Bereavement, Adjustment Disorders, and Persistent Depressive Disorder Julie Teater, MD Assistant Professor Department of Psychiatry

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)

The Five Stages of Grief (Kubler-Ross Model) DenialAngerBargainingDepressionAcceptance Not a complete list of emotions that may be felt Can be experienced in any order

Uncomplicated Bereavement (Normal Grief) This category can be used when the focus of clinical attention is a reaction to the death of a loved oneBy definition, this is NOT a mental disorderHowever, 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

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

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.

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

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.

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

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 functioningResolve within 6 months of termination of the stressor and its consequencesA 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

Exclusions to Adjustment Disorders Normal bereavement Psychotic symptoms Major Depressive Episode

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

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

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.

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

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

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:

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