In
an adjustment disorder, a psychological response occurs to an
identifiable stressor or life event. This response includes significant
emotional or behavioral symptoms that are usually manifested as
decreased performance at work and temporary changes in social
relationships. The life stressor may be a single event such as
termination of a relationship; a recurrent situation, such as seasonal
business crises; a continuous stressor, such as living in a crime-ridden
neighborhood; a prolonged circumstance, such as a chronic, debilitating
medical condition; or multiple events, such as business difficulties
plus marital problems. In adjustment disorder with anxiety, the
predominant symptoms include nervousness, worry, or jitteriness. The
disorder does not meet the criteria for another psychiatric disorder
such as major depression.Risk: As many as 50% of individuals who experience a specific stressor, such as cardiac surgery, will experience an adjustment disorder.
Incidence and Prevalence: Adjustment
disorders are fairly common, depending upon the population studied.
They occur in up to 12% of general hospital patients who are referred
for a mental health consultation and in 10% to 30% of those in mental
health outpatient settings.
History: Diagnosis is based on criteria listed in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition, Text Revision). The symptoms should occur within 3 months of
the recognizable stressful condition and not persist longer than 6
months after resolution of the stressful event or its consequences,
unless the symptoms are in response to a chronic stressor. The symptoms
or behaviors are identified as either a marked distress that is in
excess of what would be expected, or a significant impairment in social
or occupational functioning. The stress-related disturbance cannot be
diagnosed as another specific psychiatric disorder or be merely an
exacerbation of a pre-existing psychiatric disorder, and the symptoms
cannot be related to bereavement. However, adjustment disorder may be
diagnosed in the presence of another psychiatric disorder if the latter
does not account for the pattern of symptoms that have occurred in
response to the stressor.
Physical exam: The physical exam is important in ruling out anxiety caused by the physiological effects of a medical condition such as hypothyroidism or chronic obstructive pulmonary disease.
Observation of the individual's orientation, dress, mannerisms,
behavior, and content of speech provide essential signs to help diagnose
adjustment disorder with anxiety. For example, there may be poor
attention to grooming, or verbalizations inconsistent with emotional
state (affect), such as saying "I feel fine" while clenching the jaw and
frowning. Physical manifestations of anxiety may include sweaty palms,
rapid pulse, pale or flushed skin, frequent sighing, and restless
behavior such as pacing or fidgeting.
Tests: Psychological
testing, such as the Minnesota Multiphasic Personality Inventory - 2
(MMPI-2) or the State-Trait Anxiety Inventory, can be a useful adjunct
to diagnosing Adjustment Disorders. It is better to utilize objective
psychological tests, such as the MMPI - 2 or the Millon Clinical
Multi-axial Inventory-III (MCMI-III), instead of subjective inventories,
such as the State-Trait Anxiety Inventory. Inventories and other
subjective tests may allow outcomes of the testing to be easily
influenced by the test taker, resulting in exaggeration of psychological
distress.
| Psychotherapy
is the treatment of choice for adjustment disorders. Ending the
stressful situation or removing the individual from the stressful
situation is desirable. Group therapy has been effective, especially when individuals in the group have experienced similar stressors. Short-term, problem-focused, individual psychotherapy
may be helpful to explore the meaning of the stressful situation to the
individual so that the reactive anxiety may be resolved. Brief
psychotherapy, when utilized in a crisis intervention, can help resolve
the situation quickly through supportive techniques, suggestion,
reassurance, environmental modification, and even hospitalization, if
necessary. Cognitive behavioral therapy
has a strong empirical base and helps correct disordered thinking and
maladaptive behavior. Pharmacotherapy utilizes antidepressants,
anti-anxiety agents, and anxiety-relieving antidepressants to reduce
symptoms of anxiety. These should be used judiciously and for brief
periods. | | | |
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| ACOEM's
Practice Guidelines, the gold standard in effective medical treatment
of occupational injuries and illnesses, are provided in this section to
complement the disability duration guidelines.* |
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| Stress-related Conditions |
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| *
The relationship between the MDGuidelines (MDA) content and ACOEM's
guidelines is approximate and does not always link identical diagnoses.
The user should consult the diagnostic codes in both guidelines, as well
as the clinical descriptions, before assuming an equivalence. |
Source: ACOEM Practice Guidelines
| The
overall prognosis for adjustment disorder is favorable with appropriate
treatment. Adjustment disorders generally occur within a short period
of time following the stressor and, by definition, should last no longer
than 6 months after the stressor or its consequences have ended.
Individuals generally return to normal functioning within a few months. |
Adjustment disorders may be associated with alcohol or substance abuse, and physical (somatic)
complaints. If an individual with a pre-existing mental or medical
illness is also diagnosed with an adjustment disorder, the course of
that illness may be complicated or prolonged, such as by decreased
compliance with recommended treatment or increased hospital length of
stay. In the presence of serious symptoms, other psychiatric disorders
must be considered and ruled out.
Adjustment disorders are typically not associated with suicidal ideation
or suicidal attempts. Anxiety adjustment disorder is a low-level
diagnosis, in which the distress is quite short-lived and the individual
can typically function on most levels. If the suicidal ideation
diagnosis component is added, using clinical evaluation standards such
as those of the American Psychiatric Association (APA), this moves the
individual into a different diagnosis category altogether. |
| Work
restrictions or accommodations are necessary only infrequently, for the
most serious cases. In these instances, time-limited restrictions and
work accommodations should be individually determined based on the
characteristics of the individual's response to the disorder, the
functional requirements of the job and work environment, and the
flexibility of the job and work site. The purpose of the
restrictions/accommodations is to help maintain the worker's capacity to
remain at the workplace without a work disruption, or to promote timely
and safe transition back to full work productivity. Often, the sense of
fulfillment and distraction from one's concerns that work can provide
may improve symptoms and speed recovery. |
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