A 33-year-old woman comes to the office due to low mood and anxiety for the past 5 weeks. The patient broke up with her boyfriend 6 weeks ago and was recently passed over for a promotion at work. She says, "Nothing ever works out for me. I'm never going to find anyone at my age, and the people getting promotions are all younger than me." The patient has been "stress eating" on the weekends but reports no weight changes and continues to work out regularly. She has difficulty falling asleep and often lies awake at night worrying about her future. The patient likes having dinner with her friends but says, "I miss having a boyfriend to spend time with." The patient has no psychiatric history. Vital signs are within normal limits. Physical examination is unremarkable. She appears tearful and tends to look at the floor while speaking; she has no suicidal ideation. Which of the following is the most appropriate management for this patient?
Adjustment disorder | |
Clinical features |
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Differential diagnosis |
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Management |
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SIGECAPS = Sleep disturbance, loss of Interest, excessive Guilt, low Energy, impaired Concentration, Appetite disturbance, Psychomotor agitation/retardation, and Suicidal ideation. | |
This patient's 5-week history of mild mood symptoms (eg, low mood, anxiety, hopelessness, sleep disturbance) in response to psychosocial stressors (eg, relationship, work) is most consistent with an adjustment disorder. Her symptoms are insufficient in number and severity to meet diagnostic criteria for a major depressive episode, which would involve more persistent sadness and anhedonia, and additional depressive symptoms (eg, low energy, impaired concentration, excessive guilt, suicidal thoughts), which this patient does not describe. The duration of her symptoms is not enough to diagnose a generalized anxiety disorder, which requires that symptoms persist for at least 6 months.
A nonpharmacological approach (ie, psychotherapy as opposed to pharmacotherapy) is the most appropriate intervention for this patient. Psychotherapy can directly target the patient's maladaptive responses to stress, including the dysfunctional thought patterns contributing to her low mood and anxiety (eg, feeling that nothing ever works out for her, worrying about the future) while avoiding potential adverse effects from medication. Pharmacotherapy alone or in combination with psychotherapy should be reserved for patients who have more severe, persistent, and impairing symptoms.
(Choices A, B, and C) The antidepressants bupropion, escitalopram, and mirtazapine would be appropriate first-line treatments for a patient with more severe and impairing symptoms who meets criteria for a major mood or anxiety disorder.
(Choice E) Reassurance only would be appropriate for a patient whose symptoms are not functionally impairing. This patient's dysfunctional behavioral and thought patterns would be best addressed with psychotherapy, which could also target her vulnerability to developing depressive or anxiety symptoms in response to future psychosocial stressors.
Educational objective:
Psychotherapy is the preferred treatment approach for patients with adjustment disorders.