Transcript ADJUSTMENT DISORDER

Joy P. Malinit, MD, DPBP, FPPA
TERMINAL OBJECTIVE
Upon completion of this
period of instruction,
the student will render
an accurate DSM-IV TR diagnosis
when presented with
symptoms characteristic of
an ADJUSTMENT DISORDER
ENABLING OBJECTIVES
• State the DSM-IV TR criteria for an
adjustment disorder & symptom subtypes
• Know the etiologic factors linked to
adjustment disorders
• Give differential diagnosis for adjustment
disorders
• Learn clinical management of adjustment
disorders
ADJUSTMENT DISORDER
Introduced in DSM-III (1980) to
describe conditions in which a
person develops psychological
symptoms in response to
stressful events
Categorized in
DSM I : transient situational personality disorders
DSM II: transient situational disturbances
ADJUSTMENT DISORDER
• Categories used to diagnose disorders in
persons who adjusted poorly
• To difficult situations
• To newly experienced environmental factors in the
absence of serious underlying personality defects
• In DSM-IV TR
• Maladaptive reaction within 3 months of the stressor
• Cannot persist for more than 6 months after termination of
the stressor or its consequences
Diagnostic Criteria for
Adjustment Disorder
A. The development of emotional or behavioral symptoms in
response to an identifiable stressor (s) occurring within 3
months of the onset of the stressor (s).
B. These symptoms or behaviors are clinically significant as
evidenced by either of the following:
1. Marked distress that is in excess of what would be expected
from exposure to the stressor
2. Significant impairment in social or occupational (academic)
functioning
C. The stress-related disturbance does not meet the criteria for
another specific axis I disorder and is not merely an
exacerbation of a preexisting axis I or axis II disorder.
Diagnostic Criteria for
Adjustment Disorder
D. The symptoms do not represent bereavement.
E. Once the stressor (or its consequences) has terminated, the
symptoms do not persist for more than an additional 6
months.
Specify:
Acute: If the disturbance lasts less than 6 months
Chronic: If the disturbance lasts for 6 months or longer
KEY POINTS
• stress-related
• disproportionately overwhelmed or overly intense in their
responses to given stimuli
• non-psychotic disturbance
• short-term
• time-limited: beginning within 3 months of the stressful
event & symptoms lessen within 6 months upon removal
of the stressor or when new adaptation occurs
ADJUSTMENT DISORDER
With
depressed mood
With
disturbance of conduct
With anxiety
With mixed disturbance
of emotions & conduct
With mixed anxiety &
depressed mood
Unspecified
5 SUBTYPES: diagnosis depends on predominant
symptoms that develop in response to stressor
SUBTYPES & SPECIFIERS
With depressed mood:
predominant symptoms are depressed mood, tearfulness,
& feelings of hopelessness
With anxiety:
Palpitations, nervousness, worry, jitteriness, agitation
- in children: fears of separation from major attachment figures
With mixed anxiety and depressed mood:
combination of anxiety and depression.
With disturbance of conduct:
violation of rights of others or major age-appropriate
societal norms (truancy, vandalism, reckless driving, fighting)
SUBTYPES & SPECIFIERS
With mixed disturbance of emotions and conduct:
predominant manifestations are both emotional symptoms
(e.g., depression, anxiety) & disturbed conduct
Unspecified:
Atypical maladaptive reactions (inappropriate responses
to diagnosis
of physical illness-massive denial & severe noncompliance, physical complaints,
social withdrawal or academic inhibition) to stressors not classifiable
as one of the other subtypes
EPIDEMIOLOGY
Prevalence in general population:
2%- 8%
Frequency in hospital & psychiatric clinics:
5%-10%
Commonly diagnosed on consultation-liaison
services at general hospitals:
50%
•
•
•
Cardiac surgery patients: 51%
Newly hospitalized cancer patients: 32%
Adolescents with diabetes mellitus: 36%
EPIDEMIOLOGY
More common in women,
unmarried persons &
young persons
Behavioral symptoms:
• Among adolescents: acting out
• Adults: mood or anxiety
symptoms
May occur at any age
• average is mid-20s
ADJUSTMENT DISORDER
essor
Maladaptive
Not an expected healthy response
Reaction
ETIOLOGY
 stress is thought to be the common antecedent
 caused by a disruption of the process of
adaptation
 symptoms result from disruption of normal
functioning caused by stress
 acute & chronic stress differ in physiologic &
psychological terms
 meaning of stress is influenced by ecologic modifiers
systems, resilience)
(e.g, support
ETIOLOGY: STRESSORS
• a single event
(termination of a romantic relationship)
• multiple stressors (marked business difficulties & marital problems)
• recurrent (periodic examinations or associated with seasonal business
crises)
• continuous (living in a crime-ridden neighborhood, living in poverty)
• sudden or shocking stressors that are not anticipated
NATURE OF STRESSORS
• Stressors may affect a single
individual (failure in an important
examination), an entire family, or a
larger group or community (as in a
natural disaster)
• Some stressors may accompany
specific developmental events
(going to school, leaving the parental
home, getting married, becoming a
parent, failing to attain occupational
goals retirement)
3 FACTORS TO UNDERSTAND ….
• Nature of the stressor
• Conscious & unconscious
meanings of the stressor
• Pre-existing constitutional
& psychological
vulnerability
REMEMBER…
Most people are resilient &
do not develop
psychiatric symptoms in
response to stressful
situations
Suggest underlying
vulnerability
PSYCHODYNAMIC EXPLANATIONS
THINK OF A BONE …
 if enough pressure is applied,
it fracture
Amount of pressure applied differ from person to person
Depend on age, gender, physical well-being
Healthy bone will break if subjected to sufficient stress
Osteoporotic bone will “break” more rapidly
ETIOLOGY: INTRAPERSONAL CONTEXT
• Age, gender, culture influence the nature &
meaning of stressors to the individual
•Intelligence, flexibility & range of coping skills,
defense mechanisms affect adaptive capacity
•Previous trauma, unresolved conflicts or
developmental issues may also act as vulnerability
factors
ETIOLOGY: INTRAPERSONAL CONTEXT
•Level of situational adversity actually has a low
correlation with the severity of response to
stress
•Some seem sensitive to even minor stressors,
while others remain resilient even to extreme
trauma
•Personality is a major determinant
•highly anxious temperament may make one
more prone to over react to a stressful event
PSYCHODYNAMIC EXPLANATIONS
Unpleasant childhood
experiences could lead to
fixation at certain stages of
development  triggers
regression when sufficient
stress is applied
Each person has “breaking
point”
– Depends on amount of
stress applied, underlying
constitution, personality
structure & temperament
PRECIPITANTS OF ADJUSTMENT DISORDER
Adolescent
%
Adults
%
School problems
60
Marital problems
25
Parental rejection
27
Separation/divorce
23
Alcohol /Drug problem
26
Move
17
Parental separation
25
Financial problems
14
Girlfriend/boyfriend problems
20
School problems
14
Marital problems in parents
18
Work problems
9
Move
16
Alcohol/Drug problem
8
Legal problems
12
Illness
6
Work problems
8
Legal problems
6
Other
60
Other
81
Common Stressors for Children
 New school year / new school
 Disrupted / changed family situation
 Peer rejection / disliked / loss
 Parental illness
 Death of a parent / grandparent
 Moving to a new community
Associated Features & Disorders




Decreased performance at school
Temporary changes in social relationships
Suicide attempts & suicide
Excessive substance use




Somatic complaints
Individuals with pre-existing mental disorders
General medical / surgical patients
Complicate the course of illness (decreased compliance with
medical regimen, increased length of hospital stay)
ECOSYSTEMIC MODEL
 Individual, family & community change is
inevitable and continuous
 Protective factors can be introduced through any
relationship in any part of the ecosystem
 Ability to connect with & rely on adults outside the family
 School, church & community programs to connect youth
with caring adults
ECOSYSTEMIC MODEL
 Improve school climate
 Improve parent involvement
 Increase positive peer support
 Provide education & support prior to the onset of
symptoms
 Family counseling
 Effective communication & education
 Improving coping strategies
PETER
• 19-year-old college freshman brought by
mother for evaluation
• since coming home from vacation, demeanor
has been subdued, a marked departure from
his usual personality
• observed to be absent-minded & withdrawn
from the usual family after-dinner activities,
leaving abruptly with his dinner untouched
• mother feared that he might have become
involved in the college drug culture &
confronted him
PETER
• stormed out of the house, tearful &
somewhat agitated but returned &
apologized to his mother & retired to his
room
• father asked to speak with him & learned of
his recent break-up with his high-school
sweetheart & that college life has been
extremely challenging for a “probinsyano”
lad studying in Manila
• denied any use of substances and agreed
to see some one to "talk things through"
PETER
• had become depressed for the first week
after the break-up, with poor appetite & loss of
interest in his usual activities, mostly the ones
they both enjoyed
• concentration had been poor lately but was
improving
• slept poorly the first couple of days but had
started sleeping better
• denied any thoughts of suicide or of harming
his girlfriend but did feel hopeless the first
couple of days initially
PETER
• aware his behavior had been strange, but
he felt he had to deal with the break-up as a
man without involving the family
• had lost some weight, he attributed it
mostly to the stress of his college work &
being in a new environment getting used to
"eating fast food” instead of home cooked
meals
PETER
• denied use of alcohol or substances,
though he had been exposed to and
offered many times by his college pals.
• had insight into his problems & was willing
to work with the physician to address his
issues
PAUL
• considered by friends and colleagues to be at
the prime of his life at 35
• owner of a successful business, owned several
properties & was able to balance this with a
happy, close-knit family life
• sudden diagnosis of renal failure due to years of
undetected hypertension came as a big blow to
him
PAUL
• when initially he was told that he needed to go
on long-term renal dialysis, he still remained
quite positive & expressed a desire to
“remain strong”
• Had to stop work for two months as a result of
his hospitalization & recuperation
• When he returned to his business, he found that
he had lost a number of his major clients.
• Felt hampered by his lack of stamina & inability
to put in long hours as before
PAUL
• had to sell his property to raise money to pay
for medical bills
• began to feel despondent & low in mood for
the subsequent 2 months
• anxious whenever he thought of his illness &
financial troubles
– continued to run the business but was no longer
as efficient as before
– irritable & became angered easily
PAUL
• sleep & appetite were normal, although his
libido was diminished
– still enjoyed outings with the family on
weekends
• referred by nephrologist because, of late, his
blood pressure has been increasingly more
difficult to control due to non-compliance with
medication
• occasionally also neglected dietary advice or
fluid restrictions
PAUL has…
Adjustment disorder with depressed mood.
• Intervention directed firstly to improving his
compliance with anti-hypertensive medication &
other medical advice.
• Opportunity given for him to express his feelings of
anger & helplessness resulting from his illness.
• Educated him about his illness & treatment
enhanced his sense of control & responsibility.
• Group therapy with other renal dialysis patients
helpful in providing support for him & his wife.
PAUL
• Over the next few weeks, he began to gain better
acceptance & control over his illness and his mood
improved considerably.
• Although his stamina was poor and tired easily due
to the renal disease, he was still able to enjoy his
hobbies and spend time with his family.
• He continued to be active in a support group for
renal patients and became a source of
encouragement for other patients facing the
prospect of life-long dialysis.
DIAGNOSIS &
DIFFERENTIAL DIAGNOSIS
 In making diagnosis, crucial question is
“what is patient having trouble adjusting to?”
 Without a stressor to cause maladjustment,
no adjustment disorder is present.
 Even when stressor exists, other MAJOR
mental disorders must be ruled out as
causing symptoms.
 Other axis I disorders take precedence
 Stressor cannot represent bereavement
NO!!! NO!!! NO!!!
AXIS I: Adjustment Disorder
AXIS II: Personality Disorder
“Because Personality Disorders are
frequently exacerbated by stress, the
additional diagnosis of Adjustment
Disorder is usually NOT made”
DSM-IV p 625
DIFFERENTIAL DIAGNOSIS
 Major depressive episode
in response to a specific stressor
 Personality disorders
frequently exacerbated by stress
 Acute & Posttraumatic Stress Disorder
require the presence of an extreme stressor & a specific
constellation of symptoms
DIFFERENTIAL DIAGNOSIS
 Psychological Factors Affecting Medical
conditions—
for Adjustment Disorder the psychological symptoms
develop in response to the medical condition & do not
precede it
 Bereavement
 Non-pathological reactions to stress
 Symptoms due to the direct physiological effects
of a General Medical Condition
NOTE ! NOTE ! NOTE !
Psychological Factors
Affecting Medical Condition, specific
 In
psychological symptoms, behaviors or other factors
exacerbate a general medical condition, complicate
treatment for a general medical condition or otherwise
increase the risk of developing a general medical
condition.
 In Adjustment Disorder, the relationship is the
reverse (the psychological symptoms develop in response to the
stress of having or being diagnosed with a general medical
condition).
 Both conditions may be present in some individuals.
COURSE & OUTCOME
Generally transient, lasting days or weeks
Some chronic (woman with alcoholic husband)
Can persist no longer than 6 months after
termination of stressor or its consequences
When disturbance lasts longer, condition may
meet criteria for another disorder
COURSE & OUTCOME
With appropriate treatment, favorable
outcome in adults
In adolescents, more varied outcomes
May later have mood disorders or
substance-related disorders
Adolescents require longer time to
recover than adults
Treatment
Stressor
Adjustment Disorder
Eliminated
Reduced
Accommodated
Maladaptive
Response
(psychological reaction)
CLINICAL MANAGEMENT
Psychotherapy
• Most widely used intervention
• Remains treatment of choice
Individual
Group
- provide supportive atmosphere for persons who have
experienced similar stressor
GOALS OF PSYCHOTHERAPY
 Identify & analyze the
stressors & determine
whether they can be
eliminated or minimized.
 Clarify & interpret the
meaning of the stressor for
the patient.
 Reframe the meaning of the
stressor.
GOALS OF PSYCHOTHERAPY
 Illuminate the concerns &
conflicts the patient
experiences
 Manage themselves &
stressor
 Maximize the patient's coping
skills
 establish relationships
 attend support groups
PSYCHOTHERAPY
• Brief, goal-directed, supportive
• Therapy could hasten recovery
• 50% of patients treated resolve in 1 month
• Be aware of problems of secondary gain
• Medication for target symptom
Crisis Intervention & Case Management
• Short-term treatments aimed to resolve
situations quickly
• Uses supportive techniques, suggestion,
environmental modification & even
hospitalization
• Frequency & length of visits for
crisis support vary according to
patients’ needs
CLINICAL MANAGEMENT
Medications
• May be beneficial & prescribed based on
patient’s predominant & specific
symptoms for a brief time
• Example:
– Depressed mood with initial insomnia: hypnotic
for few days
– Anxiety: brief course of benzodiazepine
– Signs of decompensation or impending
psychosis: antipsychotic
– Traumatic grief: SSRIs
REFERENCES
TEXTBOOK OF PSYCHIATRY, Nancy Andreasen
Study Guide to DSM-IV by Fauman
KAPLAN & SADOCK’s Synopsis of Psychiatry,
10th edition
A STRESS -FREE ,
GOOD DAY TO ALL..