12. Adjustment disorders

Adjustment disorders result from stressors that significantly impact on the person's emotions and behaviors.

Adjustment Disorder

DSM-IV CATEGORIES

309.xx Adjustment disorder

309.0 Adjustment disorder with depressed mood

309.24 Adjustment disorder with anxiety

309.28 Adjustment disorder with mixed anxiety and depressed mood

309.3 Adjustment disorder with disturbance of conduct

309.4 Adjustment disorder with mixed disturbance of emotions and conduct

309.9 Adjustment disorder unspecified (specify if: acute/chronic)

Adjustment disorders are emotional or behavioral symptoms that develop in reaction to identifiable psychosocial stressors. It's typical for the client to experience severe impairment in social, occupational (academic), or other areas of daily functioning. Often, the presenting behaviors are exaggerated in comparison to the usual responses to a particular stressor. Common types of stressors include relationship loss or difficulties, business crises, chronic illness, occupational problems, academic distress, and struggles with certain developmental events, such as becoming a parent. The maladaptive reaction tends to occur within 3 months after onset of the stressor and persists for no longer than 6 months when the symptoms are acute. Sometimes the symptoms develop in response to a chronic stressor, such as a debilitating illness, or when the distress has prolonged consequences, such as the problems that occur after a divorce. The symptoms of an adjustment disorder don't represent bereavement situations. Adjustment disorders can begin at any age and are seen in both females and males.

SYMPTOMS ASSOCIATED WITH ADJUSTMENT DISORDERS
DISORDER TYPE	SYMPTOMS
With depressed mood	Despondent, tearful, feeling of hopelessness
With anxiety	Tense, worried, jittery, fear of separation in children
With mixed anxiety and depressed mood	Combination of emotions, such as anxiety, depression, anger, and ambivalence
With disturbance of conduct	Violation of rights of others, social norms, and rules
With mixed disturbance of emotions and conduct	Anxiety, depression, and violation of human rights and social rules
Unspecified	Physical symptoms not diagnosed as a physical condition or disorder; social withdrawal occurring without anxiety or depression; anxiety related to work, school, or learning situations

Research on the biological basis of adjustment disorders focuses on the stress hormones that are released when intense emotions are experienced. These hormones assist in mediating the body's physical and emotional responses to distress. Episodes of acute stress disrupt the hypothalamic-pituitary-adrenal pathway. (For further information, see Symptoms Associated with Adjustment Disorders.)

COMMUNICATION STRATEGIES

• Encourage the client to express his feelings.
• Obtain information on how the client perceives himself.
• Talk with the client about stressful situations and ways to relieve them.
• Have the client identify concerns about relationships and social or occupational functioning.
• Discuss the client's coping patterns and ability to tolerate stress.
• Address the existence and strength of the client's support system.
• Discuss the client's personal goals for the future.

NURSING DIAGNOSIS: IMPAIRED ADJUSTMENT

Probable Causes	Defining Characteristics
Chronic sensory or cognitive overload due to employment, family, or social stressors Current or previous involvement in a crisis situation Change in health status Loss of employment, family, or social role Lack of support systems	Difficulty problem solving Fear of change or loss in current roles or relationships Verbalization of inadequacy Difficulty managing anger and anxiety Verbalization of depression

Long-Term Goal The client will demonstrate mastery of strategies used to cope with losses or limitations.

Short-Term Goal #1: The client will acknowledge the need to change his environment, relationships, or activities to cope more effectively with loss or limitations.

Interventions and Rationales

• Have the client describe his personal lifestyle and level of functioning before the occurrence of stressors. This information helps the nurse identify the client's strengths and areas in which more effective coping is necessary.
• Encourage the client to discuss how stressors impair his capacity to function normally. Discussion of the effects ofstressors enables the client to verbalize awareness of difficulties and plan for change.
• Encourage the client to verbalize feelings associated with perceived losses, limitations, or stressors. Verbalizing feelings can decrease client anxiety and give the nurse insight into the client's situation.
• Discuss how voluntary changes in the client's environment, relationships, or activities can influence adjustment to loss or other limitations. The nurse helps the client prepare for change by talking about what needs to happen in order for change to occur.
• Have the client identify uncomfortable feelings and fears about implementing lifestyle changes. Assisting the client in acknowledging uncomfortable feelings sets the stage for dealing with them.

Short-Term Goal #2: The client will plan to assimilate needed lifestyle changes.

Interventions and Rationales

• Review coping methods that the client has been using. Review of current skills allows the client to alter or build on previous coping skills.
• Help the client brainstorm alternative methods of handling stressors. Brainstorming helps the client generate different ideas for managing problems.
• Examine with the client the positive and negative aspects of alternative methods of coping. Examining various coping strategies allows the client to evaluate how these perspectives will impact his lifestyle.
• Teach and have the client practice problem-solving strategies, such as observation (gathering and analyzing facts about a problem) and exploration (focusing on how a problem came about). Clients need assistance with developing a systematic approach to managing problems.
• Work with the client to establish new support systems or use available ones composed of family and friends. Support systems enable the client to have access to assistance in meeting needs when necessary.
• Make the client aware of community support systems and how to access them. Community resources provide the client with additional strategies for making lifestyle changes.

NURSING DIAGNOSIS: SELF-ESTEEM DISTURBANCE

Probable Causes	Defining Characteristics
Exposure to negative feed back History of family conflict Personal rejection by others History of multiple life crises	Verbalization of inadequacy Negative self-talk Projection of blame on others Sensitivity to criticism Inability to accept positive feedback

Long-Term Goal The client will verbalize a positive sense of self by making constructive statements about self and the future.

Short-Term Goal #1: The client will discuss fears and feelings.

Interventions and Rationales

• Encourage the client to explore feelings about his current life situation. Verbalization of feelings enables the client to begin exploring the origin of these feelings.
• Encourage examination of decisions and self-concepts that seem to have a negative impact on the client's life. This activity allows the nurse to help the client discover what invalid assumptions led to the poor decisions and self-concept.
• Have the client identify aspects of himself that generate negative feelings and lower self-esteem. Discussing aspects of himself that the client views as negative is the first step toward promoting client self-acceptance or changing those aspects that are thought to be undesirable.
• Discuss with the client the relation between fear of failure and negative thoughts about self. If the client understands how negative feelings such as the fear of failure generate negative thoughts about himself the client can resist labeling himself based on a single negative experience.
• Work with the client to explore fear of failure and how this fear keeps the client stuck in self-defeating behaviors. The client needs assistance in confronting the fear and developing ways tc overcome it.

Short-Term Goal #2: The client will set realistic personal goals that build on the client's positive characteristics.

Interventions and Rationales

• Work with the client to identify strengths and assets used in activities of daily living. This intervention identifies assets that may be overlooked, enhances the client's sense of personal worth, and increases self-confidence.
• Help the client identify life problems that contribute to loss of self-esteem. Many people with low self-esteem have difficulty problem solving and require assistance to make changes in their lives.
• Reinforce positive statements about abilities and self-care accomplishments, Self-esteem can be enhanced by making matter-of-fact reality statements about what the client accomplishes.

THERAPIES

The major goals of therapy are to remove the stressor or learn how to handle it and relieve associated symptoms. Therapy focuses on reestablishing a healthy level of functioning.

Individual Therapy

• Encourage the client to discuss the stressful event that precipitated the adjustment disorder.
• Help the client determine the personal meaning of the stressful situation and how it relates to past underlying conflicts and experiences.
• Use cognitive restructuring to help the client manage disturbing thoughts and behaviors.
• Help the client express and deal with distressing feelings, fears, sadness, or grief
• Help the client recognize how negative feelings can produce negative thoughts and beliefs about himself
• Assist the client in reality testing by objectively reviewing self-perceptions and evaluating interpersonal feedback from family and significant others.
• Identify and discuss the client's repertoire of coping mechanisms. Warn about the temptation to self-medicate with drugs or alcohol, which can cause addiction problems.
• Teach the client stress-reduction techniques and problem-solving skills.
• Discuss how constant stress impacts one's physiologic functioning, and help the client take steps to promote physical and emotional health.
• Work with the client to develop a sense of self-trust and independence with self-care.
• Refer to appropriate support or self-help groups because being with others who have had similar experiences may be helpful.

COMMON STRESS MANAGEMENT TECHNIQUES

Deep breathing Ten-to-one count (breathe deeply, say the number 10, stowty exhale, repeat down to number 1) Alternate-nostril breathing Progressive relaxation (active or passive) Biofeedback (promotes conscious control over Involuntary body functions, such as blood pressure and heart rate) Therapeutic touch (transfer of energy from one part of tt» body to another or transfer of the healer's energies to the client) Rotting (realignment of body structure by massaging deep connective tissue to promote emotional release and physical healing) Btoenergetics (decrease in muscle tension through the release of emotions) Autogenic training (self-regulation of the autonomic nervous system) Visualization or imagery Imagination and positive thinking Meditation Self-hypnosis Thought stopping Refuting negative or irrational self-talk

MEDICATIONS

Medications are not given to clients with adjustment disorders because the condition is typically self-limiting.

• If the client is extremely anxious, antianxiety drugs may be ordered.
• If the client is experiencing symptoms of depression, provide further evaluation and determine ifantidepressant medication is needed. (See Appendix D for medication information.)

FAMILY CARE

• Discuss the management of adjustment disorders, and explain that these conditions are usually self-limiting.
• Work with the family to identify stressors and develop ways re cope with or change precipitating conditions.
• Help family members strengthen their communication skills.
• Explore with the family the need to prepare and plan for lifestyle changes that accommodate the client's limitations in order to control how the change happens.
• Have the family discuss how lifestyle change has a better chance of happening if each family member participates in the process.
• Help family members identify and build on their strengths.
• Reinforce the family's use of problem-solving skills.
• Make referrals to self-help or support groups as needed. (For further information see Common Stress Management Techniques.)