Adjustment disorder diagnosis: Improving clinical utility.

OBJECTIVES: Adjustment disorder (AD) is a frequent diagnosis in clinical practice worldwide. After long neglect in mental health research, the new DSM definition and in particular the ICD-11 model of AD is about to create a fresh impulse for research on AD and for refined clinical use of the diagnosis. METHODS: This paper outlines the clinical features of AD according to the ICD-10, ICD-11 and DSM-5 definitions, and provides case vignettes of patients with AD with clinical presentations of dominating anxiety, depressed mood or mixed symptom presentations. The available clinical assessments and diagnostic tools are described in detail, together with findings on their psychometric properties. RESULTS: The current AD definitions are consistent with a new nosological grouping of AD with posttraumatic stress disorder in the chapter on trauma- and stressor-related disorders, or stress response syndromes. CONCLUSIONS: This nosological specification opens new avenues for neurobiological and psychological research on AD and for developing novel therapies.

Gender similarities in somatic depression and in DSM depression secondary symptom profiles within the context of severity and bereavement.

BACKGROUND: Most population studies report higher rates of depression among women than men, and some researchers have observed gender differences in depression symptoms overall, or in sub-groupings (e.g. somatic depression). However, gender symptom differences have been inconsistent, prompting this investigation of gender differences in secondary DSM symptom profiles in the context of bereavement status, age, and depression severity. METHODS: Individuals with symptoms of core depression (flat affect or anhedonia) were selected from a large survey of adults in the Alberta, Canada workforce. Analyses involved the comparison of gender profiles across the seven DSM-IV secondary depressive symptoms plus a MANOVA of sex, bereavement, and age, with secondary symptoms comprising the dependent variable. RESULTS: Gender profiles were very similar, irrespective of depression severity or bereavement. Secondary symptoms were marginally more common among women and more frequent among bereaved young adults, but there was no evidence for a gender-related somatic factor. LIMITATIONS: First, data were gathered only for persons in the workforce and thus may not be generalizable to, for example, stay-at-home parents or those with employment issues. Second, the focus here is restricted to DSM symptoms, leaving risk factors, social roles, and brain functioning for separate investigation. Third, inferences were drawn from associations between groups of persons, rather than between individuals, requiring caution when speculating about individual attributes. CONCLUSIONS: Gender differences in depression represent a difference in amount, not kind, suggesting that the range of depressive experiences is similar for men and women. There was no gender difference ascribable to somatic depression.

A Brief Measure of the International Classification of Diseases-11 Adjustment Disorder: Investigation of Psychometric Properties in an Adult Help-Seeking Sample.

Adjustment disorder is one of the most prevalent mental disorders. However, there are almost no measures available for its assessment. We aimed to analyze the psychometric properties of a brief version of the International Classification of Diseases (ICD)-11 adjustment disorder scale (Adjustment Disorder New Module-8; ADNM-8) in a help-seeking sample. Data from 1,174 participants with an average age of 35 years who registered for the internet-based self-help adjustment disorder intervention were analyzed. Psychometric properties of the brief 8-item self-report (ADNM-8) scale measuring the 2 core adjustment disorder symptoms of preoccupation and failure to adapt were tested. Confirmatory factor analysis (CFA) was applied for the analysis of construct validity. CFA supported the 2-factor structure of ADNM-8. Further research is needed for validation of ADNM-8 in cross-cultural studies.

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.

Measuring the ICD-11 adjustment disorder concept: Validity and sensitivity to change of the Adjustment Disorder - New Module questionnaire in a clinical intervention study.

Adjustment disorder (AjD) is a frequent but under-researched diagnosis due in part to a lack of specific symptom criteria and adequate tools of measurement. The ICD-11 for the first time proposes a positive symptom catalogue to define AjD. This study presents a validation of the Adjustment Disorder - New Module (ADNM), the first symptom severity measure for AjD according to the ICD-11 concept. Validity and sensitivity to change were investigated in a sample of 190 individuals with a DSM-IV diagnosis of AjD. The ADNM scales demonstrated convergent and discriminant validity for anxiety symptoms (Hamilton Anxiety Scale; psychic anxiety r = 0.18-0.31), functional impairment (Sheehan Disability Scale; r = 0.18-0.47), and depression (Montgomery-Asberg Depression Scale; r = 0.13-0.30). At baseline 78% of the individuals with a DSM-IV diagnosis of AjD were also classified so by the ADNM. Repeated-measures ANOVA indicated significant ADNM-symptom decrease during treatment, replicating the patterns of the Hamilton Anxiety Scale, Sheehan Disability Scale, and Clinical Global Impression Scale. This article presents the first use of the ADNM as a measure for ICD-11 AjD in a randomized-controlled intervention study of AjD. It provides support for the construct validity and sensitivity to symptom change of this scale during pharmacological treatment.

Adjustment disorder: Empirical study of a new diagnostic concept for ICD-11 in the general population in Lithuania.

OBJECTIVE: Adjustment disorder (AD) is one of the most debated diagnoses in psychiatry since it has been recognised as vaguely defined and causing a lot of difficulties in clinical practice. We aimed to analyse the structure of adjustment disorder based on International Classification of Diseases (ICD)-11 proposals by the WHO ICD-11 Working Group on the Classification of Disorders Specifically Associated with Stress in the general population in Lithuania. Three structural models of adjustment disorder were tested using Confirmatory Factor Analysis (CFA). METHOD: Data from the sample of 649 participants who experienced at least one significant stressor during the last two years was included in CFA analysis. Stressor exposure and AD symptoms were measured with the Lithuanian version of the Adjustment Disorder New Module (ADNM-20). RESULTS: The CFA analysis revealed that the two core factor model of the AD with two core symptoms: preoccupation and failure to adapt fitted data the best in contrast to other two models. CONCLUSION: The study supports the ICD-11 proposal for the structure of adjustment disorder with two core symptoms: preoccupation and failure to adapt. Further studies are needed to analyse the structure of AD in other populations.

Adjustment disorder as proposed for ICD-11: Dimensionality and symptom differentiation.

Although Adjustment Disorder as a diagnostic category is widely used in clinical practice it is critically discussed that it has not been conceptualized as a category with unique symptoms. Hence, the conceptualization of Adjustment Disorder is subject to substantive change in ICD-11 including core symptoms and additional features in a uni-faceted concept. Adjustment Disorder was assessed with a self-rating instrument in a representative sample of the German general population (N=2512). Confirmatory factor analyses (CFA) were applied to test the dimensionality of symptoms according to the new diagnostic concept. Latent class analysis (LCA) was applied to test whether there are distinguishable subgroups with respect to symptomatology. 2.0% of the sample were diagnosed with Adjustment Disorder according to the new diagnostic algorithm. The proposed six factor model shows best fit with good reliability of the factors in the CFA compared to competing models. However the factors are highly correlated and not distinguishable. The LCA identified three latent classes, reflecting low, mild and moderate to severe symptoms. The findings support the uni-faceted concept of Adjustment Disorder as it is conceptualized in the new diagnostic concept in ICD-11 in a general population sample. This clearer diagnostic concept will inform research as well as clinical practice.

[The systematics of psychogenic depressions (reactions of complicated grief)].

OBJECTIVE: Reactive depression provoked by the loss of loved ones is a controversial problem of modern psychiatry based on the diametrically opposite conceptions. The author suggests a clinical typology of these depressions based on a psychopathological analysis of trigger mechanisms and constitutional predisposition. MATERIAL AND METHODS: Fifty-five patients, aged from 31 to 65 years (mean age 46.9±13.9 years), were examined. The course of depression, including previous psychogenia, was followed up for 5-15 years (mean 11.5±3.6 years). RESULTS AND CONCLUSION: Three types of catathymic complexes (affective dissonance, affective resonance and affective imbalance) can be considered as a significant parameter responsible for trigger mechanisms of these psychogenias and their further dynamics. Each type determines not only the psychopathological structure of psychogenic depression but has a predictive validity thus allowing to predict the dynamics of depression and its nosological attribution.

Adjustment disorders in Asians and Asian Americans.

In the DSM-5, adjustment disorders have undergone a conceptual shift with a new designation as a constellation of stress-related conditions in response to exposure to a distressing event which may be perceived as traumatic or non-traumatic. This is in contrast to its previous description in DSM-IV-TR, which focused on the presence of significant distress following a crisis event, but did not require the individual to meet the criteria for a more serious disorder. This paper will present a brief overview of the clinical nosology, etiology, and treatment modalities for adjustment disorders with Asian and Asian American populations.

Prolonged grief: where to after Diagnostic and Statistical Manual of Mental Disorders, 5th Edition?

PURPOSE OF REVIEW: Although there is much evidence for the construct of prolonged grief, there was much controversy over the proposal to introduce a prolonged grief diagnosis into Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), and it was finally rejected as a diagnosis in DSM-5. This review outlines the evidence for and against the diagnosis, and highlights the implications of the DSM-5 decision. RECENT FINDINGS: Convergent evidence indicates that prolonged grief characterized by persistently severe yearning for the deceased is a distinct construct from bereavement-related depression and anxiety, is associated with marked functional impairment, is responsive to targeted treatments for prolonged grief, and has been validated across different cultures, age groups, and types of bereavement. Although DSM-5 has rejected the construct as a formal diagnosis, evidence continues to emerge on related mechanisms, including maladaptive appraisals, memory and attentional processes, immunological and arousal responses, and neural circuitry. SUMMARY: It is most likely that the International Classification of Diseases (ICD-11) will introduce a diagnosis to recognize prolonged grief, even though DSM-5 has decided against this option. It is probable that the DSM-5 decision may result in more prolonged grief patients being incorrectly diagnosed with depression after bereavement and possibly incorrectly treated. The DSM-5 decision is unlikely to impact on future research agendas.

Complicated grief in children--the perspectives of experienced professionals.

A total of 39 very experienced clinicians and researchers worldwide responded to a survey consisting of both structured and open-ended questions on complicated grief in children. The questions assessed their opinion on: a) what constitutes complicated grief in children; b) whether to develop a diagnosis for children as suggested for adults and, if so, would adult criteria be sufficient for children; and c) other aspects of normal and complicated grief in children. The analyses showed that the professionals struggled with defining complicated grief in children, although they agreed that the major defining aspects were intensity, duration, and longevity of reactions. They identified traumatic and delayed or inhibited grief as major types, and also agreed that adult criteria were inappropriate for children.

Is the distinction between adjustment disorder with depressed mood and adjustment disorder with mixed anxious and depressed mood valid?

BACKGROUND: In the DSM-IV, adjustment disorder is subtyped according to the predominant presenting feature. The different diagnostic code numbers assigned to each subtype suggest their significance in DSM-IV. However, little research has examined the validity of these subtypes. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical profiles of patients diagnosed with adjustment disorder subtypes to determine whether there was enough empirical evidence supporting the retention of multiple adjustment disorder subtypes in future versions of the DSM. METHODS: A total of 3,400 psychiatric patients presenting to the Rhode Island Hospital outpatient practice were evaluated with semistructured diagnostic interviews for DSM-IV Axis I and Axis II disorders and measures of psychosocial morbidity. RESULTS: Approximately 7% (224 of 3,400) of patients were diagnosed with current adjustment disorder. Adjustment disorder with depressed mood and with mixed anxious and depressed mood were the most common subtypes, accounting for 80% of the patients diagnosed with adjustment disorder. There was no significant difference between these 2 groups with regard to demographic variables, current comorbid Axis I or Axis II disorders, lifetime history of major depressive disorder or anxiety disorders, psychosocial morbidity, or family history of psychiatric disorders. The only difference between the groups was lifetime history of drug use, which was significantly higher in the patients diagnosed with adjustment disorder with depressed mood. CONCLUSIONS: There is no evidence supporting the retention of both of these adjustment disorder subtypes, and DSM-IV previously set a precedent for eliminating adjustment disorder subtypes in the absence of any data. Therefore, in the spirit of nosologic parsimony, consideration should be given to collapsing the 2 disorders into 1: adjustment disorder with depressed mood.

"Subthreshold" depression: is the distinction between depressive disorder not otherwise specified and adjustment disorder valid?

OBJECTIVE: Patients with clinically significant symptoms of depression who do not meet the criteria for major depressive disorder or dysthymic disorder are considered to have subthreshold depression. According to DSM-IV, such patients should be diagnosed with depressive disorder not otherwise specified (NOS) if the development of the symptoms is not attributable to a stressful event or with adjustment disorder if the symptoms follow a stressor. Research on the treatment of subthreshold depression rarely addresses the distinction between depressive disorder NOS and adjustment disorder. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the validity of this distinction. METHOD: From December 1995 to June 2011, 3,400 psychiatric patients presenting to the Rhode Island Hospital outpatient practice were evaluated with semistructured diagnostic interviews for DSM-IV Axis I and Axis II disorders and measures of psychosocial morbidity. RESULTS: Slightly less than 10% (n = 300) of the 3,400 patients were diagnosed with depressive disorder NOS or adjustment disorder with depressed mood. The patients with depressive disorder NOS were significantly more often diagnosed with social phobia (P < .05) and a personality disorder (P < .01). The patients with depressive disorder NOS reported more anhedonia, increased appetite, increased sleep, and indecisiveness, whereas the patients with adjustment disorder reported more weight loss, reduced appetite, and insomnia. There was no significant difference between the groups in overall level of severity of depression or impaired functioning. The patients with depressive disorder NOS had a nonsignificantly elevated morbid risk of depression in their first-degree relatives. DISCUSSION: Clinically significant subthreshold depression was common in psychiatric outpatients, and the present results support the validity of distinguishing between depressive disorder NOS and adjustment disorder with depressed mood. Future studies of the treatment of subthreshold depression should account for this diagnostic distinction.

Development of an ICF-based core set of activities and participation for patients with mental disorders: an approach based upon data.

OBJECTIVE: To use data and patient involvement to identify categories within the International Classification of Functioning, Disability and Health (ICF) component activities and participation relevant for patients with affective, somatoform, anxiety and adjustment disorders. DESIGN: The first step was to identify systematically, outcome instruments used in randomized controlled trials, to relate item content to the ICF. Then four patient focus group discussions (n = 21 participants) were conducted, and finally an expert panel (n = 11 participants) was used to identify the most relevant categories in therapy settings. PARTICIPANTS: Focus groups: inpatient psychotherapy patients. Expert panel: clinicians, stakeholders, patient representative. RESULTS: In the literature search, 313 measures were identified, which included 1562 meaningful concepts (separate content units). These were allocated to ICF categories that were validated and complemented in focus groups and by an expert panel. The resulting core set includes 27 categories related to the nine chapters of the ICF component activities and participation. CONCLUSIONS: A core set of items, set within the World Health Organization ICF and relevant to the treatment of people with affective, somatoform, anxiety and adjustment disorders, has been developed based on existing evidence.

Mental illness and mental health: is the glass half empty or half full?

During the past century, the scope of mental health intervention in North America has gradually expanded from an initial focus on hospitalized patients with psychoses to outpatients with neurotic disorders, including the so-called worried well. The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, is further embracing the concept of a mental illness spectrum, such that increasing attention to the softer end of the continuum can be expected in the future. This anticipated shift rekindles important questions about how mental illness is defined, how to distinguish between mental disorders and normal reactions, whether psychiatry is guilty of prevalence inflation, and when somatic therapies should be used to treat problems of living. Such debates are aptly illustrated by the example of complicated bereavement, which is best characterized as a form of adjustment disorder. Achieving an overarching definition of mental illness is challenging, owing to the many different contexts in which DSM diagnoses are used. Careful analyses of such contextual utility must inform future decisions about what ends up in DSM, as well as how mental illness is defined by public health policy and society at large. A viable vision for the future of psychiatry should include a spectrum model of mental health (as opposed to exclusively mental illness) that incorporates graded, evidence-based interventions delivered by a range of providers at each point along its continuum.

Diagnostic inflation: causes and a suggested cure.

There have been a striking diagnostic inflation and a corresponding increase in the use of psychotropic drugs during the past 30 years. DSM-5, scheduled to appear in May 2013, proposes another grand expansion of mental illness. In this article, we will review the causes of diagnostic exuberance and associated medical treatment. We will then suggest a method of stepped care combined with stepped diagnosis, which may reduce overdiagnosis without risking undertreatment of those who really need help. The goal is to control diagnostic inflation, to reduce the harms and costs of unnecessary treatment, and to save psychiatry from overdiagnosis and ridicule.

Should prolonged grief be reclassified as a mental disorder in DSM-5?: reconsidering the empirical and conceptual arguments for complicated grief disorder.

The proposed changes to DSM-5 will create new categories of mental disorder (referred to here generically as Prolonged Grief Disorder'' [PGD]) to diagnose individuals experiencing prolonged intense grief reactions to the loss of a loved one. Individuals could be diagnosed even if they have no depressive or anxiety symptoms but only symptoms typical of grief (e.g., yearning, avoidance of reminders, disbelief, feelings of emptiness). The main challenge for such proposals is to establish that the proposed diagnostic criteria validly discriminate a genuine psychiatric disorder of grief from intense normal grief. With this test in mind, I evaluate the soundness of four empirical arguments and one conceptual argument that have been put forward to support such proposals: (1) PGD has discriminant validity because distinctive, pathognomonic symptoms distinguish it from normal grief; (2) PGD has discriminant validity because it identifies grief symptoms that are of greater absolute severity than in normal grief; (3) PGD has predictive validity because it implies a chronic, interminable process of grieving, thus a derailment of the normal process of grief resolution; (4) PGD has predictive validity because it predicts negative mental and physical health outcomes unlikely in normal grief; and (5) PGD has conceptual validity because grief is analogous to a wound or, alternatively, lengthy grief is analogous to a wound that does not heal. Upon close examination, each of these arguments turns out to have serious empirical or conceptual deficiencies. I conclude that the proposed diagnostic criteria for PGD fail to discriminate disorder from intense normal grief and are likely to yield massive false-positive diagnoses. Consequently, the proposal to add pathological grief categories to DSM-5 should be withdrawn pending further research to identify more valid criteria for diagnosing PGD.

Should adjustment disorder be conceptualized as transitional disorder? In pursuit of adjustment disorders definition.

BACKGROUND: The DSM classification of an adjustment disorder is frequently criticized for not being well differentiated from other disorders. AIMS: A possible reason for this is the vague definition of the term adjustment in social science literature. Hence, the current paper discusses the definition of adjustment and its implications for understanding maladjustment. METHOD: Differential definitions of the terms adjustment, adaptation, socialization and coping are outlined, leading to the proposition that each one of them represents a different type of demand that is imposed on an individual who encounters a transitional event. Moreover, the four types of demands might be the possible sources of maladjustment. CONCLUSION: Helping people in transition requires an identification of the source, or combination of sources, that have led to the adjustment problem first, followed by the implementation of an adequate helping approach.

[How do general practitioners deal with patients they do not consider to be depressed but who are classified as such according the PHQ-9?]. / Was erzählen Hausärzte über ihre Patienten, bei denen sie eine vorliegende Depression nicht diagnostiziert haben?

OBJECTIVES How GPs describe their patients who they did not identify as suffering from depression but who were classified as such by PHQ-9? What conclusions can be drawn with regard to how depression is dealt with and the illness model in use? METHOD GPs who took part in a screening study were asked in interviews to talk about some of their patients - not being informed that these were those not identified as depressive by them. This study comprises 21 narrative interviews from 18 GPs. Analysis by Framework method by Lewis and Ritchie. RESULTS The low identification rate of depression is not the result of failed recognition of "psychological problems" but of other factors centring on GPs' particular way of working and their concepts about mental illness: making a diagnosis only in a contextual way of interpreting symptoms; using the time passing as a help for diagnosing; emphasis on the impairment rather the diagnosis; considering the therapeutic consequences before making a diagnosis; a tolerance concerning "deviation" respectively wider view on "normality". CONCLUSION Understanding the different ways of conceptionalizing mental illness by psychiatrists and general practitioners is basic for their cooperation.