Adjustment Disorder versus Anxiety Disorder

 Respond to your  colleagues by comparing the differential diagnostic features of the  disorder you were assigned to the diagnostic features of the disorder  your colleagues were assigned.

NOTE( Disorder assigned to me: Anxiety Disorder)

Adjustment Disorder versus Anxiety Disorder

Adjustment  disorder is the development of emotional symptoms in response to an  identifiable stressor occurring within 3 months of the onset of the  stressor.  The distress from an adjustment disorder is out of proportion to the severity and intensity of the stressor.  The  adjustment disorder can have specifiers such as “with depressed mood,”  “with anxiety,” and “with mixed anxiety and depressed mood,” “with  disturbance of conduct,” and “with mixed disturbance of emotions and  conduct.”  Adjustment  disorders are classified as a “Trauma and Stressor-related disorder” in  the DSM (American Psychiatric Association [APA], 2013) and resolve  within 3 months of removing the stressor.  Treatment is usually made up of brief psychotherapy (Gabbard, 2014).

Generalized  Anxiety Disorder (GAD) is not born out of one identified stressor  (though stressors can worsen signs and symptoms) but is excessive  anxiety and worry about a number of situations and events and require 3  or more of the following symptoms:  restlessness/feeling  “keyed up”, easily fatigued, difficulty concentrating, irritability and  muscle tension, and sleep disturbances. The anxiety symptoms have been  going on for at least 6 months and is causing clinically significant  distress in functioning (APA, 2013).

Adjustment  disorder can be seen as a disorder of exclusion; if symptoms do not  meet criteria for another psychiatric disorder, and there is a an  identified precipitant of symptoms occurring within 3 months, adjustment  disorder may be the most logical diagnosis.  Adjustment  disorder does not have a “checklist” of symptoms to make an objective  determination of distress or dysfunction (Gabbard, 2014).

When I worked on the psychiatric unit in the Navy, we saw a lot of young sailors with adjustment disorder.  Entering  the military was enough of a stressor that they were displaying some  conduct or emotional issues that prevented them from doing their job  well.  Many times, they wanted a service discharge but more often our psychiatrists returned them to work with therapy and medication.  If they were admitted to the hospital 3 times within a year, they would be administratively discharged.

Diagnostic Criteria for OCD

Obsessive-Compulsive  Disorder (OCD) is characterized by recurrent intrusive thoughts,  images, or urges (obsessions) that typically cause intense anxiety; to  alleviate anxiety and function in the world, clients with OCD must  perform repetitive mental or behavioral actions (compulsions) related to  their obsession according to rigidly defined rules.OCD typically starts  in childhood or adolescence, persists throughout a person’s life, and  can produce substantial impairment in functioning (Sadock et al.,  2017).  Among adults in the  United States, prevalence rates are 2.3 percent, with females affected  slightly more than males in adulthood, while males have higher rates  that begin in childhood (Ruscio et al., 2010).  Seventy-six  perfect of adults with OCD have another anxiety disorder, 63 percent  have a mood disorder (commonly depression), and 23 to 32 percent have a  co-morbid obsessive-compulsive personality disorder (Kessler et al.,  2005).

Psychotherapy and Psychopharmacological Treatment

For the OCD patient, I would definitely begin to measure OCD symptoms with the Yale-Brown Obsessive Compulsive Scale.  There  is a self-report scale that clinicians can use which shows good  convergent validity as compared to the interview, as well as internal  consistency and test-retest reliability.  As  providers get busier and busier, using a self-report to track efficacy  of treatment becomes essential (Steketee et al., 1996).

Therapy is the mainstay of treatment for patients with OCD.  CBT  may be more effective than SSRI’s or Clomipramine; though many  providers use therapy and medication in combination, there is no  evidence to show superiority of combination treatment over the most  effective psychotherapies (Ming, 2016).  The most common type of therapy uses exposure and response prevention (ERP).  This  treatment leads to the habituation of anxiety related to obsessions so  that rituals are no longer necessary to reduce anxiety.  Psychoeducation  is also important as anxiety may increase during exposure as the client  needs to know that the short term “pain” will produce long term “gains”  (Gabbard, 2014).

If  CBT/ERP is not available, or the patients symptoms are severe enough to  warrant medication, SSRI’s are first-line; all of the SSRI’s (except  Lexapro and Celexa) have been approved for the treatment of OCD (Soomro  et al., 2008).  Clomipramine, a tricyclic antidepressant, is a second line option due to it’s increase side effect profile (Stahl, 2018).  In general, SSRI’s and Clomipramine leads to improvement in 40-60% of patients with OCD (Pigott, 1999).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). APA Publishing.

Gabbard, G.O. (2014).  Gabbard’s treatment of psychiatric disorders (5th ed.).   American Psychiatric Publications.

Kessler,  R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E.  (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV  disorders in the National Comorbidity Survey Replication.  Archives of General Psychiatry62(6), 617–627. https://doi.org/10.1001/archpsyc.62.6.617

Ming T. S. (2016). Network meta-analyses and treatment recommendations for obsessive-compulsive disorder. The lancet. Psychiatry3(10), 920–921. https://doi.org/10.1016/S2215-0366(16)30281-4

Pigott,  T. A., & Seay, S. M. (1999). A review of the efficacy of selective  serotonin reuptake inhibitors in obsessive-compulsive disorder. The Journal of clinical psychiatry60(2), 101–106. https://doi.org/10.4088/jcp.v60n0206

Ruscio,  A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The  epidemiology of obsessive-compulsive disorder in the National  Comorbidity Survey Replication. Molecular Psychiatry15(1), 53–63. https://doi.org/10.1038/mp.2008.94

Sadock, B., Sadock, V., and Ruiz, P. (2017). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Stahl, S. M. (2018). The prescriber’s guide (5th ed.). Cambridge University Press.

Soomro,  G. M., Altman, D., Rajagopal, S., & Oakley-Browne, M. (2008).  Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for  obsessive compulsive disorder (OCD). The Cochrane database of systematic reviews2008(1), CD001765. https://doi.org/10.1002/14651858.CD001765.pub3

Steketee, G., Frost, R., & Bogart, K. (1996). The Yale-Brown Obsessive Compulsive Scale: interview versus self-report. Behavior Research and Therapy34(8), 675–684. https://doi.org/10.1016/0005-7967(96)00036-8

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