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16.04.2014

Axis i diagnosis of major depressive disorder, ringing in ear after q-tip - Review

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The diagnostic category of adjustment disorder (AD) made its first appearance in DSM-III in 1968, replacing the previous “transient situational disturbance” of DSM-II, and shortly after was included in ICD-9. This definition excludes the diagnosis if there is another Axis I or II disorder to which the symptoms may be attributed or if the symptoms are due to bereavement (Table). ICD-10 limits the time frame of onset to within 1 month of the causative stressor and, as with DSM-IV, categorizes it as one of exclusion, specifying that the criteria for an affective disorder must not be met. Symptoms caused by mood fluctuations in response to day-to-day stressful events that occur in persons with borderline (emotionally unstable) personality disorder are not classified as AD. The second dilemma is the differentiation of AD from other Axis I disorders, such as generalized anxiety disorder (GAD) and major depression disorder (MDD).
This suggests that the current diagnostic system based on symptom thresholds is limited and that in DSM-5 more emphasis should be placed on the specific symptom clusters and their quality.
PrevalenceAD is underresearched, and most of the large epidemiological surveys of the general population lack any prevalence data for AD, including the Epidemiological Catchment Area study, the US National Comorbidity Survey, and the National Psychiatric Morbidity surveys of Great Britain.4-6 As a result, the diagnostic category of AD has not received the attention that it warrants and most of the scientific data are derived from smaller studies made up of particular clinical groups. A major problem in studying AD is the absence of any specific diagnostic criteria with which to make the diagnosis. Structured diagnostic and screening instruments for ADStructured interviews are frequently considered the gold standard in psychiatric research because they eliminate the subjective element of the diagnostic process; however, for purposes of diagnosing AD, there are problems.


The categories in ICD-10 are brief depressive reaction, prolonged depressive reaction, mixed anxiety and depressive reaction, with predominant disturbance of other emotions, with predominant disturbance of conduct, with mixed disturbance of emotions and conduct, and with other specified predominant symptoms.
So the diagnosis can be made even when the index event has resolved or the 6-month time frame has been reached if consequences continue. There is nothing to assist the clinician in making this distinction except that ICD-10 requires both functional impairment and symptoms to make the diagnosis, while DSM requires symptoms or impairment. Thus, a young woman with children who had received a diagnosis of stage IV cancer 3 weeks earlier and now has low mood, is not sleeping, is unable to get pleasure from life, has recurrent thoughts of dying, and has poor concentration might variously be thought to be experiencing an appropriate reaction, an AD, or MDD. ICD-10 is silent on the knock-on effect of stressors but allows a 2-year period of symptoms in the prolonged depressive subtype. For this reason, clinical diagnosis with all its associated problems is the only standard currently available.
A further reason for monitoring is that the symptoms may represent a disorder, such as evolving MDD that emerges more clearly over time. Instead, in DSM-5 clinicians will be encouraged to rate severity of symptoms along continuums developed for each disorder. Secondly, the importance of some disorder categories has been recognised either by allocating them to their own chapter or by recognising them as new individual diagnostic categories.


DSM-5 focuses more on the behavioural symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of the previous three. Asperger’s disorder, childhood disintegrative disorder, pervasive developmental disorder) in an attempt to provide more consistent and accurate diagnosis for children with autism (see Chapter 16).
This is the case with Attenuated Psychosis Syndrome, Major Depression, and Generalized Anxiety Disorder, and this runs the risk of increasing the number of people that are likely to be diagnosed with common mental health problems such as anxiety and depression. Once again, these initiatives run the risk of medicalizing states that are not yet full-blown disorders, and could facilitate the diagnosis of normal developmental processes as psychological disorders.Thirdly, there are concerns that changes in diagnostic criteria will result in lowered rates of diagnosis for some particularly vulnerable populations.
DSM-5 has attempted to recognise the importance of the dimensionality of symptoms by introducing dimensional severity rating scales for individual disorders. Having said this, there are still many significant problems associated with DSM, and diagnosing and labelling people with specific psychological disorders raises other issues to do with stigma and discrimination.



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