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Adjustment disorders must be distinguished from anxiety disorders, affective disorders, and personality disorders exacerbated by stress and from somatic disorders with psychic overlay
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medications such as carbamazepine (400 800 mg daily) will often mitigate impulsivity and difficulty with anger management Benzodiazepines such as clonazepam (1 4 mg daily) will reduce anxiety and panic attacks when used in adequate dosage, but dependency problems are a concern, particularly when the patient has had such problems in the past
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Stress reduction techniques include immediate symptom reduction (eg, rebreathing in a bag for hyperventilation) or early recognition and removal from a stress source before fullblown symptoms appear It is often helpful for the patient to keep a daily log of stress precipitators, responses, and alleviators Relaxation and exercise techniques are also helpful in reducing the reaction to stressful events
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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
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Ehlers A et al Early psychological interventions for survivors of trauma: a review Biol Psychiatry 2003 May 1;53(9):817 26 [PMID: 12725974] Katon WJ et al Dissemination of evidence-based mental health interventions: importance to the trauma field J Trauma Stress 2006 Oct;19(5):611 23 [PMID: 17075915] Stevens LM et al JAMA patient page Posttraumatic stress disorder JAMA 2006 Aug 2;296(5):614 [PMID: 16882969] Vaiva G et al Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma Biol Psychiatry 2003 Nov 1;54(9):947 9 [PMID: 14573324]
B Social
The stress reactions of life crisis problems are a function of psychosocial upheaval, and patients frequently present with somatic symptoms 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 therapist 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 context and facilitates the sometimes difficult decisions the patient eventually must make (eg, change of job or relocation of adult-dependent offspring)
C Psychological
Prolonged in-depth psychotherapy is seldom necessary in cases of isolated stress response or adjustment disorder Supportive psychotherapy (see above) with an emphasis on the here and now and strengthening of existing coping mechanisms is a helpful approach so that time and the patient s own resiliency can restore the previous level of function In posttraumatic stress syndromes, psychological debriefing in a single session, once a mainstay in prevention of PTSD, is now considered to be ineffective and possibly harmful Posttraumatic stress syndromes respond to interventions that help patients integrate the event in an adaptive way with some sense of mastery in having survived the trauma Early cognitive behavioral therapy has been shown to speed recovery Marital problems are a major area of concern, and it is important that the clinician have available a dependable referral source when marriage counseling is indicated
ANXIETY DISORDERS & DISSOCIATIVE DISORDERS
ESSENTIALS OF DIAGNOSIS
Overt anxiety or an overt manifestation of a coping mechanism (such as a phobia), or both Not limited to an adjustment disorder Somatic symptoms referable to the autonomic nervous system or to a specific organ system (eg, dyspnea, palpitations, paresthesias) Not a result of physical disorders, psychiatric conditions (eg, schizophrenia), or drug abuse (eg, cocaine)
D Medical
Judicious use of sedatives (eg, lorazepam, 1 2 mg orally daily) for a limited time and as part of an overall treatment plan can provide relief from acute anxiety symptoms Problems arise when the situation becomes chronic through inappropriate treatment or when the treatment approach supports the development of chronicity In PTSD, early treatment of anxious arousal with blockers (eg, propranolol, 80 160 mg daily) may lessen the peripheral symptoms of anxiety (eg, tremors, palpitations) and help prevent development of the disorder; however, research in this area is preliminary Antidepressant drugs particularly selective serotonin reuptake inhibitors (SSRIs) in full dosage are helpful in ameliorating depression, panic attacks, sleep disruption, and startle responses in chronic PTSD Sertraline and paroxetine are approved by the US Food and Drug Administration (FDA) for this purpose Antiseizure
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