Case study - A common diagnosis not widely recognised

A patient struggles after the breakdown of her marriage. By Dr Nicholas Thomas and Dr David Fackrell.

A 40-year-old woman arrived in the surgery. She had no significant past medical history apart from having two children, aged five and seven. She was visibly upset, and said her 10-year marriage had broken down three months ago. She was separated.

Some patients have severe reactions to stressful situations

She was worried as she was finding it difficult to return to her normal life. She explained she was feeling lethargic, frequently broke into tears, had difficulty functioning at work, and was unable to socialise with friends.

Her mood seemed low and she was fatigued. She was irritable to others, had poor concentration, and suffered from anxiety when out in large groups. All of these symptoms had developed in the last three months.

Practical implications
Colleagues and friends were distancing themselves from her, and her work was suffering. This was intensifying her emotional state. She was not having any hallucinations or delusions and had no suicidal ideation.

We explored the practical and emotional issues surrounding her separation. Financially she was secure, but she was having difficulties with after-school care, which her husband used to help her with.

Maladaptive reaction
A serious mental disorder was ruled out. Rather than depression, I reassured her that this was a common reaction termed adjustment disorder. It is defined as a maladaptive reaction to a psychosocial stressor (in this case marital separation) that occurs within three months of the onset of that stressor.

The reaction causes a significant impairment in social or occupational functioning, and once the stressor and its consequences have ceased, the symptoms should not persist for longer than six months.

The primary aims for management are in helping to provide support for the patient to resolve any ongoing problems and in doing so to assist with 'natural' adjustment processes. Recognition is needed of how difficult she is finding things. Avoiding 'medicalising' her distress is essential.

A discussion about support networks is paramount, including effects this may have on the children. Provision of contacts and an awareness of maladaptive defence mechanisms (ie alcohol abuse) is recommended.

Non-directive counselling
If further counselling is required, non-directive counselling is the first choice treatment. This can help with the problem and reduce denial and avoidance. The support gained from counselling helps patients to gain perspective, establish relationships, and contact support groups. Self-help groups can lead to a quicker recovery.

No medical treatment should be given. Psychotropic medications have been shown to have little efficacy in treating adjustment disorder. Reassurance and advice by a skilled GP is just as effective as drug therapy.

Should severe anxiety symptoms continue, a short course of a benzodiazepine is acceptable.

The patient should be encouraged to return to their usual activities within a few weeks, and a further consultation should be offered to see how the situation develops. Explain that most patients recover fully from adjustment reactions.

This patient made an excellent recovery and was very happy with the support given at the time.

  • Dr Thomas is ST1, GPVTS Oxford deanery and Dr Fackrell is ST1 CMT, West Midlands deanery

Learning points

  • Adjustment disorder is a debilitating reaction to a stressful event or situation, usually lasting less than six months.
  • Six ICD-10 subtypes: brief depressive reaction; prolonged depressive reaction; mixed anxiety and depressive reaction; predominant disturbance of other emotions; predominant disturbance of conduct; mixed disturbance of emotions and conduct.
  • Depression may be a complication of adjustment disorder.
  • Treatment is mainly supportive.
  • No medical treatment should be given.
  • Reassure and offer follow-up consultation.


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