Adjustment Disorders and Somatisation

Question 1

What is adjustment disorder?

Answer 1

A diagnosis of exclusion

Onset of symptoms usually within 1 month of traumatic / difficult event and usually length of symptoms is <6 months

Question 2

What events may trigger adjustment disorder?

Answer 2

Bereavement
Changing schools / jobs
Moving area

Condition would not have occurred without the precipitating event but someone’s personality and resilience to stress can increase their risk of adjustment disorder (ie would something else have happened at another time that would also have set it off?)

Question 3

How is adjustment disorder different from PTSD?

Answer 3

PTSD has acute anxiety and panic symptoms as well as hyper-vigilance and hyer-reactivity, as well as flashbacks

Adjustment disorder = more subtle

• Mild symptoms of depression and anxiety
• The feeling of inability to cope

In more extreme cases, may develop conduct disorder - reckless driving, aggressive behaviour and truancy are examples

Question 4

What differentials should be excluded before diagnosing adjustment disorder?

Answer 4

PTSD
Depression
Anxiety

(note normal grief reaction can last up to 6 months after someone has died)

Question 5

What is the management of adjustment disorder?

Answer 5

Reassurance that the reaction is temporary

CBT

Question 6

What two variables should be considered when determining if someone’s response to an event is an appropriate psychological response or when it becomes a mental health problem?

Answer 6

The nature and severity of event

The nature and severity of the patient’s reaction to the life event

Question 7

List four categories of ways in which people may respond to stress

Answer 7

1) Adjustment reaction
2) Acute stress reaction or PTSD
3) Dissociative disorder
4) Another major mental illness eg depressive illness, anxiety or psychotic disorder

Question 8

Differentiate between an acute stress reaction and PTSD

Answer 8

Stressor must be traumatic = a stressor that occurs outside of the range of normal human experience and would be experienced as traumatic by any normal person

Acute stress reaction - occur immediately after of within a few minutes of stressor:

• Combat fatigue
• Dazed
• Narrowing of attention
• Inability to process external stimuli and disorientation
• Amnesia for the episode

Usually resolves in a few hours

PTSD occur within 6 months

Question 9

What is dissociative disorder?

Answer 9

Disruption in naturally occurring functions of consciousness, memory, identity, perception and movement

Awareness and control of behaviour becomes separate from the individuals personality

Not open to voluntary control

ICD-10 requires there to be evidence of psychological causation (stressor)

Question 10

What are people with dissociative disorder often rediagnosed as having?

Answer 10

Epilepsy
Depression
Schizophrenia

Question 11

What types of dissociation are commonly associated with severe prolonged depression and anxiety?

Answer 11

Depersonalisation - person feels like their body is in some way strange or unreal

Derealisation - external reality seems strange of unreal

Question 12

What are the seven stages of grief?

Answer 12

1) Shock
2) Denial
3) Anger
4) Bargaining
5) Depression
6) Testing - seeking realistic solutions
7) Acceptance

Question 13

Over what time period is experiencing symptoms considered an adjustment disorder?

Answer 13

> 6 months = form of adjustment disorder

Question 14

List some reactions people may experience that are not characteristic of a normal bereavement reaction

Answer 14

Guilt about other things other than the action taken or not taken by the pt at the time of their loved ones death

Thoughts of death that extend beyond thinking that they would be better off dead or would have rather been the one that died instead of their loved one

Morbid preoccupation with worthlessness

Marked psychomotor retardation

Prolonged and marked functional impairment

Hallucinatory experiences other than the pt thinking they are occasionally seeing or hearing the deceased loved one

Question 15

What are somatisation disorders?

Answer 15

Psychological disorders that exhibit physical symptoms or take the form of physical disorders

No discernable physical or organic reason for these symptoms, leading to the presumption that they are caused by a psychological disorder

Do not happen voluntarily and are completely beyond the individuals control

Question 16

What are the two most common forms of somatisation?

Answer 16

1) Somatisation disorder (Briquet’s syndrome) = specific symptoms they complain of
- S for somatisation and S for symptoms

2) Hypochondrial disorder = people are convinced of having a specific disease
- Pt misinterpret normal bodily sensations and think that it means they have a serious medical disease
- Eg they think they have HIV or cancer

Question 17

What are the most common symptoms complained of in somatisation?

Answer 17

GI - n&v, diarrhoea, food intolerance, belching, regurgitation, abdo pain, constipation

Skin - itching, burning, numbness

Sexual - loss of libido, ejaculatory or erectile dysfunction, irregular menses, dysmenorrhoea

Urinary - dysuria, freq, urinary retention

Neuro - paralysis, sensory loss, hearing of vision loss, diplopia, seizures, difficulty swallowing, impaired coordination

NB pt must have numerous symptoms from more than one of these groups (not just one symptom in isolation)

Question 18

What are pt with somatisation disorders highly at risk of?

Answer 18

Iatrogenic complications

Eg multiple abdo adhesions from having multiple explorative laparoscopies

Question 19

What is the ICD-10 for somatisation disorder?

Answer 19

1) At least 2 years of symptoms with no organic explanation found
2) Persistent refusal by the pt to accept reassurance from several doctors that there is no physical cause
3) Some degree of functional impairment due to the symptoms and resulting behaviour

Question 20

How can a pt behaviour help to distinguish between somatisation and hypochondriacal disorder?

Answer 20

Often in somatisation disorder, pt ask for TREATMENT for their symptoms

In hypochondriacal disorder the pt becomes fixated on the diagnosis and so they will often be demanding INVESTIGATIONS to confirm this diagnosis

Question 21

What is body dysmorphic syndrome?

Answer 21

A specific type of hypochondriacal disorder where people become concerned / preoccupied with a specific defect or deformity eg a crooked nose or ugly hands

Question 22

What is conversion disorder?

Answer 22

A perceived loss of motor or sensory function

• Psychological pain is concerted into the somatic or phyiscal form
• Often neurological symptoms eg paralysis, blindness, sensory loss, peripheral visual loss ‘looking down tube’

Question 23

How is a conversion disorder different from a factitious disorder?

Answer 23

In factitious disorder the pt purposefully feigns symptoms

In conversion disorder the motor and sensory loss are involuntarily experienced