A 35-year-old man comes to the office due to poor sleep and feeling "worthless." His insomnia and poor self-esteem began 2 months ago when he discovered that his girlfriend was romantically involved with one of her co-workers. The patient was very disappointed by this news as he thought he and his girlfriend were close and had a good sexual relationship. He immediately ended the relationship and has since stopped socializing, preferring instead to stay home alone. He admits to having little interest in dating women now, even when they seem to be a good match. Although the patient continues to meet his deadlines and fulfill all his professional responsibilities, he feels less motivated at work. He continues to go to the gym regularly, as exercising helps him "escape from feelings" he still has for his former girlfriend. He reluctantly admits to occasionally using marijuana to help him sleep. The patient has no psychiatric history. There is a family history of depression in his older sister, who was successfully treated with venlafaxine. Which of the following treatments is the most appropriate management for this patient?
Differential diagnosis of depressed mood | |
Major depressive disorder |
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Persistent depressive disorder (dysthymia) |
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Adjustment disorder with depressed mood |
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Normal stress response |
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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 development of sleep disturbance, low self-esteem, and social isolation in response to the stress of a romantic breakup is consistent with an adjustment disorder. Adjustment disorder is characterized by emotional or behavioral symptoms that develop within 3 months of exposure to an identifiable stressor and rarely last more than 6 months after the stressor ends. Diagnosis requires evidence of significant distress or impairment, as seen in this patient's seeking help for his symptoms and social impairment. He lacks sufficient symptoms to meet the criteria for major depressive disorder as he does not have evidence of impaired concentration, low energy, appetite disturbance, psychomotor agitation or retardation, or suicidal ideation; therefore, the diagnosis of adjustment disorder is appropriate.
The treatment of choice for adjustment disorder is psychotherapy, which focuses on developing coping mechanisms and improving the individual's response to and attitude about the stressful situation. Helping this patient cope with his feelings of disappointment, improve his self-esteem, and eventually become open to new relationships would be appropriate.
(Choices A, B, C, and E) The antidepressants bupropion, fluoxetine, mirtazapine, and venlafaxine would all be first-line pharmacologic treatment options if the patient met the criteria for major depressive disorder. Bupropion has the advantage of not causing sexual side effects but can be activating and worsen insomnia. If the patient develops major depression, the serotonin-norepinephrine reuptake inhibitor venlafaxine could be considered given the history of a positive response in a first-degree relative.
(Choice F) Zolpidem is a nonbenzodiazepine hypnotic used to treat insomnia. Targeting this patient's sleep disturbance alone would not adequately address his adjustment disorder.
Educational objective:
Adjustment disorder involves symptoms causing marked distress and impairment that develop within 3 months in response to a stressor. It is not diagnosed if symptoms meet the criteria for another specific disorder (eg, major depressive disorder). The treatment of choice is psychotherapy that focuses on improving coping skills and promoting a return to functioning.