A 61-year old woman comes to the office due to insomnia. She has had difficulty falling asleep since her divorce was finalized 2 months ago and she relocated to a new state to be closer to her daughter and grandchildren. The patient's sleep is restless and she is frequently awakened by household noises. During this time, she has also felt anxious and tense. The patient is overwhelmed by financial worries and the responsibilities of living on her own. Although previously outgoing, she now avoids opportunities to meet new people and socializes only with her daughter. The patient has no psychiatric history but does have a history of hypothyroidism treated with levothyroxine. Physical examination is unremarkable. TSH is 1.6 µU/mL. Which of the following is the most likely diagnosis?

Question

A 61-year old woman comes to the office due to insomnia.  She has had difficulty falling asleep since her divorce was finalized 2 months ago and she relocated to a new state to be closer to her daughter and grandchildren.  The patient's sleep is restless and she is frequently awakened by household noises.  During this time, she has also felt anxious and tense.  The patient is overwhelmed by financial worries and the responsibilities of living on her own.  Although previously outgoing, she now avoids opportunities to meet new people and socializes only with her daughter.  The patient has no psychiatric history but does have a history of hypothyroidism treated with levothyroxine.  Physical examination is unremarkable.  TSH is 1.6 µU/mL.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient developed anxiety symptoms in the setting of a recent stressor (eg, divorce and relocation); the absence of previous anxiety and brief duration make adjustment disorder the most appropriate diagnosis. Adjustment disorder involves emotional or behavioral symptoms (eg, anxiety, depression, disturbance of conduct) developing within 3 months of an identifiable stressor and lasting no longer than 6 months once the stressor or its consequences ceases. Symptoms in an adjustment disorder must be distressing and impairing (eg, this patient seeks medical attention for insomnia and is socially isolative) but are insufficient to meet full criteria for another mental disorder. (Choice A) In acute stress disorder, the symptoms of re-experiencing (ie, intrusive memories and flashbacks), avoidance, negative mood, dissociation, and hyperarousal last from 3 days to 1 month following a life-threatening traumatic event. This patient's symptoms do not meet the criteria for this disorder, and her stressor is not life-threatening. (Choices C and E) Although untreated thyroid conditions and excessive doses of levothyroxine may cause mood and sleep disturbance, this patient's hypothyroidism is adequately controlled, as evidenced by her normal TSH level. (Choice D) Although anxiety, tension, and poor sleep are symptoms of generalized anxiety disorder, this diagnosis requires that symptoms last ≥6 months. (Choice F) A normal stress response is differentiated from an adjustment disorder by milder symptoms, lack of marked distress, and lack of social or occupational impairment. This patient's significant distress and impairment make adjustment disorder the correct diagnosis. Educational objective: Adjustment disorder involves emotional or behavioral symptoms occurring within 3 months of an identifiable stressor. The diagnosis is indicated when the patient has significant distress and impairment but does not meet full criteria for another mental disorder. __________ References: Adjustment disorders in primary care: prevalence, recognition and use of services. (http://www.ncbi.nlm.nih.gov/pubmed/22576725) Adjustment disorder: epidemiology, diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19845414)

A 61-Year Old Woman Comes to the Office Due to Insomnia