CASE BASED DISCUSSION 2- GROUP C

15/5/2020
ADJUSTMENT DISORDER 11am

YEAR 5 ROTATION 5 OVERVIEWED BY : PROF

HUSSAIN
GROUP C MEMBERS
Kogilavaanie Chellathurai BMS 15091458
Loo Jin Qian BMS 15091445
Nida Nawaz BMS 15091734
Suganesvaran BMS 15091450
Alan Kuok Che Lonn BMS 14091236
Tan Xuan Yung BMS 15091517
Pathmapriya Ganesan BMS 15091387
Mohd Syadzwan A'fee bin Maidin BMS 15091514
Gan Chin Neng BMS 14091879
Mohamad Rafiq bin Shadick BMS 14091046
Regeshschereni Sugumaran BMS 15091646
Ubaidullah Hamoodh Rasheed BMS 15091458
CASE SCENARIO
Mr. LR 34 year old officer was seen in my clinic with a history of not able to
sleep and having low mood because of recent MCO. His main worry was
about his job and what happen if he might loss his job. He has been trying to
self medicate himself by buying over the counter sleeping pill but after 4
weeks of using it, he still find hard to fall asleep.
Q1.Discuss what further assessment would you like to conduct?
Q2.What is his most like MSE findings?
Q3.Discuss provisional and differential diagnosis
Q4.Discuss management based on your provisional diagnosis
Q5.Discuss the prognosis of his condition?
QUESTION 1-DISCUSS WHAT
FURTHER ASSESSMENT
WOULD YOU LIKE TO
CONDUCT?
IDENTIFY THE CAUSE OF
PROBLEM
•To create a time frame of when this inability to fall sleep and low mood
starts?
•Is stressor identifiable?
•Identify the intensity of stressor and severity of distress.
•If there is any impairment in social, occupational or other important areas of
functioning.
•Does the patient have any pre-existing mental disorders?
- to rule out exacerbation of disorder
•Any recent bereavement of family, friends or loved ones?
•Is the anxiety or worry excessive?
•Other associated symptoms ( except anxiety and worry) such as
Any loss of weight and appetite
Restlessness, headache and palpitations
Being easily fatigued.
Difficulty concentrating or mind going blank.
Irritability.
 Muscle tension.
Sleep disturbance (difficulty falling or staying asleep, or restless,
unsatisfying sleep).
 DIAGNOSTIC CRITERIA :
ADJUSTMENT DISORDER
A. The development of emotional or behavioral symptoms in response to an
identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant, as evidenced by one or both

of the following:
1. Marked distress that is out of proportion to the severity or intensity of the
stressor, taking into account the external context and the cultural factors that
might influence symptom severity and presentation.

2. Significant impairment in social, occupational, or other important areas of

functioning.
C. The stress-related disturbance does not meet the criteria for another mental disorder
and is not merely an exacerbation of a preexisting mental disorder.

D. The symptoms do not represent normal bereavement.

E. Once the stressor or its consequences have terminated, the symptoms do not persist for
more than an additional 6 months.
Specify whether:

With depressed mood

- Low mood, tearfulness, or feelings of hopelessness are predominant.

With anxiety
- Nervousness, worry, jitteriness, or separation anxiety is predominant.

With mixed anxiety and depressed mood

- A combination of depression and anxiety is predominant.
With disturbance of conduct
- Disturbance of conduct is predominant.

With mixed disturbance of emotions and conduct

- Both emotional symptoms (e.g., depression, anxiety) and a disturbance of
conduct are predominant.

Unspecified
- For maladaptive reactions that are not classifiable as one of the specific
subtypes of adjustment disorder.
QUESTION 2-WHAT IS HIS MOST
LIKELY MSE FINDINGS?
General appearance
•Mr LR ,34 year old male, appeared to be his stated age.
•Agitation, poor eye contact and inattentive
•Neglect of dressing and grooming (inattentive to personal appearance)
Behavior and psychomotor activity
•Sleep disturbances
Speech
•His speech is relevant and coherent. Decreased amount, monotone, speaks slowly
and volume is very slow as if murmuring.
Mood
•Mood is anxious ,shamed and depressed.
Affect
Sad
Thought content
•Recurrent thoughts of losing job.
•May have suicidal thoughts.
•Diminished ability to think and concentrate.
•Feelings of hopelessness, worthlessness and guilt.
•No delusions
Thought Process
•No flight of ideas, no loosening of association

Perceptual disturbances
•No auditory or visual hallucinations
Sensorium and cognition
I. Alertness:
Appears alert and co-operative.

II. Orientation:
He is oriented to time, place and person.

III.Attention and Concentration:

He is not so attentive, unable to concentrate and easily distractible.
Memory:
I. Immediate Memory: Good
II. Recent Memory: Good
III.Remote Memory: Good
Fund of Knowledge:
He knows who the current prime minister of Malaysia.
Abstract thinking:
He knows the differences and similarities between an apple and an orange
Judgement: Good
Personal – If there’s a fire in the house, he would try to turn it off.
Social – If she found a wallet, she would give it to the police.
Insight:
He has good insight, as he tries to self medicate.
 QUESTION 3- DISCUSS
PROVISIONAL AND
DIFFERENTIAL DIAGNOSIS
PROVISIONAL DIAGNOSIS
Adjustment disorder with mixed anxiety and depressed
mood
•Presence of a stressful life event (MCO)
•Symptoms of depression and anxiety
•History of not able to sleep, low mood and worry about losing
his job because of recent MCO
DIFFERENTIAL DIAGNOSIS
•Insomnia
•Anxiety disorder
•Major depressive disorder
•Mixed anxiety depression
•Acute stress disorder
 QUESTION 4- DISCUSS
MANAGEMENT BASED ON
YOUR PROVISIONAL
DIAGNOSIS
SUPPORTIVE
PSYCHOTHERAPY
•Treatment of choice for adjustment disorder.
•Supportive techniques and reassurance
•Group therapy can be useful for patients who have had similar stresses.
•After successful therapy, patients sometimes emerge from an adjustment disorders
stronger than in the premorbid period.
•Psychotherapy can help persons adapt to stressors that are not reversible or time
limited and can serve as a preventive intervention if the stressor does remit.
CRISIS INTERVENTION
•Crisis intervention and case management are short-term treatments aimed at helping
persons with adjustment disorders resolve their situations quickly by
 Supportive technique
 Suggestion
 Reassurance
 Environmental modification
 Even hospitalization, if necessary.

•The frequency and length of visits for crisis support vary according to patients’
needs; daily sessions may be necessary, sometimes two or three times each day.
•Flexibility is essential in this approach.
PHARMACOTHERAPY
•No studies have assessed the efficacy of pharmacological interventions in
individuals with adjustment disorder
•It may be reasonable to use medication to treat specific symptoms for a brief time.
•Depending on the type of adjustment disorder, a patient may respond to an
antianxiety agent (Benzodiazepines) or to an antidepressant.
•Selective serotonin reuptake inhibitors have been found useful in treating symptoms
of traumatic grief.
 QUESTION 5-DISCUSS THE
PROGNOSIS OF HIS CONDITION?
•With appropriate treatment, the overall prognosis of an adjustment disorder is generally
favourable.
•Most patients return to their previous level of functioning within 6 months.
•Once the stressor has terminated, the symptoms do not persist.
•May be chronic if the stressor is chronic or recurrent.
•Be wary of the risk of suicidal attempt.
•Some persons (particularly adolescents) who receive a diagnosis of adjustment disorder later
have mood disorders or substance related disorders.
•Good prognostic factor: Age (34y/o), family background, no personality disorder, no history of
suicide attempt and good insight as he tries to self medicate.
•Bad prognostic factor: premorbid personality (narcissistic), not coping well for minor issues
and prolong use of benzodiazepines.
REFERENCES
•Kaplan and Sadock's Synopsis of Psychiatry 11th edition
•Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5
THANK YOU