1038
CMDT 2013
25 cc
Psychiatric Disorders Stuart J. Eisendrath, MD Jonathan E. Lichtmacher, MD
Common Psychiatric Disorders
Stress & Adjustment Disorders (Situational Disorders)
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E sse n t i a l s o f d i a g n o s i s
Anxiety or depression clearly secondary to an identifiable stress. `` Subsequent symptoms of anxiety or depression commonly elicited by similar stress of lesser magnitude. `` Alcohol and other drugs are commonly used in self-treatment. ``
``General Considerations Stress exists when the adaptive capacity of the individual is overwhelmed by events. The event may be an insignificant one objectively considered, and even favorable changes (eg, promotion and transfer) requiring adaptive behavior can produce stress. For each individual, stress is subjectively defined, and the response to stress is a function of each person’s personality and physiologic endowment. Opinion differs about what events are most apt to produce stress reactions. The causes of stress are different at different ages—eg, in young adulthood, the sources of stress are found in the marriage or parent-child relationship, the employment relationship, and the struggle to achieve financial stability; in the middle years, the focus shifts to changing spousal relationships, problems with aging parents, and problems associated with having young adult offspring who themselves are encountering stressful situations; in old age, the principal concerns are apt to be retirement, loss of physical capacity, major personal losses, and thoughts of death.
``Clinical Findings An individual may react to stress by becoming anxious or depressed, by developing a physical symptom, by running
away, having a drink, overeating, starting an affair, or in limitless other ways. Common subjective responses are fear (of repetition of the stress-inducing event), rage (at frustration), guilt (over aggressive impulses), and shame (over helplessness). Acute and reactivated stress may be manifested by restlessness, irritability, fatigue, increased startle reaction, and a feeling of tension. Inability to concentrate, sleep disturbances (insomnia, bad dreams), and somatic preoccupations often lead to self-medication, most commonly with alcohol or other central nervous system depressants. Maladaptive behavior in response to stress is called adjustment disorder, with the major symptom specified (eg, “adjustment disorder with depressed mood”).
``Differential Diagnosis Adjustment disorders must be distinguished from anxiety disorders, affective disorders, and personality disorders exacerbated by stress and from somatic disorders with psychic overlay. Adjustment disorders may have symptoms that overlap with other disorders, such as anxiety symptoms, but they occur in reaction to an identifiable life stressor such as a difficult work situation or romantic breakup. Adjustment disorders are diagnosed when the symptoms do not fit with a more specific diagnosis such as major depressive disorder which requires at least five criteria. Patients with adjustments disorders have marked distress after a stressor and significant impairment in social or occupational functioning. Adjustment disorders are regarded as acute if less than 6 months or chronic if longer.
``Treatment A. Behavioral Stress reduction techniques include immediate symptom reduction (eg, rebreathing in a bag for hyperventilation) or early recognition and removal from a stress source before full-blown symptoms appear. It is often helpful for the patient to keep a daily log of stress precipitators, responses, and alleviators. Relaxation, mindfulness-based stress reduction, and exercise techniques are also helpful in reducing the reaction to stressful events.