Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 25-03: Psychiatric Adjustment Disorders + Key Features Download Section PDF Listen +++ +++ 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 a generalized anxiety disorder +++ General Considerations ++ Stress exists when the adaptive capacity of the individual is overwhelmed by events The event may be an insignificant one when objectively considered 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 The causes or sources of stress are different at different ages Young adulthood Marriage or parent-child relationship Employment relationship Struggle to achieve financial stability Middle years Changing spousal relationships Problems with aging parents Problems associated with having young adult offspring who themselves are encountering stressful situations Old age Retirement Loss of physical and mental capacity Major personal losses Thoughts of death Distressing emotional and behavioral symptoms in response to stress is called adjustment disorder, with the major symptom specified (eg, "adjustment disorder with depressed mood") + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Common subjective responses Anxiety Sadness Fear Rage Guilt Shame Acute and reactivated stress manifestations Restlessness Irritability Fatigue Increased startle reaction 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 CNS depressants +++ Differential Diagnosis ++ Anxiety disorders Mood disorders Bereavement Other stress disorders, such as posttraumatic stress disorder Personality disorders exacerbated by stress Somatic disorders with psychic overlay + Diagnosis Download Section PDF Listen +++ +++ Diagnostic Procedures ++ Obtain history Identify precipitating sources of stress + Treatment Download Section PDF Listen +++ +++ Medications ++ Judicious use of sedatives (Table 25–1) (eg, lorazepam, 0.5–1 mg two or three times daily orally) for a limited time and as part of an overall treatment plan can provide relief Short-term use of selective serotonin reuptake inhibitors targeting dysphoria and anxiety may be useful ++Table Graphic Jump LocationTable 25–1.Commonly used antianxiety and hypnotic agents (listed in alphabetical order within classes).View Table||Download (.pdf) Table 25–1. Commonly used antianxiety and hypnotic agents (listed in alphabetical order within classes). Medication Usual Daily Oral Doses Usual Daily Maximum Doses Cost for 30 Days of Treatment Based on Maximum Dosage1 Benzodiazepines (used for anxiety) Alprazolam (Xanax)2 0.5 mg 4 mg $101.40 Chlordiazepoxide (Librium)3 10–20 mg 100 mg $42.00 Clonazepam (Klonopin)3 1–2 mg 10 mg $152.25 Clorazepate (Tranxene)3 15–30 mg 60 mg $560.40 Diazepam (Valium)3 5–15 mg 30 mg $22.50 Lorazepam (Ativan)2 2–4 mg 4 mg $5.46 Oxazepam (Serax)2 10–30 mg 60 mg $126.00 Benzodiazepines (used for sleep) Estazolam (Prosom)2 1 mg 2 mg $29.70 Flurazepam (Dalmane)3 15 mg 30 mg $26.40 Midazolam (Versed)4 5 mg $1.24/dose Quazepam (Doral)3 7.5 mg 15 mg $738.00 Temazepam (Restoril)2 15 mg 30 mg $24.30 Triazolam (Halcion)5 0.125 mg 0.25 mg $110.00 Miscellaneous (used for anxiety) Buspirone (Buspar)2 10–30 mg 60 mg $217.80 Phenobarbital3 15–30 mg 90 mg $33.90 Miscellaneous (used for sleep) Eszopiclone (Lunesta)5 2–3 mg 3 mg $350.10 Hydroxyzine (Vistaril)2 50 mg 100 mg $24.60 Ramelteon (Rozerem) 8 mg 8 mg $419.70 Suvorexant (Belsomra) 5–10 mg 20 mg $438.90 Zaleplon (Sonata)6 5–10 mg 10 mg $112.50 Zolpidem (Ambien)5 5–10 mg 10 mg $137.10 1Average wholesale price (AWP, for AB-rated generic when available) for quantity listed. Source: IBM Micromedex Red Book (electronic version) IBM Watson Health, Greenwood, CO, USA. Available at https://www.micromedexsolutions.com (cited April 8, 2020). AWP may not accurately represent the actual pharmacy cost because wide contractual variations exist among institutions.2Intermediate physical half-life (10–20 hours).3Long physical half-life (> 20 hours).4Intravenously for procedures.5Short physical half-life (1–6 hours).6Short physical half-life (about 1 hour). +++ Therapeutic Procedures ++ Behavioral interventions 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 improving the reaction to stressful events Social therapeutic procedures While it is not easy for the patient to make necessary changes (or they would have been made long ago), it is important for the clinician to establish the framework of the problem, since the patient's denial system may obscure the issues Clarifying the problem allows the patient to begin viewing it within the proper frame and facilitates the sometimes difficult decisions the patient eventually must make (eg, change of job) Psychotherapy Prolonged in-depth psychotherapy is seldom necessary in cases of isolated stress response or adjustment disorder Supportive psychotherapy with an emphasis on strengthening existing coping mechanisms is a helpful approach + Outcome Download Section PDF Listen +++ +++ Prognosis ++ A return to satisfactory function after a short period is part of the clinical picture of this syndrome Resolution may be delayed if others' responses to the patient's difficulties are thoughtlessly harmful or if the secondary gains outweigh the advantages of recovery The longer the symptoms persist, the worse the prognosis There is also evidence that stress-related disorders are associated with increased risk of autoimmune disease, although this mechanism has yet to be elucidated + Reference Download Section PDF Listen +++ + +Song H et al. Association of stress-related disorders with subsequent autoimmune disease. JAMA. 2018 Jun 19;319(23):2388–400. [PubMed: 29922828]