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4327.0 - National Survey of Mental Health and Wellbeing: Users' Guide, 2007  
Latest ISSUE Released at 11:30 AM (CANBERRA TIME) 11/02/2009   
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3. MENTAL DISORDERS AND CONDITIONS


OVERVIEW

This chapter provides information on the mental disorders and conditions collected in the 2007 National Survey of Mental Health and Wellbeing (SMHWB). The survey was designed to produce diagnoses of mental disorders by two classification systems:

  • the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV); and
  • the WHO International Classification of Diseases, Tenth Revision (ICD-10).

This chapter also contains information on:
A brief comparison of differences between the diagnostic assessment criteria used for the 1997 and 2007 surveys is provided in Chapter 4 for both classifications (DSM-IV and ICD-10). The comparisons focus on the differences in assessment criteria, rather than on minor question wording or sequencing changes, as these are thought to have negligible impact on comparability.

More information on measuring mental health, including details on the World Mental Health Survey Initiative version of the World Health Organization's (WHO) Composite International Diagnostic Interview (CIDI), version 3.0 (WMH-CIDI 3.0), is provided in Chapter 2.


SCREENER

A screener was introduced to the WMH-CIDI 3.0 to try to alleviate the effects of learned responses. The module included a series of introductory questions about the respondent's general health, followed by diagnostic screening questions for the primary disorders assessed in the survey, eg depressive episode. The screener questions are designed to determine if a person is likely to have symptoms of particular disorders. The use of screener questions has been shown to increase the accuracy of diagnostic assessments, by reducing the effects of learned responses due to respondent fatigue. Other disorders, such as Obsessive-Compulsive Disorder (OCD), were screened at the beginning of the individual module.

The introductory questions to the screener are part of a standard ABS module, which measures the respondents' perceptions of their overall health and life in general. These questions do not take into account specific illnesses or problems the person may have, only their perceived level of health or life in general.

The remaining questions in this module are diagnostic screener questions, which are linked to later modules in the survey instrument. This includes a number of 'second chance' questions, where the respondent is given more than one chance to endorse symptoms, which would 'screen' them into a particular diagnostic module. People were only asked a 'second chance' question if they said 'No' to the first question. For example, 'Have you ever in your life had an attack of fear or panic when all of a sudden you felt very frightened, anxious or uneasy?' If this question was not endorsed, then the following 'second chance' question was asked - 'Have you ever had an attack when all of a sudden:
  • you became very uncomfortable;
  • you either became short of breath, dizzy, nauseous or your heart pounded; or
  • you thought you might lose control, die or go crazy?'


MENTAL DISORDERS

The survey provides WMH-CIDI 3.0 diagnoses for selected mental disorders according to both the ICD-10 and DSM-IV classifications. Variations in the diagnostic assessment criteria for each classification may therefore give differing estimates for the overall prevalence of mental disorder, as well as for specific disorders. The survey included mental disorders that:
  • were expected to affect more than 1% of the population;
  • were able to be diagnosed through the CIDI; and
  • were likely to be identified through a household survey.

In 2007, the prevalence of mental disorders is based on the diagnosis of a lifetime disorder, with or without symptoms in the 12 months prior to interview. In comparison, the 1997 survey considers only symptoms during the 12 months prior to interview for diagnosis.


Probe questions

The CIDI instrument probes respondents through a series of questions about symptoms, problems or experiences in order to establish whether these were clinically significant and also whether they were due to medication, drugs, alcohol or a physical illness or injury.

The questions on clinical significance assessed whether the symptoms were sufficiently severe for the person to seek professional help, or whether the symptoms interfered with his or her life or activities excessively. The symptoms were considered below clinical significance if the person:
  • did not tell a doctor or other health professional about the symptoms;
  • did not take medication for them more than once; and
  • did not feel that they interfered with his or her life a lot.

The probe questions excluded symptoms due to the effects of psychoactive substance use (medication, drugs or alcohol), or physical illness or injury. Questions sought to establish whether symptoms were always the result of the person:
  • using medication, drugs or alcohol; or
  • having a physical illness or injury.

If either of these explanations, or some combination of the two, accounted for all of the occurrences of the symptoms, then these symptoms did not count towards a diagnosis of mental disorder.


ICD-10 diagnoses of mental disorders

The following ICD-10 diagnoses were assessed by the survey:

Anxiety disorders
  • Panic Disorder
  • Agoraphobia
  • Social Phobia
  • Generalised Anxiety Disorder
  • Obsessive-Compulsive Disorder
  • Post-Traumatic Stress Disorder

Affective disorders
  • Severe Depressive Episode
  • Moderate Depressive Episode
  • Mild Depressive Episode
  • Dysthymia
  • Hypomania
  • Mania
  • Bipolar Affective Disorder

Substance use disorders
  • Harmful use - alcohol
  • Harmful use - opioids
  • Harmful use - cannabinoids
  • Harmful use - sedatives
  • Harmful use - stimulants
  • Dependence syndrome - alcohol
  • Dependence syndrome - opioids
  • Dependence syndrome - cannabinoids
  • Dependence syndrome - sedatives
  • Dependence syndrome - stimulants


DSM-IV diagnoses of mental disorders

The following DSM-IV diagnoses were assessed by the survey:

Anxiety disorders
  • Panic Disorder with/without Agoraphobia
  • Agoraphobia with/without Panic Disorder
  • Social Phobia
  • Generalised Anxiety Disorder
  • Obsessive-Compulsive Disorder
  • Post-Traumatic Stress Disorder

Affective disorders
  • Major Depressive Episode
  • Major Depressive Disorder
  • Minor Depressive Disorder
  • Recurrent Brief Depression
  • Dysthymic Disorder
  • Hypomanic Episode
  • Manic Episode
  • Bipolar I Disorder
  • Bipolar II Disorder

Substance use disorders
  • Abuse - alcohol
  • Abuse - opioids
  • Abuse - cannabinoids
  • Abuse - sedatives
  • Abuse - stimulants
  • Dependence - alcohol
  • Dependence - opioids
  • Dependence - cannabinoids
  • Dependence - sedatives
  • Dependence - stimulants


Hierarchy rules

The classification system for some of the mental disorders contain diagnostic exclusion rules so that a person, despite having symptoms that meet diagnostic assessment criteria, will not meet criteria for particular disorders because the symptoms are believed to be accounted for by the presence of another disorder. In these cases, one disorder takes precedence over another. These exclusion rules are built into the diagnostic algorithms.

The WMH-CIDI 3.0 includes two versions of diagnoses in the algorithms for a number of the mental disorders, based on:
  • a 'with hierarchy' version - which specifies the full diagnostic criteria consistent with the DSM-IV or ICD-10 classification system (ie the exclusion criteria are enforced); and
  • a 'without hierarchy' version - which applies all diagnostic criteria except the criteria specifying the hierarchical relationship with other disorders.

An example of a disorder specified with and without hierarchy is the Harmful Use of alcohol. The ICD-10 states that in order to meet the diagnostic assessment criteria for Harmful Use, criteria cannot be met for Dependence on the same substance during the same time period. The ‘with hierarchy’ version of the Harmful Use of alcohol will therefore exclude cases where Dependence on alcohol has been established for the same time period. The ‘without hierarchy’ version includes all cases of alcohol Harmful Use regardless of coexisting alcohol Dependence. Note that a person can meet criteria for Dependence on alcohol and the hierarchical version of Alcohol Harmful Use if there is no overlap in time between the two disorders.

The survey publication, National Survey of Mental Health and Wellbeing: Summary of Results, 2007 (cat. no. 4326.0) presents the ICD-10 prevalence rates with the hierarchy rules applied, except for the comorbidity data, which are presented without hierarchy. The mental disorders specified with and without hierarchy are outlined later in this chapter and an example of the differences in prevalence rates with and without hierarchy rules applied is provided in the following table.

4. 12-MONTH MENTAL DISORDERS(a), Comparison of ICD-10 and DSM-IV diagnostic criteria with and without hierarchy rules applied

ICD-10 with hierarchy
ICD-10 without hierarchy
DSM-IV with hierarchy
DSM-IV without hierarchy

Anxiety disorders
Panic Disorder
410.3
410.3
286.8
286.8
Agoraphobia
450.4
450.4
108.8
108.8
Social Phobia
759.9
759.9
672.9
672.9
Generalised Anxiety Disorder
436.1
515.1
344.9
572.5
Obsessive-Compulsive Disorder
305.6
305.6
429.7
429.7
Post-Traumatic Stress Disorder
1 031.9
1 031.9
701.0
701.0
Total Anxiety disorders
2 303.0
2 303.0
1 884.3
1 925.0
Affective disorders
Depressive Episode(b)(c)
652.4
800.2
767.7
947.0
Dysthymia
203.8
323.9
177.8
316.2
Bipolar Affective Disorder(d)
285.6
285.6
142.5
142.5
Total Affective disorders
995.9
998.8
933.1
1 005.2
Substance Use disorders
Alcohol Harmful Use/Abuse
470.1
626.0
461.9
603.6
Alcohol Dependence
230.2
230.2
229.0
229.0
Drug Use disorders(e)
231.4
231.4
230.6
230.6
Total Substance Use disorders
819.8
819.8
811.3
811.3
Any 12-month mental disorder(f)
3 197.8
3 197.8
2 828.9
2 835.2
No 12-month mental disorder(g)
12 817.5
12 817.5
13 186.4
13 180.1
Total persons aged 16-85 years
16 015.3
16 015.3
16 015.3
16 015.3

(a) Persons who met criteria for diagnosis of a lifetime mental disorder and had symptoms in the 12 months prior to interview.
(b) ICD-10 diagnosis includes Severe/Moderate/Mild Depressive Episode.
(c) DSM-IV diagnosis includes Major Depressive Episode and Major/Minor Depressive Disorder.
(d) DSM-IV diagnosis includes Bipolar I and Bipolar II Disorders.
(e) Includes Harmful Use/Abuse and Dependence.
(f) A person may have had more than one 12-month mental disorder. The components when added may therefore not add to the total shown.
(g) Persons who did not meet criteria for diagnosis of a lifetime mental disorder and those who met criteria for diagnosis of a lifetime mental disorder but did not have symptoms in the 12 months prior to interview.



Comorbidity

Comorbidity refers to the occurrence of more than one disorder at the same time. Comorbidity may refer to the co-occurrence of mental disorders and the co-occurrence of mental disorders and physical conditions. The existence of some conditions may predispose individuals to others. For example, severe social phobia may contribute to depression and alcohol dependence. Further, the presence of mental and/or physical conditions in combination is likely to compound the difficulties people face. The 2007 SMHWB enables analysis of comorbidity, both in terms of the number of disorders, and the combinations of different types of comorbidity.


Onset, recency and persistence

All of the disorder-specific sections assess the onset and recency of symptoms, as well as the persistence of episodes.

Onset

The onset of symptoms was obtained by asking the respondent their exact age the very first time they had a particular symptom or episode.

Recency

The recency of symptoms was determined by asking the respondent their exact age the last time they had a particular symptom or episode.

Questions about onset (first time) and recency (last time) were asked for each group of symptoms that may have corresponded to a diagnosis of mental disorder. Therefore, if a person had experienced symptoms or an episode in the 12 months prior to interview they were asked how recently this occurred. With the exception of dysthymia, responses were categorised as:
  • within the month prior to interview;
  • two months to six months prior to interview; or
  • more than six months prior to interview.

Persistence

Persistence relates to the length of time that a symptom or episode was present. Depending on the mental disorder being assessed, a person may have been asked to provide their age in years for:
  • the first time when symptoms or an episode occurred;
  • the worst period of symptoms or worst episode; or
  • the most recent time when symptoms or an episode occurred.

From the information provided, persistence was calculated within the diagnostic algorithms and the duration output in years. The persistence questions varied across mental disorders, recognising that they may be:
  • episodic (eg depression, mania);
  • clusters of attacks (eg panic disorder); or
  • fairly persistent dispositions (eg phobias).

Note that in the 1997 survey, persistence was referred to as duration.


ICD-10 DIAGNOSTIC ASSESSMENT CRITERIA

Introduction

The following information provides descriptions of the WMH-CIDI 3.0 diagnostic assessment criteria according to the WHO International Classification of Diseases, Tenth Revision (ICD-10). Note that not all exclusions specified in the ICD-10 were able to be addressed in the survey. Therefore, some of the descriptions differ from the ICD-10.


ICD-10 Anxiety disorders

Anxiety disorders generally involve feelings of tension, distress or nervousness. A person may avoid, or endure with dread, situations which cause these types of feelings. The disorders within this group assessed in this survey are:
Panic Disorder

A panic attack is a discrete episode of intense fear or discomfort that starts abruptly and reaches a peak within 10 minutes. At least four symptoms must be present from the list below, one of which must be from the first four:
  • pounding heart;
  • sweating;
  • trembling or shaking;
  • dry mouth;
  • difficulty breathing;
  • feeling of choking;
  • chest pain or discomfort;
  • nausea or abdominal distress;
  • dizziness or feeling light-headed;
  • feelings of unreality or depersonalisation;
  • fear of passing out or losing control;
  • fear of dying;
  • hot flushes or cold chills; or
  • numbness or tingling sensations.

The essential feature of Panic Disorder is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances (ie do not occur in the presence of a phobia, or in situations of danger) and are therefore unpredictable.

Agoraphobia

The disorder is characterised by marked and consistently manifest fear in, or avoidance of, at least two of the following situations:
  • crowds;
  • public places (ie using public transport; standing in a line in a public place; being in a department store, shopping centre, or supermarket; being in a movie theatre auditorium, lecture hall, or church; being in a restaurant or any other public place);
  • travelling alone (ie travelling alone or being alone away from home); or
  • travelling away from home.

At least two of the following anxiety symptoms must have been present together with the feared situation and one of these symptoms must be from the first four listed:
  • pounding heart;
  • sweating;
  • trembling or shaking;
  • dry mouth;
  • difficulty breathing;
  • feeling of choking;
  • chest pain or discomfort;
  • nausea or abdominal distress;
  • feeling dizzy or light-headed;
  • feelings of unreality or depersonalisation;
  • fear of passing out, or losing control;
  • fear of dying;
  • hot flushes or cold chills; or
  • numbness or tingling sensations.

The person also experiences significant emotional distress due to the avoidance or the anxiety symptoms and recognises that these are excessive or unreasonable.

Social Phobia

The disorder is characterised by fear and/or avoidance of one or more social or performance situations such as:
  • meeting new people;
  • talking to people in authority;
  • speaking up in a meeting or class;
  • going to parties or social gatherings;
  • performing in front of an audience;
  • taking an important exam or interviewing for a job;
  • working while someone watches;
  • entering a room when others are already present;
  • talking with or disagreeing with people they don't know very well;
  • writing, eating or drinking while someone watches;
  • using a public bathroom; or
  • dating.

The presence of Social Phobia is also characterised by:
  • The fear of either being the focus of attention or of behaving in a way that will be embarrassing or humiliating; or the avoidance of either being the focus of attention, or of situations where there is fear of behaving in an embarrassing or humiliating way.
  • At least two anxiety symptoms (see the list in Agoraphobia) must be present in the feared situation at some time since the onset of the disorder, together with at least one of the following: blushing or shaking; nausea or fear of vomiting; or the urgency or fear of losing control of bowels or bladder.
  • Significant distress caused by the symptoms or by the avoidance and the person recognises that these are excessive or unreasonable.

Generalised Anxiety Disorder (GAD)

The disorder is characterised by a period of at least six months with tension, worry and apprehension about everyday events and problems. The disorder is not due to a physical disorder or substance use. At least four of the following symptoms must be present, with at least one of the first four:
  • pounding heart;
  • sweating;
  • trembling or shaking;
  • dry mouth;
  • difficulty breathing;
  • feeling of choking;
  • chest pain;
  • nausea, stomach pain or discomfort;
  • dizziness;
  • feelings of unreality or depersonalisation;
  • fear of losing control or passing out;
  • fear of dying;
  • hot flushes or cold chills;
  • numbness or tingling sensations;
  • muscle tension or aches and pains;
  • restlessness;
  • feeling on edge;
  • a sensation of a lump in the throat;
  • exaggerated response to minor surprises;
  • difficulty concentrating;
  • irritability; or
  • trouble getting to sleep because of worry.

Hierarchy rules have been applied to GAD. To meet criteria for the 'with hierarchy' version:
  • GAD does not occur exclusively within the duration of Panic Disorder; and
  • GAD is not exclusively associated with social and performance situations (ie Social Phobia); and
  • GAD does not occur exclusively within the duration of (and is not exclusively associated with) obsessions and compulsions (ie Obsessive-Compulsive Disorder).

The original exclusion rules from the ICD-10 also consider the presence of other phobic disorders and hypochondriacal disorder. As the 2007 SMHWB did not collect information for Specific Phobia or Hypochondriacal Disorder, the GAD prevalence may include some people with these disorders.

Obsessive-Compulsive Disorder (OCD)

Either obsessions or compulsions (or both) are present on most days for at least two weeks. Obsessions (thoughts, ideas or images) and compulsions (acts) share the following features, all of which must be present:
  • repetitive and unpleasant, and at least one obsession or compulsion is acknowledged as excessive or unreasonable;
  • the person tries to resist them, and at least one obsession or compulsion that is unsuccessfully resisted must be present;
  • the person derives no pleasure from the obsessive thought or compulsive act;
  • the obsessions or compulsions cause distress or interfere with the person's social or individual functioning; and
  • the respondent considers that the obsessions and compulsions do not occur exclusively within episodes of depression (this is based on self-reported information, not according to a diagnosis made by the CIDI).

Post-Traumatic Stress Disorder (PTSD)

The disorder is characterised by symptoms experienced within six months of exposure to an extremely traumatic event which would be likely to cause pervasive distress in almost anyone. In order to be assessed for this disorder, a person had to report that they had experienced at least one of the following traumatic events:
  • direct combat experience in a war;
  • a war or ongoing terror as a peacekeeper;
  • a war as an unarmed civilian;
  • living in a place with ongoing terror;
  • ever being a refugee;
  • being kidnapped or held captive;
  • being exposed to a toxic substance;
  • a life-threatening car accident;
  • a life threatening accident;
  • a fire, flood or other natural disaster;
  • a man-made disaster or bomb explosion;
  • a life-threatening illness;
  • being beaten as a child;
  • being beaten by a spouse or partner;
  • being beaten by anyone else;
  • being held up or threatened with a weapon;
  • rape;
  • sexual molestation;
  • being stalked;
  • an unexpected death of someone very close;
  • a son or daughter with a life-threatening illness or injury;
  • traumatic experience (rape) of someone very close;
  • witness serious physical fights at home as a child;
  • someone being badly injured or killed, or unexpectedly seeing a dead body;
  • doing something that accidentally led to serious injury or death of another person;
  • seriously injure, torture or kill another person on purpose;
  • witnessing atrocities; or
  • any other extremely traumatic or life-threatening events, including events they did not wish to describe.

People were asked to determine which event was their worst traumatic event. To meet the criteria for this disorder, a person must have reported all of the following reactions:
  • the event is persistently remembered or relived (eg flashbacks, dreams, or distress when reminded of the event), or they experience distress when exposed to circumstances resembling or associated with the event;
  • they exhibit an actual or preferred avoidance of circumstances resembling or associated with the event, which were not present before that event; and
  • they exhibit either an inability to recall some or all aspects of the trauma or two or more symptoms of increased sensitivity and arousal (difficulty in falling or staying asleep; irritability; difficulty concentrating; hypervigilance; exaggerated startle response).


ICD-10 Affective disorders

Affective disorders involve mood disturbance, or change in affect. Most of these disorders tend to be recurrent and the onset of individual episodes can often be related to stressful events or situations. Disorders within this group include:
Depressive Episode

A Depressive Episode lasts for at least two weeks and is characterised by the presence of a number of the following symptoms:
  • depressed mood;
  • loss of interest in activities;
  • lack of energy or increased fatigue;
  • loss of confidence or self esteem;
  • feelings of self-reproach or excessive guilt;
  • thoughts of death or suicide, or suicide attempts;
  • diminished ability to concentrate, think or make decisions;
  • change in psychomotor activity; agitation or retardation;
  • sleep disturbance; or
  • change in appetite.

The survey collected information to differentiate between three different types of Depressive Episode, based on the number of symptoms a person experienced:
  • Severe Depressive Episode - all of the first three symptoms from the above list and additional symptoms from the remainder of the list to give a total of at least eight.
  • Moderate Depressive Episode - at least two of the first three symptoms from the above list and additional symptoms from the remainder of the list to give a total of at least six.
  • Mild Depressive Episode - at least two of the first three symptoms from the above list and additional symptoms from the remainder of the list to give a total of at least four.

Hierarchy rules have been applied to all of the Depressive Episodes. To meet criteria for the 'with hierarchy' versions, a person cannot have met criteria for either Hypomanic or Manic episodes in their lifetime.

The three types of Depressive Episode collected by the survey are also mutually exclusive. A person cannot be diagnosed with Moderate Depressive Episode if the criteria for a Severe Depressive Episode have already been met and a diagnosis of a Mild Depressive Episode is considered only when the other two types of depression have been excluded. This criteria is applied regardless of whether the 'with hierarchy' or 'without hierarchy' version of the disorder is used.

Dysthymia

A disorder characterised by at least two years of constant (or constantly recurring) chronic depressed mood, where intervening periods of normal mood rarely last for longer than a few weeks. During some of the periods of depression, at least three of the following are present:
  • reduced energy or activity;
  • insomnia;
  • loss of self-confidence or feeling inadequate;
  • difficulty in concentrating;
  • frequent tearfulness;
  • loss of interest in or enjoyment of sex and other pleasurable activities;
  • feeling of hopelessness or despair;
  • feeling unable to cope with everyday responsibilities;
  • pessimism about the future or brooding over the past;
  • social withdrawal; or
  • reduced talkativeness.

Hierarchy rules have been applied to Dysthymia. To meet criteria for the 'with hierarchy' version:
  • a person must not have met criteria for episodes of Hypomania or Mania in their lifetime; and
  • there must be no episodes of Severe or Moderate Depression identified within the first two years of Dysthymia.

Hypomania

Hypomania is characterised by elevated or irritable mood to a degree that is abnormal for the person concerned and sustained for at least four consecutive days. Symptoms lead to some interference with daily living but to a lesser degree than Mania. At least three of the following symptoms must be present:
  • increased activity or restlessness;
  • increased talkativeness;
  • distractibility;
  • decreased need for sleep;
  • increased sexual energy;
  • overspending or other types of reckless or irresponsible behaviour; or
  • over-familiarity or increased sociability.

Hierarchy rules have been applied to Hypomania. To meet criteria for the 'with hierarchy' version, the person cannot have met criteria for an episode of Mania in their lifetime.

The original exclusion rules also consider the presence of any Depressive Episodes, Cyclothymia and Anorexia Nervosa. As the 2007 SMHWB did not collect information for Cyclothymia or Anorexia Nervosa (and the presence of Depressive Episodes was not assessed in the diagnostic algorithm), Hypomania may include some persons with these disorders.

Mania

Mania is characterised by a person's mood being elevated, expansive or irritable and definitely abnormal for their personality. The episode lasts for at least seven days (unless the episode is severe enough to require hospitalisation), causes severe interference with personal functioning, is not directly caused by substance use or a physical condition, and is characterised by at least three of the following (four if the mood is merely irritable):
  • increased activity or restlessness;
  • increased talkativeness;
  • flight of ideas or the feeling that thoughts are racing;
  • loss of normal social inhibitions;
  • decreased need for sleep;
  • inflated self-esteem or grandiosity;
  • distractibility;
  • reckless behaviour; or
  • marked sexual energy or sexual indiscretions.

Bipolar Affective Disorder

The disorder is characterised by episodes of Mania or Hypomania either alone or in conjunction with Depressive Episodes. For this survey, a person met diagnosis of Bipolar Affective Disorder if they met the criteria for Mania or Hypomania and experienced at least two episodes of mood disturbance, consisting of either:
  • one episode of Mania or Hypomania and one of Depression; or
  • two episodes of Mania or Hypomania.


ICD-10 Substance Use disorders

The survey collected information on the Harmful Use and Dependence on alcohol and other substances. Detailed questions about alcohol use were only asked if the person had at least 12 standard alcoholic drinks in a 12-month period.

Standard drink

A standard drink contains 12.5ml of alcohol. the serving size determines the number of standard drinks per serve, as shown in the following table:

5. STANDARD DRINKS, by serving size

Type of alcohol
Serving size
Standard drinks

Light beer
Can or stubbie
0.8
Medium light beer
Can or stubbie
1.0
Regular beer
Can or stubbie
1.5
Wine (9-13%)
100ml
1.0
Spirits
30ml nip
1.0
Spirits (approx 5%)
Can
1.5-2.5


Detailed questions about drug abuse and dependence were only asked if a person had:
  • misused prescription medication more than five times in their lifetime; or
  • used the same type of illicit drug (eg speed, ecstasy, marijuana) more than five times in their lifetime.

Alcohol Harmful Use

A diagnosis occurs where there is clear evidence that the use of alcohol was responsible for (or substantially contributed to):
  • physical or psychological harm, including impaired judgement; or
  • dysfunctional behaviour which may have led to disability or had adverse consequences for interpersonal relationships.

The nature of the harm should be clearly identifiable by including at least one of the following:
  • frequent interference with work or other responsibilities;
  • causing arguments or other serious problems with family, friends, neighbours or co-workers;
  • jeopardising safety because of alcohol use; or
  • being arrested or stopped by police for drink driving or drunken behaviour.

Hierarchy rules have been applied to Alcohol Harmful Use. To meet criteria for the 'with hierarchy' version, a person cannot have met a diagnosis of Alcohol Dependence during the same time period (ie the duration of the two disorders must not overlap).

Alcohol Dependence Syndrome

A maladaptive pattern of behaviour in which the use of alcohol takes on a much higher priority for a person than other behaviours that once had greater value. The central characteristic is the strong, sometimes overpowering, desire to consume alcohol despite significant alcohol-related problems. A diagnosis was achieved if three or more of the following occurred within the same year:
  • strong desire or compulsion to consume alcohol;
  • difficulties in controlling alcohol consumption behaviour;
  • withdrawal symptoms (eg fatigue, headaches, diarrhoea, the shakes or emotional problems);
  • tolerance to alcohol (eg needing to drink a larger amount for the same effect);
  • neglect of alternative interests because of alcohol use; or
  • continued use despite knowing it is causing significant problems.

Drug Use Disorders

The Harmful Use and Dependence on drugs was only assessed if a person had used an illicit drug or misused prescription medication more than five times in their lifetime. The misuse of prescription medication includes:
  • using medicine/s without the recommendation of a health professional;
  • overusing medicines; or
  • taking medicines for any other reason than as prescribed.

A general assessment was made for Harmful Use and Dependence on any drugs. The Harmful Use and Dependence on four specific categories of drugs were also assessed. The categories of drugs were:
  • opioids (eg heroin, methadone, opium);
  • cannabiniods (eg marijuana, hashish);
  • sedatives (eg serepax, sleeping pills, valium); and
  • stimulants (eg amphetamines, speed).

Other Substance Harmful Use

This survey collected information on:
  • Harmful Use - opioids
  • Harmful Use - cannabinoids
  • Harmful Use - sedatives
  • Harmful Use - stimulants

A diagnosis occurs where there is clear evidence that the use of opioids/cannabinoids/sedatives/stimulants were responsible for (or substantially contributed to):
  • physical or psychological harm, including impaired judgement; or
  • dysfunctional behaviour which may have led to disability or had adverse consequences for interpersonal relationships.

The nature of the harm should be clearly identifiable by including at least one of the following:
  • frequent interference with work or other responsibilities;
  • causing arguments or other serious problems with family, friends, neighbours or co-workers;
  • jeopardising safety because of substance use; or
  • being arrested or stopped by police for driving while intoxicated or other behaviour while intoxicated.

Hierarchy rules have been applied to Other Substance Harmful Use. To meet criteria for the 'with hierarchy' versions, a person cannot have met a diagnosis of Dependence on the same substance during the same time period (ie the duration of the two disorders must not overlap).

Other Substance Dependence Syndrome

This survey collected information on:
  • Dependence Syndrome - opioids
  • Dependence Syndrome - cannabinoids
  • Dependence Syndrome - sedatives
  • Dependence Syndrome - stimulants

Opioid/Cannabinoid/Sedative/Stimulant Dependence Syndrome is a maladaptive pattern of substance use in which the use of the substance takes on a much higher priority for a person than other behaviours that once had greater value. The central characteristic is the strong, sometimes overpowering, desire to take the substance despite significant substance-related problems. A diagnosis was achieved if three or more of the following occurred for the same substance in the same 12-month period:
  • strong desire or compulsion to take the substance;
  • difficulties in controlling substance-taking behaviour;
  • withdrawal symptoms (eg fatigue, headaches, diarrhoea, the shakes or emotional problems);
  • tolerance to the drug (eg needing to use a larger amount for the same effect);
  • neglect of alternative interests because of substance use; or
  • continued use despite knowing it is causing significant problems.


DSM-IV DIAGNOSTIC ASSESSMENT CRITERIA

Introduction

The following information provides descriptions of the WMH-CIDI 3.0 diagnostic assessment criteria according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Note that not all exclusions specified in the DSM-IV were able to be addressed in the survey. Therefore, some of the descriptions outlined differ from the DSM-IV.


Exclusion criteria

Symptoms are not due to the direct physiological effects of a substance or general medical condition.


DSM-IV Anxiety disorders

Anxiety disorders generally involve feelings of tension, distress or nervousness. A person may avoid, or endure with dread, situations which cause these types of feelings. The disorders within this group assessed in this survey are:
Panic Disorder

The essential feature of this disorder is recurrent panic (anxiety) attacks that occur suddenly and unpredictably. At least one of the attacks has been followed by one month or more of at least one of the following:
  • concern about having additional attacks;
  • worry that the attack means that the person is 'going crazy', losing control or having a heart attack; or
  • change in behaviour because of the attacks.

Panic Disorder with/without Agoraphobia

A person may have met criteria for Panic Disorder with or without the presence of Agoraphobia.

Panic Attack

A period of intense fear or discomfort which begins suddenly and reaches a peak within ten minutes. At least four of the following symptoms are present:
  • pounding heart;
  • sweating;
  • trembling or shaking;
  • shortness of breath;
  • feeling of choking;
  • chest pain;
  • nausea;
  • dizziness;
  • feelings of unreality;
  • fear of losing control;
  • fear of dying;
  • numbness or tingling sensations; or
  • hot flushes or cold chills.

Agoraphobia

The disorder is characterised by anxiety about being in situations from which escape might be difficult (or embarrassing) or in which help may not be available if the person has a panic attack. Such situations include:
  • being outside the home alone;
  • being in a crowd;
  • travelling in trains, buses or cars; and
  • being in a public place.

The person avoids the situations, endures them with distress or requires the presence of a companion.

Agoraphobia without Panic Disorder

The symptoms of Agoraphobia relate to a fear of developing panic-like symptoms, but the person has never met the criteria for Panic Disorder.

Social Phobia

The disorder is characterised by a marked and persistent fear of one or more social or performance situations in which a person is exposed to unfamiliar people or to possible scrutiny by others. The person fears that they will act in a way (or show anxiety symptoms) that will be embarrassing or humiliating. Exposure to the feared situation almost always provokes anxiety which may take the form of a panic attack. The feared situations are avoided, or endured with distress and the person recognises that the fear is excessive or unreasonable. The disorder is accompanied by clinically significant distress and interference with normal routine and functioning.

For people who were aged less than 18 years when the symptoms last occurred, the duration of the symptoms must have been at least six months. For people who were aged at least 18 years when the symptoms last occurred, the duration of the symptoms must have been more than one year.

Generalised Anxiety Disorder (GAD)

The disorder is characterised by excessive anxiety and worry about a number of events or activities, occurring more days than not for at least six months. Three or more of the following symptoms are present (with at least some present for more days than not for the six months prior to interview):
  • restlessness;
  • fatigue;
  • difficulty concentrating;
  • irritability;
  • muscle tension; or
  • sleep disturbance.

The person finds it difficult to control the worry, and it causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

A person is excluded from diagnosis if the GAD is associated with one or more of the following self-reported conditions:
  • mental health;
  • substance use;
  • social phobias;
  • agoraphobia;
  • specific phobias;
  • obsessions;
  • compulsions; or
  • being away from home or apart from loved ones.

Hierarchy rules have been applied to GAD. To meet criteria for the 'with hierarchy' version, the symptoms/disturbance cannot have occurred exclusively during a mood disorder (Major or Minor Depressive Disorder, Dysthymia or Mania).

Obsessive-Compulsive Disorder (OCD)

The disorder is characterised by either obsessions, compulsions or a combination of both.

Obsessions are defined by the following:
  • recurrent and persistent thoughts, impulses or images that are experienced as intrusive and inappropriate and that cause marked anxiety;
  • the thoughts, impulses or images are not simply excessive worries about real-life problems;
  • the person tries to ignore or suppress such thoughts, impulses or images or to neutralise them with some thought or action; and
  • the person realises that the thoughts, impulses or images come from his or her own mind, and are not imposed from without.

Compulsions are defined by the following:
  • repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession; and
  • the behaviours or mental acts are aimed at preventing or reducing distress or some dreaded event or situation, but are not realistic or are clearly excessive.

The disorder is also characterised by the obsessions or compulsions:
  • causing marked distress;
  • being time consuming; or
  • significantly interfering with the person's normal routine or functioning.

Additionally, the person realises that the obsessions or compulsions are excessive or unreasonable.

The obsessions or compulsions cannot occur exclusively within episodes of depression. In this case, depression was based on the endorsement of questions about being sad or depressed when the symptoms of OCD occurred. Therefore, depression was self-reported and not verified medically or through a CIDI diagnosis.

Post-Traumatic Stress Disorder (PTSD)

The disorder is characterised by symptoms lasting more than one month following exposure to an extremely traumatic event in which the person experienced or witnessed:
  • an event that involved actual or threatened death or serious injury; or
  • a threat to the physical integrity of self or others.

The person's response to the event involved intense fear, helplessness or horror. The traumatic event is persistently re-experienced in one or more of the following ways:
  • recollections;
  • dreams;
  • acting or feeling as if the event were recurring;
  • distress when reminded of the event; or
  • physiological reactivity when reminded of the event.

In addition, the person exhibits avoidance of things associated with the event evidenced by three or more of the following:
  • efforts to avoid thinking, feeling or talking about the event;
  • efforts to avoid activities, places or people that arouse recollections of the event;
  • inability to recall aspects of the trauma;
  • diminished interest or participation in significant events;
  • feelings of estrangement from others;
  • restricted range of affect (e.g. unable to have loving feelings); or
  • sense of a foreshortened future.

Further, two or more of the following symptoms of increased arousal are present:
  • difficulty falling or staying asleep;
  • irritability;
  • difficulty concentrating;
  • hypervigilance; or
  • exaggerated startle response.

The disturbance causes clinically significant distress or impairment in social, occupational and other important areas of functioning.


DSM-IV Affective disorders

Affective disorders involve mood disturbance, or change in affect. Most of these disorders tend to be recurrent and the onset of individual episodes can often be related to stressful events or situations. Disorders within this group include:
Major Depressive Episode

This disorder is characterised by the presence of five or more symptoms during the same two week period, with at least one of the symptoms from the first two on the list:
  • depressed mood;
  • loss of interest and pleasure;
  • weight change or appetite disturbance;
  • sleep disturbance;
  • psychomotor changes;
  • low energy;
  • feelings of worthlessness or guilt;
  • poor concentration or difficulty making decisions; or
  • recurrent thoughts of death or suicidal ideation, plans or attempts.

These symptoms must represent a change from previous functioning, and are not better accounted for by bereavement. If the depressive episode is associated with bereavement then the episode must be longer than two months duration. In addition, the episode must be accompanied by clinically significant distress or impairment in social, occupational or other important areas of functioning.

The survey also collected information on:
Major and Minor Depressive Disorders

In order to be diagnosed with Major Depressive Disorder a person must have met criteria for a single Major Depressive Episode. Hierarchy rules have been applied to Major Depressive Disorder. For the 'with hierarchy' version, a diagnosis can only be made if a person has never met criteria for a Hypomanic or Manic Episode.

Minor Depressive Disorder is diagnosed if a person has at least two (but less than five) symptoms of a Major Depressive Episode. Hierarchy rules have been applied to Minor Depressive Disorder. For the 'with hierarchy' version, a diagnosis can only be made if a person has never:
  • met criteria for Major Depressive Episode and Dysthymia; and
  • experienced a Hypomanic or Manic Episode.

Recurrent Brief Depression

This disorder is characterised by the presence of symptoms lasting at least two days, but less than two weeks. The symptoms occur at least once a month for 12 consecutive months and are not associated with the menstrual cycle. The symptoms cause significant distress or impairment in social, occupational or other areas of functioning. At least five of the following symptoms must be present and at least one of the symptoms should be from the first two on the list:
  • depressed mood;
  • loss of interest or pleasure;
  • significant weight loss when not dieting or weight gain, or decrease or increase in appetite;
  • insomnia or hypersomnia;
  • psychomotor agitation or retardation;
  • fatigue or loss of energy;
  • feelings of worthlessness or excessive or inappropriate guilt (which may be delusional);
  • diminished ability to think or concentrate, or indecisiveness; or
  • recurrent thoughts or death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

The symptoms are not better accounted for by bereavement, or if the symptoms are associated with bereavement they have persisted for longer than two months.

Hierarchy rules have been applied to Recurrent Brief Depression. For the 'with hierarchy' version, a diagnosis can only be made if a person has never:
  • had a Depressive Episode and met criteria for Dysthymic Disorder; and
  • had a Manic Episode, Mixed Episode or Hypomanic Episode and met criteria for Cyclothymic Disorder.

As this survey did not collect information on Mixed Episode or Cyclothymic Disorder, Recurrent Brief Depression may include some people with these disorders.

Dysthymic Disorder

The disorder is characterised by a chronically depressed mood, that occurs for most of the day and on more days than not, for at least two years. There cannot have been a break of two months or more. Additionally, at least two of the following symptoms are present:
  • appetite disturbance;
  • sleep disturbance;
  • low energy;
  • low self-esteem;
  • poor concentration or difficulty making decisions; or
  • feelings of hopelessness.

The episode must be accompanied by significant clinical distress or impairment in social, occupational or other important areas of functioning.

Hierarchy rules have been applied to Dysthymia. For the 'with hierarchy' version, a diagnosis can only be made if the initial two-year period of symptoms is free of Major Depressive Episodes and the person has never had a Hypomanic or Manic episode.

Hypomanic Episode

An episode is characterised by an abnormally elevated, expansive or irritable mood lasting at least four days. Three or more of the following symptoms (four if the mood is only irritable) are present:
  • inflated self-esteem or grandiosity;
  • decreased need for sleep;
  • increased talkativeness;
  • flight of ideas or the feeling that thoughts are racing;
  • distractibility;
  • increase in goal-directed activity or psychomotor agitation; or
  • excessive involvement in pleasurable activities that have a high potential for painful consequences.

While the episode is associated with an unequivocal change in functioning, that is uncharacteristic of the person when not symptomatic, it is not severe enough to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalisation. There are no psychotic features.

Manic Episode

An episode is characterised by an abnormally elevated, expansive or irritable mood lasting at least seven days (or any duration if hospitalisation is required). Three or more of the following symptoms (four if the mood is only irritable) are present:
  • inflated self-esteem or grandiosity;
  • decreased need for sleep;
  • increased talkativeness;
  • flight of ideas or the feeling that thoughts are racing;
  • distractibility;
  • increase in goal-directed activity or psychomotor agitation; or
  • excessive involvement in pleasurable activities that have a high potential for painful consequences.

The episode causes marked impairment in:
  • occupational functioning;
  • usual social activities; or
  • relationships with others.

The episode may also necessitate hospitalisation to prevent harm to self or others. Psychotic features may be present.

Bipolar I and II Disorders

Bipolar I and Bipolar II Disorders are mutually exclusive.

Bipolar I Disorder

This disorder is characterised by the occurrence of one or more Manic Episodes. Often the person has also had one or more Major Depressive Episodes.

Bipolar II Disorder

This disorder is characterised by the presence of either:
  • Mania (excited episodes) and Major Depressive Episode; or
  • Hypomania (with episodes lasting 14 days or longer) and Major Depressive Episode with the person never having had a Manic Episode.


DSM-IV Substance Use disorders

The survey collected information on the abuse and dependence on alcohol and other substances. Detailed questions about alcohol use were only asked if the person had at least 12 standard alcoholic drinks in a 12-month period. A standard drink contains 12.5ml of alcohol. the serving size determines the number of standard drinks per serve. See 'Standard drink' earlier in this chapter.

Detailed questions about drug abuse and dependence were only asked if a person had:
  • misused prescription medication more than five times in their lifetime; or
  • used the same type of illicit drug (eg speed, ecstasy, marijuana) more than five times in their lifetime.

The misuse of prescription medication includes:
  • using medicine/s without the recommendation of a health professional;
  • overusing medicines; or
  • taking medicines for any other reason than as prescribed.

Drugs were categorised by four main types:
  • opioids (eg heroin, methadone);
  • cannabinoids (eg marijuana);
  • sedatives (eg serepax, valium); or
  • stimulants (eg amphetamines, speed).

Alcohol Abuse

A maladaptive pattern of alcohol use leading to clinically significant impairment or distress. It is evident that alcohol is responsible for or substantially contributes to physical or psychological harm, or dysfunctional behaviour. A diagnosis was achieved if one or more of the following problems occurred in the same 12-month period:
  • failure to fulfil major role obligations at school, work or at home;
  • recurrent alcohol use in situations which are physically hazardous;
  • recurrent alcohol-related legal problems; or
  • continued alcohol use despite social and interpersonal problems caused or exacerbated by the effects of alcohol.

Hierarchy rules have been applied to Alcohol Abuse. To meet criteria for the 'with hierarchy' version, a person cannot have met criteria for Alcohol Dependence.

Alcohol Dependence

A maladaptive pattern of behaviour in which the use of alcohol takes on a much higher priority for the person that other behaviours that once had greater value. The central characteristic is the strong, sometimes overpowering, desire to consume alcohol despite significant alcohol-related problems. A diagnosis was achieved if three or more of the following problems occurred in the same 12-month period:
  • tolerance, eg a need for markedly increased amounts of alcohol to achieve intoxication or desired effect;
  • withdrawal, eg characteristic withdrawal syndrome is manifested for alcohol;
  • using more alcohol or for longer periods than intended;
  • desire or unsuccessful efforts to cut down or control alcohol use;
  • a great deal of time obtaining, using or recovering from the effects of alcohol;
  • reduction in important activities because of alcohol use; or
  • continued use despite knowing it is causing significant physical or psychological problems that were likely caused or exacerbated by alcohol.

Drug Use Disorders

As outlined earlier, Substance Abuse and Dependence were only assessed where a person had:
  • misused prescription medication more than five times in their lifetime; or
  • used the same type of illicit drug (eg speed, ecstasy, marijuana) more than five times in their lifetime.

Substance Abuse

The survey collected information on:
  • Abuse-opioids;
  • Abuse-cannabinoids;
  • Abuse-sedatives; and
  • Abuse-stimulants.

Substance Abuse is a maladaptive pattern of drug use leading to clinically significant impairment or distress. It is evident that the use of opioids/cannabinoids/sedatives/stimulants were responsible for or substantially contributed to physical or psychological harm, or dysfunctional behaviour. A diagnosis was achieved if one or more of the following problems occurred in the same 12-month period:
  • failure to fulfil major role obligations at school, work or at home;
  • recurrent drug use in situations which are physically hazardous;
  • recurrent drug-related legal problems; or
  • continued drug use despite social and interpersonal problems caused or exacerbated by the effects of the drug.

Hierarchy rules have been applied to Substance Abuse. To meet criteria for the 'with hierarchy' version, a person cannot have met a diagnosis of Dependence on the same type of substance during the same time period.

Substance Dependence

The survey collected information on:
  • Dependence-opioids;
  • Dependence-cannabinoids;
  • Dependence-sedatives; and
  • Dependence-stimulants.

Substance Dependence is a maladaptive pattern of drug use in which the use of drugs takes on a much higher priority for the person than other behaviours that once had greater value. The central characteristic is the strong, sometimes overpowering, desire to take the substance despite significant substance-related problems. A diagnosis was achieved if three or more of the following occurred for the same substance in the same 12-month period:
  • tolerance, eg a need for markedly increased amounts of the drug to achieve intoxication or desired effect;
  • withdrawal, eg characteristic withdrawal syndrome is manifested for the drug;
  • using more of the drug or for longer periods than intended;
  • desire or unsuccessful efforts to cut down or control drug use;
  • a great deal of time obtaining, using or recovering from the effects of the drug;
  • reduction in important activities because of drug use; or
  • continued use despite knowing it is causing significant physical or psychological problems that were likely caused or exacerbated by the drug.


COMPARISON WITH THE 1997 SURVEY

A brief overview of the differences in the diagnostic assessment criteria used for the 1997 and 2007 surveys is provided in Chapter 4. The comparisons are segmented by the classification used for diagnosis (ICD-10 or DSM-IV), the major groups of mental disorders (Anxiety, Affective and Substance Use) and selected mental disorders. As the emphasis is on comparing differences between the two surveys, not all assessment criteria are mentioned for each disorder. A summary of the full diagnostic assessment criteria used for the 2007 survey is provided earlier in this chapter.


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