Alhefzi



Adjustment DisorderDEFINITIONIt is the development of emotional or behavioral symptoms in the context of one or more identified psychosocial stressors ; leading to impairment in social, occupational, or educational function, or the subjective experience of distress in excess of what would normally be expected for the given stressors. The stressors are ( loss of a loved one, change of employment or financial situation) DSM-IV-TR criteria of Adjustment disorderA. 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) functioningC. 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.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 if:Acute: if the disturbance lasts for less than 6 monthsChronic: if the disturbance lasts for 6 months or longerAdjustment disorders are coded based on the subtype, which is selected according to the predominant symptoms. The specific stressor(s) can be specified on Axis IVEPIDEMIOLGYThe prevalence of adjustment disorders in a clinical sample of the Western Psychiatric Institute clinical services was ten percent (10%). It is the second largest diagnostic category. The sex ratio male to female was2:1 In children and adolescents under 18 years old, it was 16 percent (16%). The sex ratio male to female was1:1 with still a slight excess of female cases.ETIOLOGYIt is presumed that without the occurrence of the stressor, the condition would not arise.1- Stressors were more likely to be chronic (>1 year) in adolescents than adults2- Precipitant for symptomatology among adolescents are School problems were the most frequent, a variety of family, boyfriend-girlfriend, and substance use problems were also common. In adults, marital problems, including separation and divorce, were the most common stressors. 3-The pre-existing mood symptomatology was the only factor that predicted a prolonged course of adjustment disorders 4-Factors that protect individuals from developing stress-related symptoms are:-Pre-existing adaptive skills -A warm and supportive relationship with the primary caregiver,- Easy and adaptable child temperament, -Healthier adjustment of the family to stress-Control over life events all predict a more positive response to stress.5- Monozygotes showing greater concordance than dizygotes for adjustment disorder.In summary, it is the interaction between the stress ,the personality and the environment that leads to the adjustment disorder.The symptomatic presentation of adjustment disorders : -Depressed mood is the most common. - Suicidal behaviour is high in adolescent- -Other vegetative symptoms(loss of appetite, decreased libido)- Social withdrawal - Insomnia-Behaviour disorders -Pessimism- Anhedonia -Irritability or anger-Fatigue -Lack of concentration -Low self-esteem - Increased motor activity- Impulsive behaviour - Substance use -Feelings of worthlessness-Hypervigilance - Hostility -Worry- Hopelessness -Tearfulness -Anticipating the worst SubtypesThe Six subtypes of adjustment disorders are : 1-Adjustment disorder with depressed mood (depression, hyposomnia, low self-esteem and suicidal indicators02-Adjustment disorder with anxious mood (generalized anxiety, increased motor activity and situational anxiety)3-Adjustment disorder with disturbance of conduct (impulsivity, lack of insight and violent behaviour)4-Adjustment disorder with mixed emotional features 5- Adjustment disorder with mixed disturbance of emotions and conduct (excessive alcohol ingestion, suspiciousness, hostility, defrauding behavior, and homicidal ideation.)6- Adjustment disorders unspecifiedAdjustment disorder subtypes did not differ from each other in the overall stressor severity or the highest level of functionning in the past year. However, the impairment in current function was greatest in the depressive and mixed emotions and conduct subtypes.DIFFERENTIAL DIAGNOSIS1-Uncomplicated bereavement: the dysfunction is within the expected range of reaction to loss.2-Major depression.3-Brief psychotic episode. 4-Generalized anxiety disorder(GAD)5-Somatoform disorder.6-Conduct disorder7-Academic, occupational,identity problems8-Post traumatic stress disorder(PTSD)9-Antisocial personality disorderThe combination of subsyndromal symptomatology and the presence of an identified psychosocial stressor distinguishes adjustment disorders from all other Axis I and Axis II disorders COURSE AND PROGNOSIS Adjustment disorder has a favourable outcome with treatment. Adolescents were more likely than adults to have severe diagnoses Adolescents developed later adult major mental disorders such as schizophrenia, bipolar I disorder, major depressive disorder, antisocial personality disorder, and drug abuse.TREATMENT Psychotherapy is the treatment of choice, it is Short-term treatment either in group or individual. Individual psychotherapy offers the patient an opportunity to better understand the meaning of the stressor and why it resulted in an impaired ability to function. . Group therapies may be particularly useful for individuals who have experienced similar stresses . General measures are: 1-Careful assessment of the nature and severity of the disturbance2- Considering the presence of risk factors that are known to be associated with poor outcome(continuation of stressors, poor premorbid functioning.)3- Minimize the impact of these stressors on day-to-day function. 4- Understand the meaning of the stressor to the patient and its association with the psychiatric symptoms at this time. 5-Assessing the patient's level of vulnerability and capacity for adaptation 6-Understand and facilitate those factors that may mitigate the pathological response to stress(helping to develop a warm and supportive relationship with family members and helping the patient increase the breadth of social support.)7- Attempting to minimize factors that maintain symptoms represents another important strategy.( include working with parents of a child with adjustment disorder to help them better cope with the stressful events in their family because positive parental adjustment minimizes the likelihood of pathological adjustment in children.8-Do not rescue those with legal problems to avoid reinforcing the socially unacceptable behaviour.2-Pharmacotherapy: The serotonin reuptake inhibitors. ................
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