Maladaptive denial of physical illness: a proposal for DSM-IV
Article Abstract:
Denial of physical illness is common, and in many cases clearly maladaptive. The authors present an argument for a new diagnostic classification subtype to adjustment disorders termed 'maladaptive denial of physical disorder'. Some people are referred for psychiatric consultation specifically because of a maladaptive denial of a physical illness. The Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R) has a code for 'noncompliance with treatment', which is noncompliance that is not a result of a mental disorder (this noncompliance can be due to denial, religious beliefs, or personal value judgments). Also included is a code for 'psychological factors affecting physical condition', which refers to stressors that effect the cause of disease. Denial poses a problem when noncompliance to treatment recommendations exacerbates the illness, and has been described as a defense mechanism against unpleasant feelings by denying reality. Sometimes denial is a necessary adaptive device, but at other times it is dangerous, which makes classifying 'healthy' and 'pathological' denial difficult. Sometimes physicians claim a patient is in denial when they are simply disagreeing with them. The authors' psychiatric consultation service consisted of many patients (10 percent of total) who were referred because they refused recommended treatment. Many of these patients were not in denial of reality, but had disagreed with or not understood the recommendations of their doctors. Some patients with denial had diagnosable psychotic disorders, but with others, it was their main symptom. This later situation is one that may be defined by the proposed classification of 'adjustment disorder with maladaptive denial of physical disorder'. This denial is a response to either the diagnosis or the symptoms of a disease, when ignoring the condition puts the patient at a high risk for serious illness or death. The patient either denies the existence of the disorder or greatly minimizes its significance. Not included in this category would be conscious decisions made for religious or personal reasons after thorough consideration of the risks and benefits, or instances where the patient has other delusions regarding the disease or the caregivers. Case studies are provided which differentiate the forms of denial discussed. Other questions regarding denial and this proposal are discussed. It is concluded that this classification would improve clinical care by clarifying the reasons for noncompliance. (Consumer Summary produced by Reliance Medical Information, Inc.)
Publication Name: American Journal of Psychiatry
Subject: Psychology and mental health
ISSN: 0002-953X
Year: 1990
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Prodromal symptoms in affective disorders
Article Abstract:
Prodromal symptoms, or the signs and symptoms that precede a disorder and that are distinctly different from those found during the acute phase of the disorder, are important in medicine because early detection of illness is often crucial to favorable treatment and outcome. But in psychiatry, research on prodromal symptoms has been rare, with the exception of studies regarding schizophrenia. The current article surveys the literature with regard to the prodromal symptoms of affective disorders, such as depression, mania, and anxiety. Twenty-four studies were found that specifically addressed the issue of prodromal symptoms, and they were in agreement that the prodromal phase, at least for mania, depression, and panic attacks, may precede the full-blown acute phase of the illness by weeks and sometimes even months. For mania, the symptoms include headaches, weariness, lack of pleasure, irritability, and sleeplessness. The prodromal phase of depression varies. In sudden-onset depression there appear to be few prodromal symptoms. Gradual-onset depression is related to ongoing stress. Neurotic-onset depression is often preceded by anxiety disorders, and fluctuating-onset depression is characterized by symptoms that fluctuate in intensity before full-blown depression sets in. Symptoms during the prodromal phase of panic disorders have not been agreed upon. Some cite avoidance behavior as a sign, while others say that avoidance is caused by the panic disorder itself. If prodromal symptoms can be more clearly identified, treatment for these disorders could be initiated sooner and might be more effective. It is recommended that attention to prodromal symptoms compliment current standards of clinical assessment, namely the identification of symptoms during the acute phases of psychiatric disorders. Studies that have been completed on prodromal symptoms need to be updated as well, as most were carried out in the 1960s. (Consumer Summary produced by Reliance Medical Information, Inc.)
Publication Name: American Journal of Psychiatry
Subject: Psychology and mental health
ISSN: 0002-953X
Year: 1991
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Seasonality and affective illness
Article Abstract:
Affective disorders are defined by the Diagnostic and Statistical Manual of Mental Disorders, third edition, as a group of disorders characterized by a disturbance in mood accompanied by a full or partial depressive or manic syndrome which cannot be attributed to another physical or mental condition. Seasonal Affective Disorder (SAD) is a not uncommon condition in which the sufferer is affected by seasonal changes of the environment. The significance of environmental factors in depression has been observed since the time of Hippocrates, but only in the past decade has this been reexamined with any seriousness. A variety of possibilities are suggested that may account for this loss of interest: the rejection of the ancient humoral theory, where seasons were thought to directly affect disease; the adoption of contemporary psychological and biological theories which stress internal rather than external processes; and the modern perception of time as being linearly progressive, rather than proceeding in a cyclic pattern. Both winter and summer affective disorders have been diagnosed and have been identified as primary conditions which are delineated by their opposing pattern of symptoms. Winter depression is characterized by oversleeping, overeating, and carbohydrate craving. The condition is responsive to phototherapy, the exposure to sunlight or to artificial light. The opposite symptoms are observed in summer depression, which include insomnia, loss of weight, and loss of appetite. The authors stress the importance of additional research, especially in light of the successful response received from the phototherapeutic treatment for winter depression. Observations made 2,000 years ago remain consistent with modern observations regarding seasonal influences of depression, and deserve more attention.
Publication Name: American Journal of Psychiatry
Subject: Psychology and mental health
ISSN: 0002-953X
Year: 1989
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