ADJUSTMENT DISORDER WITH DEPRESSION OR ANXIETY
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1 ADJUSTMENT DISORDER WITH DEPRESSION OR ANXIETY BEHAVIORAL DEFINITIONS 1 Depressive symptoms (eg, sad mood, tearfulness, feelings of hopelessness) that develop in response to an identifiable stressor (eg, medical illness, marital problems, loss of a job, financial problems, conflicts about religion) 2 Anxiety symptoms (eg, nervousness, worry, jitteriness) that develop in response to an identifiable stressor 3 Symptoms cause distress beyond what would normally be expected 4 Significant impairment in social and/or occupational functioning because of the symptoms LONG-TERM GOALS 1 Alleviate symptoms of stress-related depression through medication and/or psychotherapy 2 Alleviate symptoms of stress-related anxiety through medication and/or psychotherapy 3 Stabilize anxiety and/or depression levels while increasing ability to function on a daily basis 11
2 12 THE PSYCHOPHARMACOLOGY TREATMENT PLANNER 4 Learn and demonstrate strategies to deal with dysphoric and/or anxious moods 5 Effectively cope with the full variety of life s stressors SHORT-TERM OBJECTIVES 1 Describe the signs and symptoms of an adjustment disorder that are experienced and note their impact on daily life (1, 2, 3) 2 Describe other symptoms or disorders that may also be present (4, 5) THERAPEUTIC INTERVENTIONS 1 Explore the adjustment disorder symptoms that are experienced by the patient (eg, excessive worry about a current stressor, sad mood, decreased sleep, reduced appetite) 2 Determine what stressors are present and the time course of symptoms in relation to the stressors 3 Gather information from the patient about the impact of the symptoms on daily life (eg, impaired social or occupational functioning, neglect of routine chores) 4 Assess the patient for comorbid disorders (eg, see the Personality Disorder, Psychosis, and Panic Disorder chapters in this Planner) 5 Gather detailed personal and family history information regarding the patient s substance abuse and its potential contribution to the adjustment disorder;
3 ADJUSTMENT DISORDER WITH DEPRESSION OR ANXIETY 13 3 Verbalize any current suicidal thoughts and any history of suicidal behavior (6, 7, 8) 4 Outline a complete and accurate medical and psychiatric history, including treatment received and its effectiveness (9, 10) 5 Cooperate with a physical examination and laboratory tests (11, 12) refer the patient for in-depth substance abuse treatment, if indicated (see the Chemical Dependence chapters in this Planner) 6 Explore the patient s current and past suicidal thoughts and suicidal behavior; check for family history of suicide (see interventions designed for Suicidal Ideation in this Planner) 7 Administer to the patient an objective assessment instrument for assessing suicidality (eg, the Beck Scale for Suicidal Ideation); evaluate the results and give feedback to the patient 8 Arrange for hospitalization when the patient is judged to be harmful to himself/herself or others or unable to care for his/her basic needs 9 Explore the patient s history of previous treatment for any psychiatric disorder and the success of, as well as tolerance for, that treatment 10 Assess the patient for the presence of other medical problems and the medications used to treat them 11 Perform a complete physical and neurological examination on the patient and send his/her blood and/or urine for analysis to assess any medical problem that may contribute to the adjustment disorder (eg, cancer, diabetes, hypertension, cardiovascular disease) 12 Provide feedback to the patient regarding the results and
4 14 THE PSYCHOPHARMACOLOGY TREATMENT PLANNER 6 Pursue treatment for concurrent medical problems that may contribute to depressive and anxiety symptoms (13, 14) 7 Complete psychological testing and other questionnaires for measuring depressive and anxiety symptoms (15) 8 Express an understanding of possible causes for adjustment disorder and the relationship between substance abuse and adjustment disorder (16, 17) 9 Verbalize an understanding of treatment options, expected results from medication, and potential side effects (18, 19) implications of the physical examination and laboratory test results 13 Treat or refer the patient for treatment for any medical problem that may be causing or contributing to the adjustment disorder 14 Monitor the patient s progress in recovery from concomitant disorders and the impact on his/her mood 15 Administer objective instruments to assess the patient s depressive and anxiety symptoms (eg, Beck Depression Inventory [BDI], Hamilton Depression Rating Scale [HDRS], Montgomery Asberg Depression Rating Scale [MADRS], Hamilton Anxiety Rating Scale [HARS]); evaluate the results and give him/her feedback 16 Emphasize the negative and dangerous impact of substance abuse on adjustment disorder symptoms 17 Educate the patient on the possible contributing factors (eg, stressful life events, maladaptive coping skills) and signs of adjustment disorder 18 Discuss appropriate treatment options with the patient including medication and psychotherapy 19 Educate the patient on psychotropic medication treatment including the expected results, potential side effects, and dosing strategies
5 ADJUSTMENT DISORDER WITH DEPRESSION OR ANXIETY Participate in psychotherapy sessions as planned with the therapist (20, 21) 11 Verbalize any symptoms of anxiety that are experienced (22, 23) 12 Take prescribed antianxiety or hypnotic medications responsibly at times ordered by the physician (24, 25, 26, 27) 20 Assess the patient for potential benefit from psychotherapy and refer him/her to a psychotherapist, if necessary 21 Monitor the patient s response to psychotherapy; assess his/her ability to verbalize a basis for progress in recovery from the adjustment disorder (eg, improved mood, reduced anxiety, increased ability to cope with adversity, improved social and occupational functioning) 22 Explore the adjustment disorder symptoms that are experienced by the patient (eg, excessive worry about a current stressor, sad mood, decreased sleep, reduced appetite) 23 Determine if the patient has debilitating symptoms of anxiety (eg, worry, nervousness, reduced sleep) that interfere with his/her functioning 24 Prescribe to the patient an anxiolytic or hypnotic agent (eg, zolpidem [Ambien ], zaleplon [Sonata ], lorazepam [Ativan ], flurazepam [Dalmane ], triazolam [Halcion ], diazepam [Valium ], chloral hydrate [Noctec ], estazolam [Pro- Som ], temazepam [Restoril ]) to help the patient with sleep (see the Sleep Disturbance chapter in this Planner) 25 Consider the use of a longacting benzodiazepine (eg, clonazepam [Klonopin ], diazepam [Valium ]) to help alleviate excessive daytime anxiety
6 16 THE PSYCHOPHARMACOLOGY TREATMENT PLANNER 13 Report as to the effectiveness of the antianxiety medication and any side effects that develop (28, 29) 14 Verbalize any depressive symptoms that are experienced (30, 31) 15 Adhere to the SSRI antidepressant medication as prescribed by the physician (32, 33) 26 Avoid the use of benzodiazepines and other hypnotics if the patient has a history of substance abuse; use an alternative medication (eg, hydroxyzine [Atarax, Vistaril ], diphenhydramine [Benadryl ], trazodone [Desyrel ]) for the patient 27 Instruct the patient to minimize his/her use of medication and take it only when symptoms become intolerable 28 Titrate the medication every two to three days, as tolerated, until the patient s symptoms are controlled or the maximum dose is reached 29 Monitor the patient frequently for the development of side effects, response to medication, adherence to treatment, and abuse of the medication 30 Explore the adjustment disorder symptoms that are experienced by the patient (eg, excessive worry about a current stressor, sad mood, decreased sleep, reduced appetite) 31 Determine if the patient has debilitating depressive symptoms (eg, sad mood, tearfulness, decreased appetite) in response to a chronic stressor (eg, chronic medical illness, ongoing financial or legal problems) 32 Consider prescribing a selective serotonin reuptake inhibitor (SSRI) (eg, fluoxetine [Prozac ], sertraline [Zoloft ], paroxetine [Paxil ], citalopram [Celexa ], escitalopram
7 ADJUSTMENT DISORDER WITH DEPRESSION OR ANXIETY Report as to the effectiveness of the SSRI antidepressant medication and any side effects that develop (34, 35, 36) 17 Retain a remission or significant reduction in depressive and/or anxiety symptoms (37, 38, 39) [Lexapro ]) to help treat the patient s depressive symptoms (see the Depression chapter in this Planner) 33 Titrate the patient s SSRI antidepressant medication to the minimum effective dose for treating the patient s symptoms 34 Monitor the patient frequently for the development of side effects, response to the SSRI medication, and adherence to treatment 35 Increase the dose of the SSRI antidepressant every four to six weeks, as tolerated, until the patient has a satisfactory response or the maximum dose is reached 36 Repeat administration of objective rating instruments for assessment of the patient s depression and anxiety; evaluate the results and give him/her feedback 37 Maintain the patient on current medication until the stressor(s) resolve and/or the patient develops better coping skills to reduce his/her depression or anxiety without medication 38 Continue antidepressant treatment indefinitely if he/she has had previous episodes of adjustment disorder and has shown limited or no progress in developing adequate coping skills to effectively deal with adversity 39 Reduce medications gradually over several days to weeks; monitor closely for recurrence of symptoms and/or withdrawal
8 18 THE PSYCHOPHARMACOLOGY TREATMENT PLANNER DIAGNOSTIC SUGGESTIONS: Axis I: 3090 Adjustment Disorder with Depressed Mood Adjustment Disorder with Anxiety Adjustment Disorder with Mixed Anxiety and Depressed Mood 3093 Adjustment Disorder with Disturbance of Conduct 3094 Adjustment Disorder with Mixed Disturbance of Conduct and Emotions 3099 Adjustment Disorder Unspecified 296xx Major Depression Posttraumatic Stress Disorder 3083 Acute Stress Disorder V6282 Bereavement Alcohol Abuse Cocaine Abuse Axis II: Borderline Personality Disorder
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