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ESSENTIALS OF DIAGNOSIS

  • Anxiety or depression in reaction to an identifiable stress, though out of proportion to the severity of the stressor.

  • Symptoms are not at the severity of a major depressive episode or with the chronicity of generalized anxiety disorder (GAD).

GENERAL CONSIDERATIONS

An individual experiences stress when adaptive capacity is overwhelmed by events. The event may be an insignificant one when objectively considered, and even favorable changes (eg, promotion and transfer) requiring adaptive behavior can produce stress. For everyone, 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 and mental 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, drinking alcohol, overeating, starting an affair, or in limitless other ways. Common subjective responses are anxiety, sadness, fear, rage, guilt, and shame. 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 sometimes lead to self-medication, most commonly with alcohol or other central nervous system depressants. Emotional and behavioral distressing symptomatology in response to stress is called adjustment disorder, with the major symptom specified (eg, “adjustment disorder with depressed mood”). Even with an identifiable stressor, if the patient meets syndromal criteria for another disorder such as major depression, then the convention would be to diagnose a major depression and not an adjustment disorder with depressed mood.

DIFFERENTIAL DIAGNOSIS

Adjustment disorders are distinguished from anxiety disorders, mood disorders, bereavement, other stress disorders such as posttraumatic stress disorder (PTSD), and personality disorders exacerbated by stress and from somatic disorders with psychic overlay. Unlike many other psychiatric disorders, such as bipolar disorder or schizophrenia, adjustment disorders are wholly situational and usually resolve when the stressor resolves or the individual effectively adapts to the situation. 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. An adjustment disorder that persists and worsens can potentially evolve into another psychiatric disorder such as major depression or GAD. However, that is not the case for ...

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