A 62-year-old woman comes to the office due to insomnia and depressed mood. She describes feeling angry and sad since her husband of 35 years unexpectedly announced that he wanted a divorce 2 months ago. She says, "I was devastated because I thought we had a pretty good marriage, better than most. My whole life has been turned upside down. I can't even think about going on dates at my age." The patient stays up well past her usual bedtime worrying about living alone and supporting herself financially. She recently started drinking wine before bedtime to help her fall asleep. Although she was regularly eating lunch with friends, she has canceled multiple times because she "can't bear to go through the whole story again and again." She has no suicidal ideation. The patient is tearful when discussing the divorce but brightens when asked about her grandchildren. Which of the following is the most likely diagnosis?

Question

A 62-year-old woman comes to the office due to insomnia and depressed mood.  She describes feeling angry and sad since her husband of 35 years unexpectedly announced that he wanted a divorce 2 months ago.  She says, "I was devastated because I thought we had a pretty good marriage, better than most.  My whole life has been turned upside down.  I can't even think about going on dates at my age."  The patient stays up well past her usual bedtime worrying about living alone and supporting herself financially.  She recently started drinking wine before bedtime to help her fall asleep.  Although she was regularly eating lunch with friends, she has canceled multiple times because she "can't bear to go through the whole story again and again."  She has no suicidal ideation.  The patient is tearful when discussing the divorce but brightens when asked about her grandchildren.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d78e_320d_bc81_0f82afe8b3b2_MD0003_00 This patient's onset of depressive symptoms following the major life stressor of divorce and the absence of symptoms severe enough to diagnose major depressive disorder make adjustment disorder with depressed mood the most likely diagnosis. Adjustment disorder involves emotional or behavioral symptoms (eg, depression, anxiety, disturbance of conduct) developing within 3 months of an identifiable stressor and lasting ≤6 months once the stressor or its consequences ceases. Symptoms in an adjustment disorder must be distressing and/or impairing (eg, this patient is distressed and seeking treatment) but are insufficient to meet full criteria for another mental disorder such as major depressive disorder. This patient has sadness, anxiety, and sleep disturbance related to the divorce and living alone. However, she does not experience the pervasive sadness, anhedonia, guilt, impaired concentration, appetite disturbance, psychomotor changes, or suicidality that characterize major depressive disorder. (Choice A) Acute stress disorder is characterized by reexperiencing events (ie, intrusive memories, flashbacks), avoidance, negative mood, dissociation, and hyperarousal lasting from 3 days to 1 month following a life-threatening traumatic event. (Choice C) Generalized anxiety disorder is characterized by excessive worry over multiple issues lasting ≥6 months. (Choice D) This patient's insomnia developed in response to a stressor. It is better explained as part of an adjustment disorder and would not be diagnosed separately. (Choice E) A diagnosis of major depressive disorder requires a 2-week period of ≥5 of 9 symptoms: depressed mood, decreased interest/pleasure, appetite disturbance, sleep disturbance, psychomotor agitation/retardation, loss of energy, excessive guilt, impaired concentration, and suicidal ideation. Educational objective: Adjustment disorder involves symptoms occurring within 3 months of an identifiable stressor that cause significant distress and/or impairment. It is not diagnosed if a patient meets diagnostic criteria for another mental disorder. References: Adjustment disorder: epidemiology, diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19558652) Seasonal affective disorder, grief reaction, and adjustment disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25134873) Adjustment disorder: prevalence, sociodemographic risk factors, and its subtypes in outpatient psychiatric clinic. (http://www.ncbi.nlm.nih.gov/pubmed/28784404)

A 62-Year-Old Woman Comes to the Office Due to Insomnia