIONAL DIAGNOSTIC INTERVIEW, ADAPTATION FOR ONCOLOGY (CIDI-O).

BACKGROUND: We aimed to investigate type and frequency of stressors, predominant symptom profiles, and predictors of adjustment disorders (AD) in cancer patients across major tumor entities. METHODS: In this epidemiological study, we examined 2,141 cancer patients out of 4,020 screened with the Composite International Diagnostic Interview, adaptation for oncology (CIDI-O). AD were operationalized as subthreshold disorders according to DSM-IV criteria. RESULTS: In our sample, 265 out of 2,141 patients (12.4%) met all criteria for AD (unweighted 4-week prevalence). The disclosure of the cancer diagnosis, relapse or metastases, and cancer treatments were most frequently described as stressors associated with depressive or anxious symptoms. With regard to AD symptom profiles, patients showed high prevalence rates of affective symptoms according to the DSM-IV criteria of Major Depression: The highest prevalence rates were found for cognitive disturbances (concentration and memory problems) (88%), sleeping disturbances (86%), and depressive mood (83%). We found sex, education, and metastasis as significant predictors for AD. Higher education was the most influential predictor. Men were half as likely to report symptoms fulfilling the AD criteria as women. Patients with metastasized tumors had a more than 80% higher risk of AD than those without metastasis. However, the explained variance of our model is very small (Nagelkerke's R² = 0.08). CONCLUSIONS: Patients with AD can be identified using a standardized instrument and deserve clinical attention, as they often show severe clinical symptoms and impairments. Improving the clinical conceptualization of AD by the adding-on of potential stress-response-symptoms is necessary to identify severe psychological strain.

The mediating role of emotion dysregulation and depression on the relationship between childhood trauma exposure and emotional eating.

Exposure to childhood adversity is implicated in the etiology of adverse health outcomes, including depression, posttraumatic stress disorder (PTSD), and obesity. The relationship between childhood trauma and obesity may be related to the association of childhood trauma and risk for emotional eating. One pathway between trauma exposure, psychopathology, and emotional eating may be through emotion dysregulation and depression. The current study was undertaken to characterize demographic, environmental, and psychological risk factors for emotional eating in a primarily African American, low socioeconomic status (SES), inner-city population (N = 1110). Emotional eating was measured using the Dutch Eating Behavioral Questionnaire and the Emotional Dysregulation Scale was used to assess emotion regulation. The Beck Depression Inventory and the modified PTSD Symptom Scale were used to assess depression and PTSD, respectively. Higher levels of emotional eating were associated with body mass index, income, childhood and adulthood trauma exposure, depressive and PTSD symptoms, negative affect and emotion dysregulation. Childhood emotional abuse was the most associated with emotional eating in adulthood. Hierarchical linear regression and mediation analyses indicated that the association between childhood trauma exposure (and emotional abuse specifically) and emotional eating was fully mediated by depression symptoms and emotion dysregulation, with emotional dysregulation contributing more to the mediation effect. Together these findings support a model in which obesity and related adverse health outcomes in stress- and trauma-exposed populations may be directly related to self-regulatory coping strategies accompanying emotion dysregulation. Our data suggest that emotion dysregulation is a viable therapeutic target for emotional eating in at-risk populations.

Stressor-related disorders in tuberous sclerosis.

BACKGROUND: Patients with tuberous sclerosis complex (TSC) have high rates of psychiatric comorbidity, including mood and anxiety disorders. The aim of this study is to identify patients with stressor-related disorders such as posttraumatic stress disorder (PTSD) or adjustment disorder (AD) and to describe their clinical picture in the setting of TSC. METHODS: Retrospective review of medical charts of TSC patients referred for a stressor-related disorder to a TSC psychiatric clinic. RESULTS: We identified 7 females and 2 males (3 PTSD, 6 AD), including 4 children. Two patients with severe intellectual disability presented with aggression and the remaining patients presented with avoidance. The mean duration of symptoms at the time of the study was 21 months (range: 7 to 48 months) and 7 of the 9 patients still were having trauma-related symptoms. All the patients who received an initial diagnosis of AD had their diagnosis changed to another category because their symptoms lasted >6 months. In most cases, selective serotonin reuptake inhibitors improved the symptoms. CONCLUSIONS: Stressor-related disorders in TSC frequently linger beyond 6 months and may appear with triggering events that typically are not viewed as trauma in a normal population.

Chronic stress is linked to 5-HT(1A) receptor changes and functional disintegration of the limbic networks.

There are increasing reports about stress related cognitive and psychic declines in subjects who have no psychiatric premorbidity, depression, or major life trauma. Yet, little is known about the underlying neurobiology. Based on the typical symptomatology, fMRI data suggesting that stress activates the limbic circuits, and animal data showing a major involvement of the 5-HT(1A) receptor in stress regulation, we hypothesized that enduring daily stress causes widespread limbic dysfunctions, and specific changes of the 5-HT(1A) receptor. To test these hypotheses combined PET studies were carried out in 16 chronically stressed, and 16 non-stressed subjects. Limbic function was tested by measuring cerebral blood flow during rest, and when using an odor activation paradigm. 5-HT(1A) receptor binding potential (BP) was assessed with [(11)C]WAY100635. All subjects went through a battery of neuropsychological tests. Stressed subjects showed a functional disconnection between the amygdala and ACC/medial prefrontal cortex (mPFC), and an impaired odor activation of the ACC. They also displayed a reduced 5-HT(1A) receptor BP in the anterior cingulate (ACC), the insular-cortex, and the hippocampus. Their performance in attention-, odor discrimination-, and semantic memory tasks was impaired, and correlated with the BP-values in the respective region. The degree of reported stress was inversely correlated with activation of ACC, and the 5-HT(1A) receptor BP in the amygdala and hippocampus. Enduring every day psychosocial stress seems to be associated with a limbic reduction of 5-HT(1A) receptor binding and functional disintegration of ACC/mPFC. These changes support the notion of an impaired top-down regulation of stress stimuli, and identify potential targets for early treatment.

[Neuropsychophysiological correlates of reactive depression].

With the aim of justifying of neurophysiological correlates of depressive disorders spectral parameters of EEG, and peak latencies of the "late" components of auditory cognitive evoked potentials, and latencies of sensorimotor reactions have been analysed in middle age and elderly patients (age 53-72) during the therapy of prolonged psychogenuously provoked depressive reaction (F43.21 by ICD-10). Background depression severity has been associated with the EEG signs of decreased functional state of anterior areas of the left hemisphere, and of increased activation of the right hemisphere (especially, of its temporal regions). Pronounced improvement of clinical condition resulted from psychopharmacotherapy led to acceleration ofsensorimotor reactions, and to decrease of peak latencies of the "late" components (P2, N2 P3) of auditory cognitive evoked potentials, that have been associated with the EEG signs of improvement of functional state of posterior brain areas, of facilitation of inhibitory processes in the right hemisphere (especially, in its frontal, central and temporal regions), and of more pronounced activation of frontal areas of the left hemisphere. The data obtained are in good concordance with the views on systemic character of impairments of brain functioning in depression, as well as on preferential role of the left hemisphere in control of positive emotions, and of the right hemisphere role in control of negative emotions.

Development and validation of a self-report for the assessment of adjustment disorders.

Based on a recent diagnostic proposal for adjustment disorders a self-report assessment was developed. The current study reports validation results. Psychometric properties were examined using two different samples of 687 patients with cardiac arrhythmias and 86 patients from a psychosomatic outpatient clinic. Besides evaluating the internal structure and re-test reliability, associations with quality of life, general anxiety and depression, symptoms of posttraumatic stress disorder and coping strategies were analyzed. The factor analysis confirmed the three postulated factors: intrusion, avoidance and failure to adapt. The internal consistencies for these three scales were between α = 0.74 and 0.91. The re-rest reliability of the scales for a six-week period lay between r(tt) = 0.61 and 0.84. Medium-sized correlations were found between the scales with general anxiety and depression as well as posttraumatic stress disorder. Furthermore, the scales correlated with emotion-oriented and somewhat with proactive coping, but not with task-oriented or avoidance-oriented coping strategies. It is concluded that the self-report on adjustment disorders enables new possibilities to investigate further previously under-researched adjustment disorders.

Has "Iron" Felix Dzerzhinsky been affected by post-traumatic embitterment disorders?

Retrospective psycho-historical personality analysis of "Iron" Felix Dzerzhinsky presents an opportunity to evaluate development and progression of events and behaviors associated with the killing of hundreds of thousands during the "Red Terror". A biopsychosocial assessment provides evidence suggestive of the presence of post-traumatic embitterment disorder (PTED) as an underlying pathological catalyst for his actions. The introduction of PTED as a possible psychopathology leading to such violent and destructive events promotes the significance of understanding the diagnosis and how negative events may lead to maladaptive behaviors on a broad scale.

Suicidal intent and the HPA-axis characteristics of suicide attempters with major depressive disorder and adjustment disorders.

The main purpose of the study was to investigate Hypothalamic-Pituitary-Adrenal (HPA) axis characteristics in relation to suicidal intent among suicide attempters with Major Depressive Disorder (MDD) and Adjustment Disorders (AD). The relationship between suicidal intent, assessed by means of the Suicidal Intent Scale (SIS), and serum cortisol after a Dexamethasone Suppression Test (DST) was investigated in 78 suicide attempters, divided into diagnostic subgroups. There was a significant negative correlation between suicidal intent and post DST cortisol in patients with MDD. Our findings may be attributed to pathophysiological processes, where a high suicidal intent is revealed during a potential chronic course of MDD, which in turn results in a seemingly normal stress system.

The role of cognitive biases in short-term psychodynamic psychotherapy.

The concept of biased thinking - or cognitive biases - is relevant to psychotherapy research and clinical conceptualization, beyond cognitive theories. The present naturalistic study aimed to examine the changes in biased thinking over the course of a short-term dynamic psychotherapy (STDP) and to discover potential links between these changes and symptomatic improvement. This study focuses on 32 self-referred patients consulting for Adjustment Disorder according to DSM-IV-TR. The therapists were experienced psychodynamically oriented psychiatrists and psychotherapists. Coding of cognitive biases (using the Cognitive Errors Rating Scale; CERS) was made by external raters based on transcripts of interviews of psychotherapy; the reliability of these ratings on a randomly chosen 24% of all sessions was established. Based on the Symptom Check List SCL-90-R given before and after, the Reliable Change Index (RCI) was used. The assessment of cognitive errors was done at three time points: early (session 4-7), mid-treatment (session 12-17), and close to the end (after session 20) of the treatment. The results showed that the total frequency of cognitive biases was stable over time (p = .20), which was true both for positive and for negative cognitive biases. In exploring the three main subscales of the CERS, we found a decrease in selective abstraction (p = .02) and an increase in personalization (p = .05). A significant link between RCI scores (outcome) and frequency of positive cognitive biases was found, suggesting that biases towards the positive might have a protective function in psychotherapy. PRACTITIONER POINTS: Therapists may be attentive to changes in biased thinking across short-term dynamic psychotherapy for adjustment disorder. Therapists may foster the emergence of positive cognitive biases at mid-treatment for adjustment disorder.

Is adjustment disorder unidimensional or multidimensional? Implications for ICD-11.

In preparation for ICD-11, the adjustment disorder (AjD) diagnosis has undergone considerable revisions; however, the latent structure of AjD remains uncertain. It is unclear whether AjD is best represented as a unidimensional or multidimensional construct. This study performed a comprehensive assessment of the latent structure of AjD symptomatology and assessed its concurrent and discriminant validity. Individuals who experienced involuntary job loss (N = 333) completed a self-report measure of AjD symptoms. Seven alternative models of AjD were tested using confirmatory factor analysis. General psychological distress, impairment in social functioning, occupational self-efficacy, and sense of coherence were used as criterion variables for construct validity. In the confirmatory factor analysis, a bifactor solution with one dominant general AjD factor and 5 correlated group factors (preoccupation, failure-to-adapt, avoidance, affective reaction, and impulsivity) provided optimal fit. As expected, the AjD factor showed strong positive associations with general psychological distress and impairments in social functioning and moderately negative associations with occupational self-efficacy and sense of coherence. With regard to unidimensionality or multidimensionality of AjD symptoms, the current results indicate the plausibility of a unidimensional conceptualization. Future research should focus on essential key characteristics and a reduction of symptoms for the AjD definition.

Altered autonomic reactivity in Korean military soldiers with adjustment disorder.

Only few studies addressing the biological background of adjustment disorder (AD) exist. We examined the psychophysiological correlates indicative of autonomic regulation in AD. Heart rate variability (HRV), skin conductance, skin temperature, electromyography, and respiration were measured during serial stress tasks in 33 soldiers with AD and 60 healthy controls (HC). Patients with AD displayed lower relative power of high frequency (rHF) HRV and higher relative power of very low frequency (rVLF) HRV compared with HC at baseline. Inversely, the rHF of patients with AD remained higher and their rVLF remained lower compared with HC parameters after the single stress task, which suggests a reversed sympathovagal balance in AD. Mean heart rate and skin conductance increased during stress tasks in patients, although to a lesser extent than in HC. Skin temperature remained unchanged in all tasks in patients with AD. The tension of the frontalis muscle was higher in patients compared with HC from the second stress task onward. Thoracic breathing was more prevalent in patients with AD. Our study suggests altered autonomic reactivity in AD, which leads to a lack of sympathetic response to stress. We conclude that the distinctive biological mechanisms underlying AD are different from normal stress reactions.

The psychobiology of stress, depression, adjustment disorders and resilience.

OBJECTIVES: This paper focuses on the psychobiology of stress, depression, adjustment disorders (ADs), and resilience. Since the ADs fall under the rubric in DSM-5 of Trauma and Stressor-Related Disorders, essentials of the psychobiology of stress-response syndromes will be reviewed. METHODS: A narrative review of the psychobiology of stress-response syndromes is undertaken, and the implications for our understanding of ADs are discussed. RESULTS: Advances in our understanding of the psychobiology of stress-response syndromes provide an important foundation for understanding ADs, and for conceptualizing their diagnosis, as well as issues of resilience. CONCLUSIONS: Future investigations of the psychobiology of trauma- and stressor-related disorders may shed additional light on ADs, and ultimately improve their treatment.

Brain metabolic changes associated with predispotion to onset of major depressive disorder and adjustment disorder in cancer patients--a preliminary PET study.

OBJECTIVES: To explore neurobiological risk factors for major depressive disorder (MDD) and adjustment disorder in cancer patients by examining regional brain metabolism before psychiatric manifestation using positron emission tomography and by prospectively observing depressive and anxiety symptoms. METHOD: Cancer patients who showed no psychiatric symptoms when they underwent 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) were followed up for one year using the Hospital Anxiety and Depression Scale (HADS). Fourteen patients who showed high HADS scores and 14 patients who showed low HADS scores were assessed by a psychiatrist 2 years after the PET scan and grouped into the deterioration group (n=10) and the no-change group (n=9). 18F-FDG PET images were analyzed to examine the difference in local brain glucose metabolism between the two groups. RESULTS: The deterioration group showed a decreased glucose metabolism in the right medial frontal gyrus (BA6) and an increased glucose metabolism in the right posterior cingulate (BA29), right anterior cingulate (BA25), left subcallosal gyrus (BA25), and left caudate compared with the no-change group. CONCLUSION: Cancer patients who later developed MDD or adjustment disorder showed regional brain metabolic changes. These regions may be associated with vulnerability to the onset of MDD or adjustment disorder in cancer patients.

Regional cerebral glucose metabolism in patients with secondary depressive episodes after fatal pancreatic cancer diagnosis.

BACKGROUND: Secondary depression is common in the clinical oncology setting after pancreatic cancer diagnosis, following which the patients have to face the fact that they have a cancer with an extremely poor prognosis. However, the specific pathophysiology remains unclear. The present study examined the regional cerebral glucose metabolism using F18-fluorodeoxyglucose (F18-FDG) positron emission tomography (PET) in antidepressant-naïve pancreatic cancer patients with a depressive episode after their cancer diagnosis and before their cancer treatment. METHODS: Regional cerebral glucose metabolism in pancreatic cancer patients without any antidepressant medication after the cancer diagnosis was measured with F18-FDG PET. A depressive episode after the cancer diagnosis was defined as including major and minor depressive episodes, and was diagnosed using the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). The prefrontal and limbic regions were the primary regions-of-interest, and an uncorrected value of p<0.005 was used as significant. RESULTS: Six of 21 pancreatic cancer patients were diagnosed as having a depressive episode. Significantly higher glucose metabolism in depressed patients was found in the subgenual anterior cingulate cortex (sACC) (uncorrected p=0.002). LIMITATIONS: There was a small number of subjects, and there were no healthy controls. CONCLUSIONS: The higher metabolism in the sACC may be associated with the pathophysiology of secondary depressive episodes in patients following pancreatic cancer diagnosis.

Relationship of brainstem raphe echogenicity and clinical findings in depressive states.

Transcranial sonography (TCS) revealed reduced brainstem raphe (BR) echogenicity in major depressive disorder (MDD). Here, it was studied whether BR echogenicity discriminates MDD and adjustment disorder with depressed mood (ADDM), and whether BR echogenicity relates to depression severity or treatment responsivity. For this, 15 patients with single episodes of MDD (MDDs), 22 with recurrent MDD (MDDr), 15 with ADDM, and 50 healthy controls were investigated with TCS. Frequency of reduced BR echogenicity was similar in groups MDDs (53%), MDDr (50%) and ADDM (60%), but significantly lower in the controls (8%). Patients with reduced BR echogenicity had lower scores on the 21-item Hamilton Depression Rating Scale and the Motor Retardation Scale, compared with patients with normal BR echogenicity. BR echogenicity scores were significantly lower in SSRI responders to serotonin reuptake inhibitors (SRI) than in non-responders. Reduced BR echogenicity indicated SSRI responsivity with 70% sensitivity, 88% specificity and a positive predictive value of 88%. No impact of age, gender or antidepressant medication on BR echogenicity was found. These results indicate that reduced BR echogenicity is not related to diagnostic category of depressive state. Reduced BR echogenicity might reflect a pathology predisposing to a certain subtype of depression characterized by less psychomotor retardation and better responsivity to SRI.

The role of child adrenocortical functioning in pathways between interparental conflict and child maladjustment.

This study examined the interplay between interparental conflict and child cortisol reactivity to interparental conflict in predicting child maladjustment in a sample of 178 families and their kindergarten children. Consistent with the allostatic load hypothesis (McEwen & Stellar, 1993), results indicated that interparental conflict was indirectly related to child maladjustment through its association with individual differences in child cortisol reactivity. Analyses indicated that the multimethod assessment of interparental conflict was associated with lower levels of child cortisol reactivity to a simulated phone conflict between parents. Diminished cortisol reactivity, in turn, predicted increases in parental reports of child externalizing symptoms over a 2-year period. Associations between interparental conflict, child cortisol reactivity, and child externalizing symptoms remained robust even after demographic factors and other family processes were taken into account.

Marital conflict and risk for child maladjustment over time: skin conductance level reactivity as a vulnerability factor.

Skin conductance level reactivity (SCLR) was examined as a longitudinal mediator and moderator of relations between parental marital conflict and psychopathology among children and young adolescents. Participants were 157 boys and girls (M age at T1 = 9.31 years; SD = 1.97); there was a 2-year lag between T1 and T2 assessments. At T1, participants' SCLR was assessed in response to lab challenges. Parents completed measures of aggressive marital conflict and child adjustment at T1 and T2. Supportive of moderation effects, T1 marital conflict interacted with T1 SCLR and gender in the prediction of changes in maladjustment. The link between marital conflict and increased internalizing and externalizing symptoms was stronger for girls with higher SCLR than girls with lower SCLR. Marital conflict predicted increased externalizing behaviors for boys with lower SCLR but not higher SCLR, although levels of externalizing behaviors were similar among boys with lower and higher SCLR especially at higher levels of marital conflict. Findings build on the literature by illustrating the importance of examinations of both family risk and youth biological vulnerability for the prediction of psychopathology.