Adjustment disorder (incl. prolonged grief reaction)

Question 1

Define adjustment disorder.

Answer 1

A maladaptive* reaction to a psychosocial stressor. An unpleasant but mild affective symptoms follow a life event, but do not reach the severity needed to diagnose depression.

* it is maladaptive because it interferes with the affected person’s social or occupational functioning.

Question 2

Give some examples of situations which may cause adjustment disorder.

Answer 2

• Going to university
• Breaking up with a partner
• Moving house
• Losing a job

Question 3

What is the onset of adjustment disorder? What are the symptoms?

Answer 3

Onset is usually within one month of the stressor

Symptoms:

• fleeting anxiety
• low mood
• irritability
• sleeplessness

Question 4

Describe the severity of symptoms in adjustment disorder.

Answer 4

Person’s reaction is deemed greater than usually expected for the situation

But not severe enough to diagnose an anxiety or depressive disorder.

Question 5

How common is adjustment disorder? When does it occur and who is usually affected?

Answer 5

• any age of onset
• young single women are over represented
• medical/ surgical patients - 5 % of admissions
• psychiatric patients 10 % of sample population

Question 6

Compare and contrast adjustment disorder vs acute stress reaction.

Answer 6

Psychosocial stressors are not extreme as for acute stress reaction

Question 7

What is the management of adjustment disorder?

Answer 7

PRN: Support, reassurance, and problem-solving are often all that are needed. Expected to get better once stressor recedes.

Lecture:

Psychological

• Group therapy: may reinforce positive coping strategies Individual therapy: must be time limited to prevent dependence
• Crisis counselling: is of doubtful benefit except in those with no other support

Pharmacotherapy: Short courses of medications may be useful for brief symptom relief such as insomnia

Question 8

What is the prognosis of adjustment disorder?

Answer 8

Resolves within 6 months of end of the stressor

Question 9

What is grief?

Answer 9

A normal response to loss. Should not be diagnosed as depression.

Question 10

What are the normal stages of grief?

Answer 10

1. Denial: may include numbness and pseudohallucinations , auditory and visual. People may focus on objects that remind them of their loved one or prepare meals for them.
2. Anger: this is commonly directed against other family members and medical professionals
3. Bargaining
4. Depression
5. Acceptance

Many patients will not go through all 5 stages. This model is helpful to see if they are going through ‘normal’ grief reaction or developing a more significant problem.

Question 11

What are the signs of an abnormal grief reaction?

Answer 11

Occasionally, there is an abnormal grief reaction, where the grief is:

• Extremely intense (reaching the level for depression; disabling the person)
• Prolonged (>6 months) without relief or
• Delayed (no sign of an emotional response)

Question 12

What are the features of PGR (ICD-11)?

Answer 12

• Persistent and pervasive grief response
• Longing for the deceased/persistent preoccupation with the deceased
• Accompanied by intense emotional pain e.g.
  
  • sadness,
  • guilt,
  • anger,
  • denial,
  • blame,
  • difficulty accepting the death,
  • feeling one has lost a part of one’s self,
  • an inability to experience positive mood,
  • emotional numbness,
  • difficulty in engaging with social or other activities

Question 13

How does PGR fit in the context of social/cultural/religious norms of the individual?

Answer 13

Clearly exceeds expected social, cultural or religious norms for the individual’s culture and context + causes significant social/functional impairment

Question 14

How long does prolonged grief reaction need to occur for to be diagnosed? (ICD-11)

Answer 14

Persists >6 months

Question 15

A 63 year old woman is taken to see her GP after her daughter is worried that she has not recovered from the death of her husband a year ago. The woman constantly talks about missing her husband, blaming herself for his death from a heart attack as she did the cooking and thinks she gave him unhealthy food. She says she is “not feeling anything” anymore, describing a wave of numbness permanently covering her. She struggles to attend the drawing class she loved when her husband was still alive and when she goes, does not enjoy it. Which diagnosis best describes her symptoms?

Which diagnosis best describes her symptoms?

• A. Prolonged Grief Reaction
• B. Moderate Depression
• C. Acute Stress Disorder
• D. Adjustment Disorder
• E. Post Traumatic Stress Disorder

Answer 15

A. Prolonged Grief Reaction