26 - Adjustment disorder

Adjustment disorder

© SPMM Course DSM-IV describes OCD as an anxiety disorder along with GAD and PTSD. A change has been made in DSM-V (see the accompanying box)

Reactions to severe stress Acute stress reaction Acute stress reaction (ICD) usually starts in an hour; resolution begins within 8 hours (if the stress is hit and run) or 48 hours if it is prolonged. The presence of physical exhaustion, organic factors or disease states increases the risk. The stressor is usually one that poses a serious threat to security, integrity and social position. The patient may initially be dazed with narrowed attention; disorientation is not uncommon as a result. Sometimes agitation and overactivity are seen. Partial or complete amnesia for the acute stress reaction is not unheard of. Dissociative symptoms seem to predominate in some. Having a history of previous psychiatric disorder does NOT negate a diagnosis of acute stress reaction. Acute stress disorder is a DSM concept similar to acute stress reaction. It is defined as starting while experiencing or after experiencing the distressing event, and lasting at least two days to at most four weeks. The emphasis is on dissociation, with onset specified to be within four weeks with symptoms lasting up to 4 weeks. In DSM-4, the diagnosis of acute stress disorder requires marked symptoms of anxiety and 3 from a list of 5 dissociative symptoms- depersonalization, derealisation, a sense of numbing or detachment, reduced awareness of the surrounding and dissociative amnesia. It also specifies that the response should involve intense fear, helplessness or horror. Debriefing is used widely for treatment but with little evidence that it is effective; in some cases it may even be counterproductive. Adjustment disorder Adjustment disorder is a diagnosis in both ICD-10 and DSM-IV. In DSM-IV, it is seen as a residual category for individuals with clinically significant distress without meeting criteria for a more discrete disorder such as depression or PTSD. It is a condition that refers to the psychological reactions arising in relation to adapting to new circumstances and occurs in someone who has been exposed to a psychosocial stressor like DSM-5 AND ADJUSTMENT DISORDER Reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event. No longer a residual category for other anxiety disorders DSM-5 AND ACUTE STRESS DISORDER The stressor criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. The need for subjective response with intense fear, helplessness, or horror is removed now.

© SPMM Course divorce, separation etc., which is not catastrophic in nature. The usual presentations include anxiety, depression, poor concentration, irritability, anger, etc. with physical symptoms caused by autonomic arousals such as tremor and palpitations. Individual vulnerability plays a greater role in adjustment disorder than any other neurotic disorder. In adjustment disorder, patients may feel vulnerable to become violent though they rarely are violent. Conduct problems may be a presentation of adjustment disorder in adolescence; regressive phenomenon may be seen in children. The onset is more gradual than that of acute stress reaction, and the course is more prolonged. Social functioning is usually impaired. Onset must be within one month in ICD-10 and three months according to DSM-IV. Duration of adjustment disorder cannot exceed six months except in the subtype of prolonged depressive reaction, which can last up to 2 years. Brief depressive reaction subtype can last only up to a month. Also, the DSM-IV  Criterion  A2  regarding  the  subjective  reaction  to  the  traumatic  event  (e.g.,  “the  person’s   response involved intense fear, helplessness, or horror”)  has  been  eliminated. Bereavement and grief reaction Patients who experienced bereavement within last three months cannot be diagnosed to have an adjustment disorder. Normal bereavement is not coded in ICD 10 Chapter V, but in Chapter XXI. Normal grief: The classical symptoms experienced after bereavement which would include disbelief, shock, numbness, and feelings of unreality; anger; feelings of guilt; sadness and tearfulness; pining or searching, preoccupation with the deceased; disturbed sleep and appetite and, occasionally, weight loss; seeing or hearing the voice of the deceased (hallucinations of widowhood) Usually these symptoms gradually reduce in intensity, with the acceptance of the loss and readjustment (see the table below for the normal phases). A typical grief reaction lasts up to 12 months with an average duration of 6 months.

© SPMM Course Irrespective of age, a third of those who lose a spouse meet criteria for major depression in the first month after the death, and half of these remain clinically depressed one year later. However, in normal grief reactions substantial improvement is expected within two months to 6 months, and those who continue to meet criteria for major depression after this period should receive antidepressant or psychotherapy. Abnormal grief: It is also called as morbid or pathological or complicated grief. It is a grief reaction that is very intense, prolonged, delayed (or absent), or where symptoms outside the normal range are seen: e.g. preoccupation with feelings of worthlessness, thoughts of self-harm or suicide, excessive guilt, marked slowing of thoughts and movements, a prolonged period of lack of ability to function, hallucinatory experiences (other than the image or voice of the deceased) In ICD-10, abnormal grief reactions are coded as adjustment disorders. Abnormal grief includes Inhibited grief: Absence of expected grief symptoms at any stage Delayed grief: Avoidance of painful symptoms within two weeks of loss Chronic grief: Continued significant grief-related symptoms six months after loss ( Working with grieving adults | BJPsych Advances, http://apt.rcpsych.org/content/10/3/164_br (accessed March 31, 2015). Likely causes of abnormal grief include sudden and unexpected death of the deceased; insecure survivor; dependent or ambivalent relationship with the deceased; presence of dependent children and so cannot show grief easily; presence of previous psychiatric disorder in the survivor. Phase I Shock and protest includes numbness, disbelief and acute dysphoria Phase II Preoccupation includes yearning, searching and anger Phase III Disorganisation includes despair and acceptance of loss Phase IV Resolution gradual return to normality