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Bereavement, Adjustment disorder and PDD.ppt
1. Bereavement, Adjustment Disorders,
and Persistent Depressive Disorder
Julie Teater, MD
Assistant Professor
Department of Psychiatry
Julie.Teater@osumc.edu
2. Objectives- Bereavement, Adjustment
Disorders, and Persistent Depressive Disorder
Recognize
•the stages of grief and the bereavement process
Be able to
•differentiate normal bereavement from a Major Depressive Episode
List
•three requirements in the DSM-5 criteria for Adjustment Disorders
Learn
•the subtypes of Adjustment Disorders
List
•the DSM-5 criteria for Persistent Depressive Disorder (Dysthymia)
3. The Five Stages of Grief (Kubler-Ross Model)
Denial Anger Bargaining Depression Acceptance
• Not a complete list of emotions that
may be felt
• Can be experienced in any order
4. Uncomplicated Bereavement (Normal
Grief)
This category can be used when the focus of clinical attention is a reaction to the death of a loved one
By definition, this is NOT a mental disorder
However, it is a significant risk factor for a Major Depressive Episode
As part of their reaction to the loss, some grieving individuals present with symptoms characteristic of a Major
Depressive Episode- feelings of sadness, insomnia, poor appetite, and weight loss
Previously, you could not diagnose a MDE for 2 months following the death of a loved one- this was changed in DSM-5
to help recognize that bereavement is a severe psychosocial stressor which can precipitate a MDE and affects
suffering/functioning
5. Differentiating Normal Grief from a Major
Depressive Episode
• Emptiness and loss
• Decreases in intensity
over time, occurs in
waves (“pangs of
grief”)
• May still have positive
emotions and humor
• Preoccupied with the
deceased
• Self-esteem generally
preserved, and if not,
usually involves
perceived failings in
regards to the
deceased
• Thoughts of death and
dying typically focused
on the deceased
(“joining” the loved
one)
Grief
• Depressed mood and
anhedonia
• Persistent, not tied to
specific thoughts
• Pervasive unhappiness
and misery
• Self-critical and
pessimistic ruminations
• Worthlessness and
self-loathing is
common
• Thoughts of death and
dying are focused on
ending one’s own life
Major
Depressive
Episode
6. Additional Features of Bereavement
Bereavement varies across
ages and cultures
Those suffering may seek help
for symptoms (insomnia,
anorexia)
We can be helpful by listening,
encouraging the person to talk
about the deceased, and
advising them to use available
social supports
Antidepressants are not helpful
unless a MDE is present, but
can use meds for symptoms
(anxiety, insomnia)
Certain hallucinations are
“normal” during bereavement-
generally hearing the voice of
the deceased, seeing the
deceased, etc.
7. Persistent Complex Bereavement Disorder
This disorder is listed in the back of the DSM-5, in the section “Conditions for Further
Study”
It is characterized by severe symptoms persisting for at least 12 months after the death
in adults or 6 months in children
It shares features such as sadness, crying, and suicidal thinking with Major Depressive
Disorder, but the focus continues to be on the loss
Since this is not currently a DSM-5 diagnosis, presentations meeting this definition would
likely be characterized as an Adjustment Disorder
8. Adjustment Disorders- DSM-5 Criteria
A. The development of emotional or behavioral symptoms in response to
an identifiable stressor occurring within 3 months of the onset of the
stressor.
B. These symptoms or behaviors are clinically significant as evidenced by
one or both of the following:
(1) marked distress that is out of proportion to the severity or intensity
of the stressor.
(2) significant impairment in functioning.
C. The stress-related disturbance does not meet criteria for another
mental disorder and is not merely an exacerbation of a preexisting
mental disorder.
D. The symptoms do not represent normal bereavement.
E. Once the stressor (or its consequences) has terminated, the
symptoms do not persist for more than an additional 6 months.
9. Subtypes of Adjustment Disorders
Specify whether:
With
Depressed
Mood
With Anxiety
With Mixed
Anxiety and
Depressed
Mood
With
Disturbance
of Conduct
With Mixed
Disturbance
of Emotions
and Conduct
Unspecified
10. Features of Adjustment Disorders
Clinically significant but non-specific emotional or behavioral symptoms that develop within 3 months
of a stressor
Distress in excess of what would ordinarily be expected or impairment in functioning
Resolve within 6 months of termination of the stressor and its consequences
A stressor is necessary but not sufficient- any DSM-5 condition can worsen with stress
An Adjustment Disorder can be superimposed on another disorder and diagnosed additionally when
the other disorder cannot account for all the symptoms
Adjustment Disorders are now listed in the Trauma- and Stressor-Related Disorders chapter
11. Exclusions to Adjustment Disorders
Normal bereavement
Psychotic
symptoms
Major Depressive
Episode
12. Persistent Depressive Disorder (Dysthymia)
This is a consolidation of chronic major depressive disorder and dysthymic disorder into
Persistent Depressive Disorder
Chronic depression that is present nearly all the time for at least 2 years (1 year in
children)
The criteria changed so that one may meet full criteria for a Major Depressive Episode
during this time period (previously an exclusion)- see specifiers
13. DSM-5 Criteria for Persistent Depressive
Disorder (Dysthymia)
A. Depressed mood for most of the day, for more days
than not, as indicated by either subjective account or
observation by others, for at least 2 years. (In children,
mood can be irritable and duration must be at least 1
year.)
B. Presence, while depressed, of two or more of the
following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
14. DSM-5 Criteria for Persistent Depressive
Disorder (Dysthymia) (continued)
C. During the 2-year period of the disturbance, the person has never
been without the symptoms in Criteria A and B for more than 2
months at a time.
D. Criteria for a major depressive disorder may be continuously present
for 2 years.
E. There has never been a Manic Episode or Hypomanic Episode, and
criteria have never been met for Cyclothymic Disorder.
F. The disturbance is not better explained by a psychotic disorder.
G. The symptoms are not attributable to the physiological effects of a
substance or another medical condition.
H. The symptoms cause clinically significant distress or impairment in
functioning.
15. Specifiers of Persistent Depressive Disorder
Specify if:
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With peripartum onset
Specify if:
With pure dysthymic syndrome
With persistent major depressive episode
With intermittent major depressive
episodes, with current episode
With intermittent major depressive
episodes, without current episode
16. Specifiers of Persistent Depressive Disorder
(continued)
Specify current severity:
Mild
Moderate
Severe
Specify if:
In partial remission
In full remission
Specify if:
Early onset: prior to age 21
Late onset: age 21 or older
17. Summary
• Denial, Anger, Bargaining, Depression, Acceptance
The five stages of grief are:
• A MDE is more persistent, pervasive (not only focused on loss of the
loved one), and self-critical
Differentiate normal grief from a major
depressive episode:
• No specific treatment, but can treat symptoms (insomnia, anxiety)
Treatment of bereavement:
• Emotional and/or behavioral symptoms in response to an identifiable
stressor (resolve within 6 months of the termination of the stressor)
Adjustment disorders:
• Chronic depression that is present nearly all the time for at least 2
years (1 year in children)
Persistent Depressive Disorder:
18.
19. Thank you for completing this module
Questions? Contact me at:
Julie.Teater@osumc.edu
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Editor's Notes
Denial- person tries to shut out the magnitude or reality of the situation. It is a defense mechanism that buffers the shock.
Anger- person asks “why me?” or “this isn’t fair”. Anger is often misplaced at those close to them.
Bargaining- an attempt to regain control by avoiding or undoing the cause of grief. Often bargains with a higher power.
Depression- feelings of sadness and loss, beginning to accept that the loss is inevitable or final.
Acceptance- period of calm and withdrawal from the loved one. Coming to terms with the situation.
In grief, the predominant symptom is feelings of emptiness and loss, while in a MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure
The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves (“pangs of grief”), which tend to be associated with thoughts or reminders of the deceased; the depressed mood of MDE is more persistent and not tied to specific thoughts
The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE
The thought content in grief is generally preoccupied with thoughts of the deceased, rather than the self-critical or pessimistic ruminations seen in MDE
In grief, self-esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common
If self-derogatory ideation is present in grief, it typically involves perceived failings in regards to the deceased
If a bereaved individual thinks about death and dying, such thoughts are focused on the deceased and possibly about “joining” the deceased, whereas in MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression
The characteristic syndromes of Bereavement vary considerably in different age groups and across cultures
People experiencing Bereavement may seek help, especially for symptoms such as insomnia and anorexia
Clinicians can be helpful by listening, encouraging the person to talk about the deceased, and advising them to use available social supports
Antidepressants are not helpful unless a Major Depressive Episode is present, but anti-anxiety and sedative medications can be helpful for a short period
Certain hallucinations are “normal” during bereavement, and should not lead to a psychiatric diagnosis (generally hearing the voice of the deceased, seeing the deceased, etc.)
Specify whether :
With Depressed Mood: low mood, tearfulness, or feelings of hopelessness are predominant
With Anxiety: nervousness, worry, jitteriness, or separation anxiety is predominant
With Mixed Anxiety and Depressed Mood
With Disturbance of Conduct
With Mixed Disturbance of Emotions and Conduct: both emotional symptoms (depression, anxiety) and a disturbance of conduct are predominant
Unspecified: for maladaptive reactions that are not classifiable as of the specific subtypes of Adjustment Disorder
Clinically significant but non-specific emotional or behavioral symptoms that develop within 3 months of the onset of an identifiable psychosocial stressor
They by definition cause either distress in excess of what would ordinarily be expected or impairment in functioning
Also by definition, they resolve within 6 months of termination of the stressor and its consequences
Note that an identifiable stressor is necessary but not sufficient for diagnosis of an Adjustment Disorder. Any condition listed in the DSM-5 can begin or worsen in response to stress.
However, an Adjustment Disorder can be superimposed on another disorder and diagnosed additionally when the other disorder cannot account for all the symptoms.
Adjustment Disorders are now listed in the Trauma- and Stressor-Related Disorders chapter, along with Posttraumatic Stress Disorder and Acute Stress Disorder, as they all include exposure to a stressor as a criterion
Normal bereavement- however, adjustment disorders may be diagnosed following the death of a loved one when the intensity, quality, or persistence of grief reaction exceeds what normally might be expected (see Persistent Complex Bereavement Disorder)
Psychotic symptoms- these are incompatible with the diagnosis of Adjustment Disorder; consider Brief Psychotic Disorder instead
Major Depressive Episode- if full criteria are met for this, do not diagnose an Adjustment Disorder with depressed mood
In DSM-5, there was a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder into Persistent Depressive Disorder
It consists of a chronic depression that is present nearly all the time for at least 2 years (1 year in children)
The criteria changed so that one may meet full criteria for a Major Depressive Episode during this time period (this was an exclusion previously for dysthymia)- see specifiers
Specify if:
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With peripartum onset
Specify if:
With pure dysthymic syndrome- full criteria for a MDE have not been met in at least the preceding 2 years
With persistent major depressive episode- full criteria for a MDE have been met throughout the preceding 2-year period
With intermittent major depressive episodes, with current episode- full criteria for a MDE are currently met, but there have been periods of at least 8 weeks in the last 2 years with symptoms below the threshold for a full MDE
With intermittent major depressive episodes, without current episode- full criteria for a MDE are not currently met but have been met, but there has been one or more MDE in the last 2 years
Specify current severity:
Mild
Moderate
Severe
Specify if:
In partial remission
In full remission
Specify if:
Early onset: prior to age 21
Late onset: age 21 or older
