A 54-year-old woman comes to the office due to increasing anxiety and depression over the past 6 weeks. The patient was diagnosed with cutaneous squamous cell carcinoma and underwent successful surgical excision 3 months ago. Despite an excellent prognosis, she has been feeling sad and worries about her future and the possibility of recurrence. She has difficulty concentrating at work and worries that her colleagues and boss have noticed. She has avoided socializing with coworkers and friends because she does not want to explain her condition. The patient still enjoys hobbies of gardening and cooking, and spending time with her family. She reports that she tends to overeat when feeling anxious and overwhelmed, but this is not new. Her sleep and energy level are unchanged. She has no feelings of guilt, low self-esteem, or suicidal ideation. Her other medical problems include hypertension and hypercholesterolemia. Physical examination shows a small, well-healed surgical scar and is otherwise unremarkable. Which of the following is the most likely explanation for her symptoms?

Question

A 54-year-old woman comes to the office due to increasing anxiety and depression over the past 6 weeks.  The patient was diagnosed with cutaneous squamous cell carcinoma and underwent successful surgical excision 3 months ago.  Despite an excellent prognosis, she has been feeling sad and worries about her future and the possibility of recurrence.  She has difficulty concentrating at work and worries that her colleagues and boss have noticed.  She has avoided socializing with coworkers and friends because she does not want to explain her condition.  The patient still enjoys hobbies of gardening and cooking, and spending time with her family.  She reports that she tends to overeat when feeling anxious and overwhelmed, but this is not new.  Her sleep and energy level are unchanged.  She has no feelings of guilt, low self-esteem, or suicidal ideation.  Her other medical problems include hypertension and hypercholesterolemia.  Physical examination shows a small, well-healed surgical scar and is otherwise unremarkable.  Which of the following is the most likely explanation for her symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c045_249c_8f63_194ec00c4e82_MD0005_00 This patient's emotional distress (sadness, worry) and functional impairment in response to her cancer diagnosis (impaired concentration affecting work, social isolation) are most consistent with an adjustment disorder. In adjustment disorder, emotional symptoms develop within 3 months of the onset of an identifiable stressor. Adjustment disorder requires that symptoms cause clear impairment in social and occupational functioning, as demonstrated in this patient. In contrast, normal stress responses are generally less severe and do not cause significant functional impairment (Choice E). Adjustment disorder is not diagnosed if the patient meets the full criteria for another DSM-5 disorder such as major depressive disorder. Adjustment disorders are common in patients with cancer, and their identification is important as patients can benefit from counseling and brief psychotherapy. These interventions help improve quality of life by decreasing depression and anxiety symptoms and preventing progression to more serious dysfunction. Physicians should not assume that anxiety and depression are "expected reactions" to a cancer diagnosis, and it is important to differentiate normal sadness and apprehension from levels of distress that cause significant impairment. (Choice B) Illness anxiety disorder is a somatic symptom disorder characterized by excessive concern about having or developing a serious, undiagnosed general medical disease persisting >6 months. (Choice C) This diagnosis is appropriate when mental symptoms are judged to be the direct result of the physiological effects of a medical condition (eg, depressive symptoms caused by hypothyroidism). (Choice D) This patient has insufficient symptoms to diagnose major depressive disorder, which requires >2-week period of at least 5 of 9 symptoms: depressed mood plus Sleep disturbance, loss of Interest, excessive Guilt, low Energy, impaired Concentration, Appetite disturbance, Psychomotor agitation/retardation, and Suicidal ideation (SIGECAPS mnemonic). This diagnosis requires significant functional impairment and may be given regardless of an identifiable precipitant. Educational objective: Adjustment disorder involves symptoms causing marked distress and functional impairment that develop within 3 months in response to a stressor. It is important to identify adjustment disorders that occur in response to a medical diagnosis as counseling and/or psychotherapy can improve symptoms and promote a return to functioning. References: Prevalence of psychiatric morbidity among cancer patients - hospital-based, cross-sectional survey. (http://www.ncbi.nlm.nih.gov/pubmed/28066004) A longitudinal study on anxiety, depressive and adjustment disorder, suicide ideation and symptoms of emotional distress in patients with cancer undergoing radiotherapy. (http://www.ncbi.nlm.nih.gov/pubmed/27411747) Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation. (http://www.ncbi.nlm.nih.gov/pubmed/24733793)

A 54-Year-Old Woman Comes to the Office Due to Increasing