A 22-year-old woman comes to student health services for evaluation of low mood and anxiety. The patient received a rejection letter a week ago from her top choice for graduate school. Although she has received multiple acceptance letters from other programs, she feels like a "failure" and has not spoken to any of her friends or family for the past few days because she is too ashamed. The patient angrily states, "I have classmates that got much worse grades and have no publications, but they all got into better schools than I did." She has been staying in bed instead of attending classes and has been eating large amounts of junk food. The patient says that her life is now "pointless" and that she would be "better off dead." She has no medical or psychiatric history. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

Question

A 22-year-old woman comes to student health services for evaluation of low mood and anxiety.  The patient received a rejection letter a week ago from her top choice for graduate school.  Although she has received multiple acceptance letters from other programs, she feels like a "failure" and has not spoken to any of her friends or family for the past few days because she is too ashamed.  The patient angrily states, "I have classmates that got much worse grades and have no publications, but they all got into better schools than I did."  She has been staying in bed instead of attending classes and has been eating large amounts of junk food.  The patient says that her life is now "pointless" and that she would be "better off dead."  She has no medical or psychiatric history.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d771_5b21_bc81_49902f9aee1d_MD0003_00 This patient's 1-week history of mood symptoms in direct response to receiving a rejection letter is most consistent with an adjustment disorder. Adjustment disorder involves emotional or behavioral symptoms that develop within 3 months of an identifiable stressor. In contrast to a normal stress response, symptoms are excessive or out of proportion to the stressor and result in significant distress and functional impairment. Although this patient is currently experiencing several depressive symptoms (ie, low mood, feelings of failure, increased appetite, passive suicidal ideation), her 1-week duration of symptoms is insufficient to meet diagnostic criteria for major depressive disorder (MDD) (Choice F). In MDD, symptoms must persist for at least 2 weeks and include at least 5 of the following 9 symptoms: depressed mood plus SIGECAPS (Sleep disturbance, loss of Interest, excessive Guilt, low Energy, impaired Concentration, Appetite disturbance, Psychomotor agitation/retardation, Suicidal ideation). (Choice A) Acute stress disorder requires exposure to a life-threatening traumatic event. It is characterized by reexperiencing events (ie, intrusive memories, flashbacks), avoidance, negative mood, dissociation, and hyperarousal lasting from 3 days to 1 month. (Choices C and E) This patient shows some features that are also seen in borderline personality disorder (eg, angry response to rejection, unstable mood, suicidality) and histrionic personality disorder (eg, excessive emotionality). However, diagnosis of personality disorders requires evidence of pervasive patterns of dysfunctional interpersonal behavior that are stable and of long duration. This patient's 1-week history of symptoms in direct response to a stressor is more consistent with adjustment disorder. (Choice D) Disruptive mood dysregulation disorder is a pediatric mood disorder characterized by persistent irritability (≥1 year) and frequent temper outbursts that begin prior to age 10. Educational objective: Adjustment disorder is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor. Symptoms cause significant distress and functional impairment but do not meet the criteria for another mental disorder. References: Adjustment disorder: current developments and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/31315203) Adjustment disorder: a diagnosis whose time has come. (http://www.ncbi.nlm.nih.gov/pubmed/29107817)

A 22-Year-Old Woman Comes to Student Health Services for Evaluation