A 46-year-old man with a history of medication-controlled hypertension comes to the office for a routine checkup. Blood pressure is 115/80 mm Hg and physical examination findings are normal. The physician notes that the patient's mood seems low. The patient admits that he has been "stressed out" for the past 2 months as a few people at work recently quit and he has had to take on more responsibility while management finds replacements. He has not been able to exercise or eat right as he is so busy. The patient feels irritable and tense at work and has had neck and shoulder pain. He is also worried about not being able to spend time with his wife, who complains that he works too much. The patient has occasional difficulty falling asleep at night after working long hours and feels tired during the day. Although he doesn't enjoy his job, he has no choice but to stay. He continues to get his work done and enjoys social activities, including playing golf on weekends. The patient drinks 2-3 cans of beer on weekends and smokes marijuana twice a month. Which of the following is the most likely diagnosis?

Question

A 46-year-old man with a history of medication-controlled hypertension comes to the office for a routine checkup.  Blood pressure is 115/80 mm Hg and physical examination findings are normal.  The physician notes that the patient's mood seems low.  The patient admits that he has been "stressed out" for the past 2 months as a few people at work recently quit and he has had to take on more responsibility while management finds replacements.  He has not been able to exercise or eat right as he is so busy.  The patient feels irritable and tense at work and has had neck and shoulder pain.  He is also worried about not being able to spend time with his wife, who complains that he works too much.  The patient has occasional difficulty falling asleep at night after working long hours and feels tired during the day.  Although he doesn't enjoy his job, he has no choice but to stay.  He continues to get his work done and enjoys social activities, including playing golf on weekends.  The patient drinks 2-3 cans of beer on weekends and smokes marijuana twice a month.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d770_70c0_bc81_033844ed5101_MD0003_00 This patient's symptoms in response to his stressful work situation (eg, mood appears low, poor sleep, fatigue) are consistent with a normal stress response. His symptoms are mild rather than excessive given the nature of the stressor; he does not meet the full criteria for any disorder; and he is not markedly distressed (eg, does not himself bring the subject up with the physician). Most importantly, the patient exhibits no impairment of social and occupational functioning, a key feature of psychiatric illness. This patient continues to function well (eg, still performs at work, enjoys socializing and leisure activities). (Choice A) Acute stress disorder is characterized by symptoms of reexperiencing (intrusive memories and flashbacks), avoidance, negative mood, dissociation, and hyperarousal lasting from 3 days to 1 month following a traumatic event. (Choice B) In adjustment disorder with depressed mood, depressive symptoms develop within 3 months of the onset of an identifiable stressor. In contrast to a normal stress response, it involves marked distress out of proportion to the stressor and/or impaired social or occupational functioning. (Choice C) Irritability, tension, and poor sleep can be seen in generalized anxiety disorder; however, this diagnosis requires excessive worries about multiple issues and duration of ≥6 months. (Choice D) Diagnostic criteria for major depressive disorder include a 2-week period of at least 5 of 9 symptoms: Depressed mood + Sleep disturbance, loss of Interest, excessive Guilt, low Energy, impaired Concentration, loss of Appetite, Psychomotor agitation/retardation, and Suicidal ideation (SIGECAPS mnemonic). This diagnosis requires significant functional impairment and may be given regardless of an identifiable precipitant. (Choice F) Although medication- or substance-induced depressive symptoms should be ruled out, there is no evidence to suggest that this patient's medication or substance use is causing his symptoms, which seem etiologically connected to his work situation. Antihypertensives seldom cause depression. Educational objective: Patients with situationally triggered depressive symptoms should be assessed for major depressive and adjustment disorders. Normal stress reactions are distinguished by lower severity and absence of marked distress or significant functional impairment. References: Overdiagnosis problems in the DSM-IV and the new DSM-5: can they be resolved by the distress-impairment criterion? (http://www.ncbi.nlm.nih.gov/pubmed/24246431) To Be or Not to Be (Stressed): the Critical Role of a Psychologically Healthy Workplace in Effective Stress Management. (http://www.ncbi.nlm.nih.gov/pubmed/26468001)

A 46-Year-Old Man with a History of Medication-Controlled Hypertension Comes