Inka Weissbecker

Proposals for mental disorders specifically associated with stress in the International Classification of Diseases-11

Mental disorders specifi cally associated with stress are exceptional in needing external events to have caused psychiatric symptoms for a diagnosis to be made. The specialty of stress-associated disorders is characterised by lively debates, including about the extent to which human suff ering should be medicalised, and the purported overuse of the diagnosis of post-traumatic stress disorder (PTSD). Most common mental disorders are potentiated or exacerbated by stress and childhood adversity. Moreover, the subjective narratives of many people with mental disorders emphasise such external events. Clinicians might inadvertently gravitate towards diagnoses of disorders specifi cally associated with stress whenever a signifi cant stressor can be identifi ed, because this approach provides a way to understand the person’s experience of symptoms, as a function of external events, that is more likely to be acceptable to the person. What could be missed in such formulations is that mental disorders specifi cally associated with stress are characterised not only by an antecedent event, but also by a distinct clinical picture with core symptoms that diff er from those of other mental disorders. WHO is developing the International Classifi cation of Diseases, version 11 (ICD-11), which is scheduled for approval in 2015. WHO is also responsible for the Mental Health Gap Action Programme (mhGAP), intended to assist with scaling up of mental health care, particularly in low-income and middle-income countries. It has launched the mhGAP intervention guide, which provides assessment and management protocols for selected conditions in non-specialised health-care settings. In response to requests from health-care providers, WHO is developing a module for this guide with disorders specifi cally associated with stress that will use proposed ICD-11 defi nitions. These activities are also relevant to WHO’s role in development of mental health policies related to humanitarian crises. Changes in the category of mental disorders specifi cally associated with stress are important because of questions about the validity of surveys showing a high rate of these diagnoses in populations who have experienced natural or man-made disasters, and about whether these diag noses are clinically useful in terms of leading to feasible and eff ective treatment. People with these disorders seek help in many health settings globally. The high level of overlap and co-occurrence with other mental disorders often challenges mental health specialists, while general medical services often note co-occurring somatic problems. The ICD-11 Working Group on this topic was asked to review scientifi c evidence and other information about use, clinical utility (as termed by WHO), and experience with relevant ICD-10 diagnoses in various health-care settings; to review proposals for the American Psychiatric Asso ciation’s Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) and consider how these may be suitable or useful for global applications; and to assemble proposals for ICD-11 with a focus on improving clinical utility. The Working Group has recommended a separate grouping of disorders specifi cally associated with stress for ICD-11, rather than combining them with anxiety disorders as in ICD-10 or DSM-IV. Disorders specifi cally associated with stress have two key characteristics: they are identifi able on the basis of diff erent psychopathology that is distinct from other mental disorders; and they arise in specifi c association with a stressful event or series of events. For each disorder in the grouping, the stressor is a necessary, although not suffi cient, causal factor. The stressor could range from negative life events within the normal range of experience (in the case of adjustment disorder) to traumatic stressors of exceptional severity (in the case of PTSD and complex PTSD). Among the controversies about existing formulations of PTSD are concerns about its overuse in populations exposed to natural or man-made disasters. One problem has been the application of the diagnosis when populations are still being actively exposed to extreme stressors—eg, continuing confl ict, uprooting to unsafe locations, or earthquake aftershocks—which makes differentiation between PTSD, adaptive fear reactions, and grief diffi cult, especially when the defi nition of PTSD includes non-specifi c symptoms. Moreover, there is a concern that an overemphasis on PTSD could contribute to clinicians failing to recognise other commonly occurring mental disorders, especially depression. Nonetheless, the appropriate use of a clearly defi ned PTSD category is one aspect of progress in evidencebased mental health care in humanitarian settings. The Working Group has recommended a refocus on the diagnosis of PTSD on three core elements, and removal of non-specifi c symptoms that are also part of other disorders. The proposed diagnostic guidelines need re-experiencing of the traumatic event, in which the event is not only remembered but experienced as occurring again; avoidance of reminders likely to produce re-experiencing of the traumatic event(s); and a perception of heightened current threat, as indicated by Lancet 2013; 381: 1683–85

Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11

The diagnostic concepts of post‐traumatic stress disorder (PTSD) and other disorders specifically associated with stress have been intensively discussed among neuro‐ and social scientists, clinicians, epidemiologists, public health planners and humanitarian aid workers around the world. PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. This paper describes proposals that aim to maximize clinical utility for the classification and grouping of disorders specifically associated with stress in the forthcoming 11th revision of the International Classification of Diseases (ICD‐11). Proposals include a narrower concept for PTSD that does not allow the diagnosis to be made based entirely on non‐specific symptoms; a new complex PTSD category that comprises three clusters of intra‐ and interpersonal symptoms in addition to core PTSD symptoms; a new diagnosis of prolonged grief disorder, used to describe patients that undergo an intensely painful, disabling, and abnormally persistent response to bereavement; a major revision of “adjustment disorder” involving increased specification of symptoms; and a conceptualization of “acute stress reaction” as a normal phenomenon that still may require clinical intervention. These proposals were developed with specific considerations given to clinical utility and global applicability in both low‐ and high‐income countries.

Mindfulness-Based Stress Reduction and Sense of Coherence Among Women With Fibromyalgia

Sense of Coherence (SOC) is conceptualized as a disposition to experience life as meaningful and manageable. Research suggests a protective effect of SOC on psychological health in stressful circumstances. This study assessed the capacity of SOC to buffer the effect of illness symptoms on psychological distress among patients with fibromyalgia. Self-reported changes in SOC after participation in a Mindfulness-Based Stress Reduction (MBSR) program were also examined. Ninety-one women with fibromyalgia provided baseline data pertaining to illness symptoms, perceived stress, and depression prior to participation in a randomized trial of MBSR. SOC and fibromyalgia symptoms were independently related to perceived stress and depression at baseline. SOC was not a statistically significant moderator of symptom effects on psychological distress. In comparison with wait-listed controls, program participants reported a significant increase in SOC after MBSR participation. These results provide the first demonstration from a randomized trial that SOC may be enhanced via intervention.

Childhood trauma and diurnal cortisol disruption in fibromyalgia syndrome

Adults with fibromyalgia syndrome report high rates of childhood trauma. Neuroendocrine abnormalities have also been noted in this population. Exploratory analyses tested relationships between retrospective reports of childhood trauma and diurnal salivary cortisol patterns among 85 women with fibromyalgia. Subjects with fibromyalgia completed self-reports of childhood physical, sexual and emotional abuse, as well as emotional and physical neglect. Recent major life events, current perceptions of stress, and depressive symptoms were also assessed. Salivary cortisol was collected six times per day for two consecutive days to assess diurnal rhythm, awakening response and mean cortisol levels. Hierarchical regression analyses were performed, controlling for age, relevant medications, life events, perceived stress, and depressive symptoms. Childhood physical abuse predicted flattened diurnal cortisol rhythms as well as greater cortisol responses to awakening. Sexual abuse was a second predictor of increased awakening cortisol responses. Patients with a history of trauma had markedly low levels of cortisol at the time of first awakening, partly explaining the results. These findings suggest that severe traumatic experiences in childhood may be a factor of adult neuroendocrine dysregulation among fibromyalgia sufferers. Trauma history should be evaluated and psychosocial intervention may be indicated as a component of treatment for fibromyalgia.

Mindfulness Meditation in Clinical Practice.

The practice of mindfulness is increasingly being integrated into contemporary clinical psychology. Based in Buddhist philosophy and subsequently integrated into Western health care in the contexts of psychotherapy and stress management, mindfulness meditation is evolving as a systematic clinical intervention. This article describes stress-reduction applications of mindfulness meditation predominantly in medical settings, as originally conceived and developed by Kabat-Zinn and colleagues. It describes process factors associated with the time-limited, group-based formal favored by this model, and presents in tabular form results of both early and more recent outcome studies.

Biological and psychological factors associated with memory function in fibromyalgia syndrome.

Fibromyalgia is a stress-related disorder characterized by chronic pain, memory impairment, and neuroendocrine aberrations. With the hypothesis that biological and psychological symptoms may underlie the cognitive problems, the relative influences of neuroendocrine function and psychological factors on declarative memory were examined among 50 women with fibromyalgia. This within-group analysis controlled for age, education, pain, and relevant medications. Neuroendocrine function and depression had significant independent associations with memory function. Higher log-transformed mean salivary cortisol levels were associated with better performance on both immediate and delayed visual recall and with delayed verbal recall. Depressive symptoms were negatively associated with verbal recall. These findings suggest that a basic disorder of endocrine stress responses may contribute to the cognitive symptoms experienced by fibromyalgia patients.

Religiosity may help preserve the cortisol rhythm in women with stress-related illness.

Objective: Fibromyalgia has been characterized as a basic disorder of endocrine stress responses in which psychological stress has been linked both with etiology and symptom severity. This study investigated associations of religiosity and spirituality with psychological and physiological (endocrine) measures of stress in a sample of women with fibromyalgia. Method: Ninety-one participants provided self-reports of religiosity and spirituality using the Duke University Religion Index (DUREL) and the Index of Core Spiritual Experiences (INSPIRIT). Psychological outcomes were measured with the Perceived Stress Scale (PSS), and diurnal salivary cortisol profiles were measured as an indicator of neuroendocrine regulation. Results: Hierarchal regression analyses controlling for age and medications likely to affect cortisol levels revealed significant associations of nonorganizational religiosity and intrinsic religiosity with the diurnal cortisol rhythm. Patients reporting medium or high religiosity had rhythmic cortisol profiles characterized by high morning and low evening levels. In contrast, cortisol rhythms of those reporting low religiosity appeared flattened. The association between intrinsic religiosity and cortisol rhythm persisted after controlling for social support. No significant effects of religiosity or spirituality on perceived stress were observed. Conclusions: These data suggest that religiosity may have a protective effect on the physiological effects of stress among women with fibromyalgia.

Mindfulness meditation alleviates fibromyalgia symptoms in women: results of a randomized clinical trial.

BackgroundSeveral recent reviews have evaluated evidence on the efficacy of Mindfulness-Based Stress Reduction (MBSR) among fibromyalgia sufferers, and concluded that more research should test effects on both psychological and physiological functioning.PurposeWe conducted a randomized prospective trial of MBSR among female fibromyalgia patients.MethodsEffects on perceived stress, pain, sleep quality, fatigue, symptom severity, and salivary cortisol were tested in treatment (n = 51) versus wait-list control participants (n = 40) using data at baseline, post-program, and 2-month follow-up.ResultsAnalyses revealed that MBSR significantly reduced perceived stress, sleep disturbance, and symptom severity, with gains maintained at follow-up. Greater home practice at follow-up was associated with reduced symptom severity. MBSR did not significantly alter pain, physical functioning, or cortisol profiles.ConclusionMBSR ameliorated some of the major symptoms of fibromyalgia and reduced subjective illness burden. Further exploration of MBSR effects on physiological stress responses is warranted. These results support use of MBSR as a complementary treatment for women with fibromyalgia (ISRCTN: 34628811).

Depression may mediate the relationship between sense of coherence and quality of life in lung cancer patients.

Lung cancer patients generally experience high levels of physical and psychological distress and decreased quality of life (QOL). Sense of coherence (SOC) has been conceptualized as a personality orientation reflecting the degree to which an individual perceives their world as comprehensible, manageable and meaningful. The present study investigated the associations of SOC with QOL in lung cancer. It also examined potential psychological mediators by which SOC may exert its influences on QOL. Fifty-six participants with non-small cell lung cancer were administered self-report assessments of SOC, QOL and psychological distress. Results revealed that SOC was positively associated with QOL and this relationship may be mediated by depressive symptoms. The current study supports the notion that SOC may be a protective factor with regard to psychological adjustment and QOL in cancer survivors.

Strengthening mental health care systems for Syrian refugees in Europe and the Middle East: integrating scalable psychological interventions in 8 countries

ABSTRACT The crisis in Syria has resulted in vast numbers of refugees seeking asylum in Syria’s neighbouring countries as well as in Europe. Refugees are at considerable risk of developing common mental disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD). Most refugees do not have access to mental health services for these problems because of multiple barriers in national and refugee specific health systems, including limited availability of mental health professionals. To counter some of challenges arising from limited mental health system capacity the World Health Organization (WHO) has developed a range of scalable psychological interventions aimed at reducing psychological distress and improving functioning in people living in communities affected by adversity. These interventions, including Problem Management Plus (PM+) and its variants, are intended to be delivered through individual or group face-to-face or smartphone formats by lay, non-professional people who have not received specialized mental health training, We provide an evidence-based rationale for the use of the scalable PM+ oriented programmes being adapted for Syrian refugees and provide information on the newly launched STRENGTHS programme for adapting, testing and scaling up of PM+ in various modalities in both neighbouring and European countries hosting Syrian refugees.