Adjustment Disorder

Question 1

Adjustment disorder: diagnostic criteria

Answer 1

1. Identifiable stressor→Emotional or behavioral sx
2. Within 3 months after onset of stressor
3. Clinically significant:
   
   • Distress in excess of what would be expected
   • Significant impairment (social or work)

Question 2

Adjustment disorders do not meet the criteria for other psychiatric disorders or bereavement. Once the stressor or its consequences has terminated the symptoms do not persist more than ______.

Answer 2

6 months

(adjustment disorder sx appear within 3 months of stressor)

Question 3

Adjustment disorder course of illness

Answer 3

• Days to weeks
• No longer than 6 months after stressor is gone

(stressor could be chronic (married to an alcoholic spouse), but to be adjustment disorder sx will stop 6 months after stressor is gone)

Question 4

Adolescents with adjustment disorder are more likely to be suicidal. _____% Of outpatient mental health patients have this diagnosis. _____ of ER patients w/self-harm

Answer 4

• 35%
• 1/3

(most adolescents w/adjustment disorder → psychiatric condition dx later in life)

Question 5

Adjustment disorder is most common in patietns w/ ______.

Answer 5

• maladaptive styles, such as those with personality disorders (borderline)

(Threshold of stress required to cause psychiatric symptoms varies by individual)

Question 6

Event if a patient has a stressor that may cause adjustment disorder, if the symptoms meet criteria for another major psychiatric disorder, which would be diagnosed?

Answer 6

psychiatric disorder

(suicide is a high risk in adjustment disorder)

Question 7

Adjustment disorder prognosis

Answer 7

Most recover within 3 months and learn from the experience

Question 8

Adjustment disorder treatment involves (4)

Answer 8

• Symptomatic treatment of anxiety and insomnia
• Search for the meaning of the stressor to the patient
• Coping strengths
• Community resources

Question 9

Define bereavement

Answer 9

“To be robbed by Death”

Question 10

Define grief

Answer 10

• Grief: the physical and emotional pain precipitated by a significant loss

(Can be due to the loss of a person, place, pet, job, object, health, independence, amputation)

Question 11

Define mourning:

Answer 11

Behaviors, rituals and observances reflecting a culture’s/religion’s views about the meaning of death and the role of the survivor

Question 12

List the different types of grief (4)

Answer 12

1. Anticipatory
2. Acute
3. Delayed
4. Complicated

Question 13

Define anticipatory grief

Answer 13

anticipating impending loss

Question 14

Define acute grief

Answer 14

1st stage of the bereavement process

Question 15

Define Delayed grief

Answer 15

Absence of expression of grief at the time of the loss

Question 16

Define Unresolved grief

Answer 16

Extreme grief symptoms

(more intense & last longer than expected)

Question 17

Define Complicated grief

Answer 17

unresolved grief + physical sx

(interferes w/function)

Question 18

What symptoms are typically seen in patients in the mourning stage of bereavement (5).

Answer 18

1. Decreased appetite
2. Decreased concentration
3. Hallucinations of the deceased
4. Self-reproach
5. Sleep disturbances

Question 19

Stages of normal bereavement (3)

Answer 19

1. Shock and denial
2. Mourning: physical, emotional sx & social isolation
3. Reorganization of life that acknowledges the loss

Question 20

Difference between mourning & MDD

Answer 20

Symptoms of mourning only last a few days

Question 21

Examples of reorganization of life that is experienced in normal bereavement

Answer 21

• different relationships
• new identity (widow, orphan, only child)

Question 22

Biggest differentiating factors between MDD & complex bereavement

Answer 22

MDD has neurovegitative sx (not eating, drinking, unable to care for themselves)

Question 23

Duration of normal bereavement

Answer 23

Indeterminate: typically do not diagnose MDD immediately following a death

Question 24

Factors for poor bereavement outcome (4)

Answer 24

1. Type of death: sudden or suicide (stigma)
2. Who: child, relationship of dependency or ambivalence w/decedent
3. Current psychological state: social support, concurrent crisis, low socioeconomic status
4. Current health: age or health

Question 25

Complicated grief (5)

Answer 25

1. Anger, resentment, bitterness
2. Regression
3. Pangs of uncomfortable emotions
4. Preoccupation (thoughts of bereaved)
5. Clinical complications: anxiety, physical morbidity, social/occupational, family dysfunction, health compromising behaviors

Question 26

Proposed criteria (DSM 5) for persistent complex bereavement disorder: within 12 months (6 months for children) more days than not:

Answer 26

• Death of someone close
• Since the death, at least one : experienced
  
  1. Persistent yearning for them
  2. Intense sorrow and emotional pain
  3. Preoccupation with the death
  4. Preoccupation w/circumstances of the death
  5. Reactive distress to death
  6. Social/identity disruption

Question 27

Describe the reactive distress to death in someone with persistent complex bereavement disorder (6).

(not in DSM 5 yet)

Answer 27

1. Marked difficulty accepting the death
2. Emotional numbness over the loss
3. Difficulty reminiscing positively
4. Bitterness or anger related to the loss
5. Avoidance of reminders of the loss
6. Self-blame

Question 28

Describe the social/identity disruption in someone with persistent complex bereavement disorder: since the death of bereft: (5)

(not in DSM 5 yet)

Answer 28

1. Want to die to be w/deceased
2. Difficulty trusting others
3. Feeling alone or detached
4. Confusion about one’s role in life
5. Difficulty or reluctance to pursue interests

Question 29

Treatment of grief (3)

Answer 29

1. Maintain stability of pre-existing psychiatric conditions
2. Group psychotherapy: interpretive and supportive
3. Medication: symptomatic for anxiety and sleep

(psychotherapy may help to establish new roles and activities; some things you don’t get over, you just get through)

Question 30

Depression and dying patient: wish to die may be an existential signal that the patient feels their ______.

Answer 30

• potential for being someone who matters is exhausted

(Depressed patients make more restrictive advanced directives than nondepressed patients, and change them when the depression resolves)

Question 31

What is the difference between suicidal ideation and the wish hasten death in a dying patient?

Answer 31

• When wish to hasten death is present, it may result from untreated psychological or physical symptoms

Question 32

Treatment for depression in a dying patient (anticipatory grief)

Answer 32

psychotherapy, antidepressants and stimulants

Question 33

Dealing with dying patients

Answer 33

1. Cheerfulness: be open to humor
2. Competence: know about the illness and treatment
3. Caring: attend to every question
4. Comfort: address the discomforts of the condition
5. Communication: what can you do to allow the patient to speak openly
6. Control: pain
7. Respect: defenses (let them be in denial)
8. Touch: may offer comfort
9. Visits: maintain frequency
10. Hope: one day at a time

Question 34

Primary agent of treatments when dealing with dying patients

Answer 34

• Physician and their relationship w/patient is the primary agent of treatment
• Help patient separate symptoms related to their life-threatening illness from others (ex: Is their HA part of the cancer?)

Question 35

Family-centered care: well-functioning families demonstrate:

Answer 35

• Supportive: high levels of cohesion
• Conflict resolvers: tolerate differences of opinion and deal with conflict constructively

Question 36

Family-centered care: dysfunctional families will demonstrate (3)

Answer 36

• Hostile: high conflict, low cohesion, and poor expressiveness
• Sullen: muted anger
• Both have high rates of morbidity

Question 37

Psychological stages of dying

Answer 37

1. Stage of Denial: “It can’t be true.”
2. Stage of Anger: “Why me?”
3. Stage of Bargaining: Often related to religious beliefs
4. Stage of Depression: anticipatory grief
5. Stage of Acceptance: patients may be emotionally neutral or euphoric

Question 38

Goals of treatment in dying patients (3).

Answer 38

1. Give patients a sense of control over their fate:
   
   • Disease manifestation (as much as you can)
   • Symptoms (teach them how to manage)
2. Attempt to predict what symptoms will occur, their timing, and their response to treatment
3. Attempt to smooth relations within the family so that family members are better able to deal with dying person

Question 39

Reasons for telling the truth to a dying patient (3)

Answer 39

1. Improve the doctor-patient relationship
2. Reduce the patient’s uncertainty
3. Improve the patient’s ability to act in their own best interest

Question 40

Modern medicine respects a competent patient’s right to autonomy, complications arise when _____.

Answer 40

• a patient is not able to express their wishes

Question 41

Settings for death (3)

Answer 41

1. home
2. hospital
3. hospice

Question 42

Life-prolonging treatment includes (4):

Answer 42

1. Mechanical ventilation
2. CPR
3. Nutrition
4. Hydration

Question 43

Physicians do not have to provide life-sustaining treatment that is considered _______.

Answer 43

futile