Introduction

This chapter covers conditions and problems that may attract clinical attention or otherwise affect diagnosis, course, prognosis, or treatment. The conditions are not diagnoses or mental disorders. They are issues that may affect patient care and help explain the need for a test, procedure, or treatment. These may also be included in medical records as useful information. Including them in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) acknowledges that a broad range of additional issues can impact patient care. Documenting them systematically is useful to clinicians and beneficial to patients.

These conditions have International Statistical Classification of Diseases and Related Health Problems codes ICD-9-CM (V codes) and ICD-10-CM (Z codes) and include: relational problems; child abuse (physical and sexual) and neglect; partner abuse or violence (psychological, physical, and sexual); educational and occupational problems; housing and economic problems; other problems related to the social environment; problems related to crime or interaction with the legal system; other health service encounters for counselling and medical advice; problems related to other psychosocial, personal, and environmental circumstances; other circumstances of personal history; problems related to access to medical treatment; non-adherence to medical treatment; overweight or obesity; and malingering,

This chapter specifically examines various problems related to relationships, child and adult maltreatment and neglect, housing and economic difficulties, and other psychosocial, personal, and environmental circumstances.

Many of the issues to be discussed occur in addition to other presentations/diagnoses. As such, they are likely to be addressed in the context of other presentations. Therefore, treatment should typically follow guidelines for main presentation/diagnosis. In addition to the conditions addressed here, refer to the DSM-5 for information on various other problems that may be the focus of clinical attention.

Australia

Relational problems

Recent statistics on incidence and prevalence indicate the number of divorces decreased in 2013 by 2279 (4.6%) and the crude divorce rate decreased from 2.2 divorces per 1000 population in 2012 to 2.1 in 2013 (Australian Bureau of Statistics [ABS], 2014). About 31.6% of children aged 5–9 years who had a natural parent living elsewhere had daily/weekly frequency of face-to-face contact between parent and child, compared to 24% of less than once a year or never (ABS, 2011).

Introduction

Bipolar disorder is a mood disorder characterised by alternating periods of euthymia, hypomania, mania, mild depression, and/or major depression. Individuals unaffected by a mood disorder tend to have a more consistent euthymic mood state. People with bipolar disorder can experience a high and low mood simultaneously, which is called a mixed episode. Bipolar disorder can be associated with psychotic features such as hallucinations, which are often mood congruent. While bipolar disorder is predominantly viewed as a mood disorder, its symptoms are more far-reaching, including changes in sleep, speech, cognitions, and physical functioning. Bipolar disorder occurs in around 1% to 3% of the population. It has a high genetic loading, with a 10% chance of inheriting it if one parent has the condition and 40% chance if both parents have it. Bipolar disorder is considered one of the most severe mental illnesses as it is lifelong, tends to be chronically relapsing for some, and is associated with a large amount of morbidity combined with a large number of episodes of self-harm, suicide attempts, and suicide completions. The most common comorbidities for bipolar disorder are anxiety and substance use. The World Health Organisation's (WHO) “burden of disease” report in 1996 (Murray & Lopez) ranked bipolar disorder as sixth in terms of overall disability among those aged 15–44 years. People with bipolar disorder die much earlier than the general population, often due to preventable health-related disorders such as smoking-related health issues, cardiovascular disease, and diabetes. Bipolar disorder is associated with a 20% to 50% risk of a suicide attempt (Jamieson, 2000).

Diagnostic criteria

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) recognises that bipolar disorder occurs on a spectrum of disorders including cyclothymic disorder, bipolar II disorder, bipolar I disorder, and other specified bipolar disorder. The DSM-5 criteria for depression and mild depression are discussed in Chapter 10. The elevated moods in bipolar disorder are hypothymia and mania as distinguished by severity, with mania the more severe elevated mood. Hypomania is an elevated state lasting up until four days whereas mania lasts more than 1 week and is associated with impaired functioning, hospitalisation, and psychotic features.

Introduction

Depression is a common yet potentially serious mental health condition that affects many Australians and New Zealanders. Although most people feel sad or down from time to time, a depressive illness or clinical depression is characterised by a sustained period of low mood and anhedonia (i.e., loss of pleasure), as well as other cognitive, emotional, and biological markers. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013), has now listed only unipolar depressive disorders within its own chapter. This deviates from previous editions (DSM-III through to DSM-IV-TR) where depressive disorders appeared in a mood disorders chapter and were listed in the same chapter as bipolar disorders.

In the DSM-5, two new depressive disorders have been added: disruptive mood dysregulation disorder and pre-menstrual dysphoric disorder. Major depressive disorder (MDD), dysthymia, substance-induced depressive disorder, and depressive disorder due to a medical condition have been retained with some minor variations in some of the diagnostic criteria. Most people diagnosed with a depressive disorder would have MDD. Generally, when clinicians and public health policymakers discuss depressive disorders, they mean MDD. This chapter will mostly focus on MDD (the term “clinical depression” is used interchangeably with MDD in this chapter).

To be diagnosed with MDD, the individual must have five or more of the following features for a 2-week period: the presence of low mood and/or anhedonia (one of these is mandatory); significant weight loss or weight gain; disturbed sleep; psychomotor agitation or slowing; listlessness; feelings of self-deprecation or guilt; poor concentration; and reoccurring thoughts of death and/or suicide (this may include a plan for suicide).

Australian and New Zealand (NZ) governments have recognised the personal, social, and economic ramifications of depression over the last decade. MDD has been directly linked to suicide, as well as family and relationship issues including parenting difficulties, poorer physical health (including diabetes and heart disease), poorer work productivity, greater workers’ compensation claims, and greater sick leave. Organisations in both Australia and NZ have adopted numerous initiatives to increase the public understanding of depression, reduce the stigma associated with depression, and ultimately prevent and treat depression.

Abnormal psychology is often a core course in both undergraduate and postgraduate psychology programs across North America, Europe, and Australasia. The vast majority of abnormal psychology textbooks come from the United States of America (US). This academic focus on US abnormal psychology is not surprising given the relatively large number of people living in the US, that it is ranked third in terms of country population in the world, and is the most populous country in which English is the primary language spoken (Statistics Times, 2016; United Nations Department of Economic and Social Affairs/Population Division, 2015). Additionally, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) originates from the US. The available US resources are, understandably, US-centric and contain mostly US statistics and applied examples. Furthermore, if reference to community resources is made these are likely to be US-based and not accessible, or of low relevance, to Australasian populations.

There are few abnormal psychology resources that present Australian and New Zealand (NZ) materials including statistics, case studies, and community resources. Recent Australian-focused resources include a special issue published by Pelling (2015) in the International Journal of Mental Health. Further, there are both Australian- and NZ-based authors publishing practice- and education-relevant abnormal psychology resources. However, up until now no resource has existed detailing the Australian and NZ experience and response to abnormal psychology matters in a succinct and applied manner. This handbook on abnormal psychology in the Australian and NZ context is designed specifically to make such academic and applied abnormal psychology resources available.

This handbook has been compiled to include material by lead researchers and applied practitioners from Australia and NZ. Consequently, the resulting resource is valuable to both students of abnormal psychology and also applied mental health practitioners across Australia and NZ. We hope you enjoy reading and making use of this handbook which purposefully highlights and showcases our Australasian research and practice relating to abnormal psychology.

Introduction

Trauma- and stressor-related disorders (TSRD) is a new category in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). The specific criterion for inclusion in this diagnostic category is the explicit exposure to a traumatic or stressful event.

Several disorders have been incorporated into the TSRD category as individuals exhibit a wide range of reactions following trauma. The disorders in this new category are reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorders (ASD), and adjustment disorders. Of these, adjustment disorder, ASD, and PTSD are the most prevalent. In order to qualify for a diagnosis of PTSD, explicit exposure to the most severe stress (PTSD Criterion A) is required, while criteria for diagnosis of an adjustment disorder requires exposure to the least level of stress.

Immediately following exposure to a distressing event, a diagnosis of an adjustment disorder or ASD (providing diagnostic criteria are fulfilled) can be established. However, the criterion for ASD is that a short-term reaction that persists from 3 days to 1 month exists. Should symptoms last longer than a month, a diagnosis of PTSD may apply if specific. For the sake of brevity, this chapter will consider only PTSD and ASD.

The development of PTSD may occur following exposure to a traumatic event where severe threat or injury occurred. However, a straightforward trajectory does not always exist. For instance, while most people with ASD also develop PTSD, many with PTSD do not initially display ASD (Bryant et al., 2008). Many develop PTSD more than 6 months post-trauma, a phenomenon known as delayed onset PTSD. McFarlane (2010) argues that a key reason for this is the escalating process of increasing sensitisation, which progresses an over-reactivity to subtle environmental cues associated with the trauma. PTSD can present at any age; however, there are separate diagnostic criteria for children under the age of 6 (Scheeringa, Zeanah, & Cohen, 2011).

Events that may precipitate PTSD include violent assault, natural disasters, wars, or accidents; for example, direct exposure to natural disasters such as bush fires in Australia (McFarlane, 1990; Parslow, Jorm, & Christensen, 2006) and earthquakes in New Zealand (NZ; Fergusson et al., 2014). Intimate interpersonal violence has the highest reported risk factor for developing PTSD (Forbes et al., 2014). Cumulative stress can also precipitate PTSD.

Introduction

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) contains 10 sleep-wake disorders: insomnia; hypersomnolence; narcolepsy; breathing related; circadian rhythm; non-rapid eye movement (NREM) sleep arousal; nightmare; rapid eye movement (REM) sleep behaviour; restless legs syndrome; and substance/medication-induced sleep difficulties. The DSM-5 nosology incorporates recent advances in our understanding of the physiological and genetic factors underpinning disordered sleep, the impact of lifespan development on sleep and pathology, and findings from treatment studies. Diagnostic formulations incorporate validated polysomnographic and neurobiologic biomarkers, which distinguish the diagnosis of sleep from most other psychiatric disorders. Unfortunately, it is not possible to review all 10 DSM-5 sleep-wake disorders in one summary chapter. As a result, this chapter will focus on those most often addressed via psychological interventions. Readers interested in a review of the full range of sleeping disorders are referred to the companion academic supplementary materials available for the current textbook.

Common to all the DSM-5 sleep-wake disorders is dissatisfaction with the quality, timing, and amount of sleep, together with evidence of impact or distress in everyday functioning. Diagnosis also depends on the sleep problem being primary in origin and not secondary to a known medical condition, disease, or health impairment. However, identifying the primary disorder can be complicated by the bidirectional and often mutually exacerbating relationship that exists between disordered sleep (e.g., insomnia, excessive sleepiness, early morning wakefulness) and many psychiatric and medical conditions. Sleep problems typically do not occur in isolation, but there is good evidence that treating sleep disorders can lead to gains, even when secondary to other medical problems.

Two distinguishing features of the sleep disorders field are: 1. the diversity of disorders; and 2. the degree to which psychological treatments play a role in therapy. Some sleep disorders are more properly addressed via medical and pharmaceutical interventions, such as narcolepsy with stimulant medication and obstructive sleep apnoea hypopnea disorder with continuous positive airway pressure (CPAP) apparatus, although cognitive behaviour therapy (CBT) has been shown to increase CPAP adherence (Agudelo et al., 2014; Richards et al., 2007).

Introduction

Children normally develop bladder and bowel control by the age of 5. Controlled toileting is a developmental milestone that happens step by step. Babies are born incontinent. They slowly develop control of their bowels at night and during the day, then gradually acquire daytime and night-time bladder continence. Most children can control their bladder and bowel by age 4–5, but some take longer to do so. Five years old is considered the cut-off age for diagnosing encopresis (faecal soiling) and enuresis (wetting).

Encopresis and enuresis are the primary toileting difficulties in childhood. These issues can affect the social and educational development of children, who can be isolated at school, excluded from peers, and face conflict with parents and teachers. They can lead the child to experience low self-esteem, poor academic achievement, and secondary social, emotional, or behavioural issues.

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) children who do not achieve toilet training by age 5 and have repeated bed or clothes wetting twice per week for 3 consecutive months, meet the criteria for enuresis (307.6); specified if: 1. nocturnal only; 2. diurnal only; and 3. nocturnal and diurnal. If the child involuntarily and repeatedly passes faeces in inappropriate places (usually undergarments) the criteria for encopresis (307.7) is met; specified if: 1. with constipation and overflow incontinence; 2. without constipation and overflow incontinence.

According to the International Statistical Classification of Diseases and Related Health Problems 2010 Edition (ICD-10; WHO, 2011), children can experience involuntary rejecting of urine, day and night, which is usually not expected considering the child's mental age, and is not a result of a lack of bladder control due to neurological disorder, epilepsy, or unusual abnormality of the urinary tract. This type of toileting issue is known as nonorganic enuresis (F98.0). The child's enuresis may be present from birth or it may have developed after bladder control. The enuresis could be associated with emotional or behavioural difficulties.

The child may experience repeated, voluntary, or involuntary passing of faeces, usually of normal consistency, in places that are not deemed appropriate in the child's sociocultural setting. In the ICD-10 this is known as nonorganic encopresis (F98.1).

Introduction

The obsessive-compulsive and related disorders span a range of conditions marked by perseverative thinking and the urge to engage in repetitive behaviours. These disorders include obsessive compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder, trichotillomania (hair pulling), and excoriation (skin picking). While often comorbid, and having similar maintaining factors and treatment approaches, the underlying distinctions between these disorders include different cognitive distortions, foci of the urges, emotional experiences, and types of behaviour. OCD is the most common of these disorders and is more frequently represented in psychological research studies. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychological Association, 2013) defines these disorders as follows.

OCD is characterised by the presence of obsessions and/or compulsions. Obsessions are defined as recurrent and persistent thoughts, urges, or images that a person experiences as intrusive, unwanted, and distressing. Once experienced, a person will often avoid known triggers of obsessional thinking. However, if triggered, compulsive attempts will be made to ignore, supress, or neutralise such thoughts and urges, and to restore a sense of safety. Compulsions may include overt repetitive behaviours (e.g., cleaning, checking) or covert mental acts (e.g., praying, counting) performed to reduce anxiety or prevent some dreaded outcome, often according to rigid rules. Examples of common obsessions and compulsions are presented in Table 13.1. Many people experience intrusive, unwanted thoughts and engage in the types of behaviours observed in OCD. A diagnosis of OCD requires that the obsessions and/or compulsions are time consuming (e.g., take over 1 hour per day), cause considerable distress, and significantly interfere with an individual's functioning.

BDD, trichotillomania, and excoriation all involve repetitive behaviours about some aspect of the body. BDD involves the preoccupation with a perceived defect or physical flaw that may be unnoticeable or only minimally noticeable to others. Common concerns include imperfect skin, thinning or excessive hair, or that facial features or body parts are too large, too small, or asymmetrical. Individuals with BDD perform repetitive behaviours such as mirror checking, excessive grooming, camouflaging with make-up or clothing, picking at perceived skin defects, and mentally comparing their appearance with others. Trichotillomania and excoriation (respectively) involve compulsive hair pulling and skin picking involving any area of the body.