An 18-year-old woman comes to the office due to difficulty sleeping and fatigue. The patient started attending college 2 months ago and lives alone in an apartment near campus. For the past month, she has been increasingly anxious at night and thinks that someone is going to break into her home despite living on the eighth floor in a safe neighborhood. The patient makes sure to check that the front and balcony doors are secure every night and locks her bedroom door before going to bed. She wakes up multiple times a night when her air conditioner turns on or when she hears street noises and often has difficulty falling back asleep. The patient struggles to stay awake during class and is worried that her lack of sleep is beginning to affect her grades. She feels tense when walking alone on campus and spends time with friends only during the day. Vital signs are within normal limits. Physical examination shows no abnormalities. She appears anxious and reports that her mood has been okay. Which of the following is the most likely diagnosis?

Question

An 18-year-old woman comes to the office due to difficulty sleeping and fatigue.  The patient started attending college 2 months ago and lives alone in an apartment near campus.  For the past month, she has been increasingly anxious at night and thinks that someone is going to break into her home despite living on the eighth floor in a safe neighborhood.  The patient makes sure to check that the front and balcony doors are secure every night and locks her bedroom door before going to bed.  She wakes up multiple times a night when her air conditioner turns on or when she hears street noises and often has difficulty falling back asleep.  The patient struggles to stay awake during class and is worried that her lack of sleep is beginning to affect her grades.  She feels tense when walking alone on campus and spends time with friends only during the day.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  She appears anxious and reports that her mood has been okay.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's onset of anxiety and insomnia in response to a major life change (living alone for the first time) is most consistent with an adjustment disorder. Her insomnia and increased anxiety developed in relation to safety concerns about being alone and fears of intruders at night. Her fatigue, in turn, negatively impacts her studies. An 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 ceases. Symptoms of adjustment disorder are distressing and impairing but do not meet criteria for another psychiatric disorder (ie, symptoms are insufficient in number, severity, or duration for another specific diagnosis). Stressors can be single or multiple; in this case, they are multiple (eg, moving away from home, living alone for the first time, starting college, feeling academic stress). (Choice A) Acute stress disorder (ASD) involves exposure to a severe and life-threatening traumatic event, intrusive reminders of the trauma (eg, flashbacks, nightmares, memories), dissociative symptoms (eg, altered sense of reality), and/or avoidance behavior. Duration is ≥3 days and <1 month. In adjustment disorder, the stressor can be of any severity. This patient lacks both the traumatic stressor and intrusive symptoms required for an ASD diagnosis. (Choice C) Although this patient's sleep disturbance, fatigue, and tension are also seen in generalized anxiety disorder (GAD), her monthlong history of symptoms is insufficient for this diagnosis. GAD is characterized by excessive, uncontrollable worry about multiple issues (eg, school, family, finances, health) for ≥6 months. Patients typically worry about minor matters and experience a chronic course. (Choice D) This patient's worrisome thoughts are time consuming and distressing; however, she does not describe them as intrusive, which would be typical of obsessive-compulsive disorder (OCD). In addition, she does not display the repetitive, ritualistic compulsive behaviors characteristic of OCD (eg, she checks the doors only once rather than repeatedly in a compulsive manner). (Choice E) This patient's new, acute-onset symptoms in response to a stressor cannot be explained by a personality disorder alone. Paranoid personality disorder involves a lifelong pattern of pervasive distrust and suspiciousness across a wide range of interpersonal contexts. Educational objective: Adjustment disorder is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor. The diagnosis is appropriate when the patient does not meet the criteria for another psychiatric disorder. References: Adjustment disorder: a diagnosis whose time has come. (http://www.ncbi.nlm.nih.gov/pubmed/29107817) Adjustment disorder: current developments and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/31315203)

An 18-Year-Old Woman Comes to the Office Due to Difficulty