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
Read full abstract
May 4, 2023
Mingtu Xu + 5
Open Access
