First Glance
| Fundamentals |
| Reactive Depression (Adjustment disorder)
The essential feature is a maladaptive reaction to an identifiable life event(s) or circumstance(s), which is not merely an exacerbation of one of the mental disorders and which is expected to remit, if and when the stressor ceases. The maladaptive nature of the reaction is indicated by the presence of either impairment in social or occupational function or symptoms or other behaviours that are in excess of the normal and expectable reaction to the stressor. There may or may not be a concurrent personality disorder or organic mental disorder, which may render the individual more venerable to the adjustment disorder. The stressors may be single, such as uncomplicated divorce, or multiple such as death of a loved one occurring at a time of marked business difficulties and physical illness. They may be recurrent, as with seasonal crop failures, or continuous, as with chronic illness or residence in a poverty in area. They may occur in a family setting, as with discordant intrafamilial relationship. They may be likely to be limited in effect to the patient, such as being the victim of a crime or having a psychological reaction to physical illness. Finally, they may be likely to occur in a group or community setting where the stressor involves many others such as a natural disaster, or persecution, based on racial, social, religious, cast or other group characteristics. Some stressors are associated with specific developmental stage, such as going to school, leaving the parental home, getting married, becoming a parent, not achieving occupational goals, the last child leaving home and retirement. The severity of the stressor is a complex function of the nature and number of stressors, their duration, reversibility, and the environmental and personal context. For example, the stress of losing one's parents is, not unexpectedly, different for a ten- year old than for 40-year old. The manifestations of the disorder are varied. Depressive or anxious features, or a combination of mixed emotional features, are particularly common, especially among adults. Physical symptoms may occur at any age, but are more likely to be seen in children or among the elderly. Disturbances of conduct may occur and are limited to children or adolescents. They may include assaultiveness, reckless driving, excessive drinking or other defaulting of legal responsibilities. In some instances a disturbance of conduct may be mixed with disturbances of emotions and in other instances withdrawal may be the primary presenting symptom; these manifestations may occur at any age. The age at onset and course are variable. The symptoms do not necessarily begin immediately after the stressor. The onset may be either immediate or delayed and either sudden or gradual. Although it is assumed that the adjustment disorder will remit when the stressor ceases, remission may also be either sudden or gradual and either immediate or delayed and in some instances the adjustment disorder may be chronic or even last life long because of the persistence of the stressor(s). The existence of a prior personality disorder or organic mental disorder may increase vulnerability to stress and predispose to the development of an adjustment disorder. The disorder is apparently quite common. Reactive depression needs to be differentiated from normal grief or uncomplicated bereavement which, although associated temporarily with impaired social and occupational functioning, is an -expected reaction to the loss of a loved one and thus is not considered an adjustment disorder. Other mental disorders from which an adjustment disorder must be distinguished, include major depressive disorder, chronic depressive disorder, brief reactive psychosis, generalized anxiety disorder, somatization disorder, the various substance-abuse use disorder, conduct disorders and post-traumatic stress disorders. Secondary Depression Depressive symptoms in relation to physical illnesses may persist longer and be more severe than those seen in adjustment disorders. However, it must be stressed that there is no clear separation between the two diagnostic categories of reactive and secondary depression. Usually the symptoms are depressive in nature but they can be those of anxiety also. The category of secondary depression allows a useful conceptual framework for understanding symptoms following physical illness. In secondary depression, depression follows and parallels a life-threatening medical illness. It also includes conditions associated with drug reactions as well as general medical conditions. This may be making the concept over inclusive and it would be more logical to restrict the term to describe affective illnesses (depression, anxiety) that follow the diagnosis of a medical illness whose nature is appreciated by the patient. These affective syndromes of depression with or without anxiety result from the patient's awareness of the illness and its implications. Some important differences need to be considered when diagnosing secondary depression in the medically ill compared with making a diagnosis of a primary depressive disorder. The characteristic somatic symptoms: insomnia, anorexia, weight-loss and bodily pains, do not have the same significance in this population and cannot be relied upon from a diagnostic viewpoint. They may all be attributable to physical disease rather than to emotional disturbance. Reliance must be placed on the psychological symptoms and draw attention to the importance of anhedonia and loss of interest in external matters. The depressed patients in medical wards are less deeply depressed but, with severity of depression equated, they more often had feelings of pessimism, helplessness, anxiety and self-pity but less often had suicidal feelings. The core symptoms of depression in medical patients were identified as: feeling like a failure, loss of interest in people, feeling punished, suicidal ideas, dissatisfaction, difficulty with making decisions and crying. Symptomatic depressive disorders This term is best used for depressive disorders presenting with symptoms characteristically associated with functional disorder but in which cerebral dysfunction can be assumed with reasonable certainty from the patient's clinical condition. This implies that the functional symptoms develop as a result of organic brain disease. The category of secondary depressive disorders is certainly a useful one but in the context of physical is best restricted to those disorders which appear to arise from the emotional of the illness. They therefore develop in patients who are already aware that they are ill and who have evaluated the implication of their illness. In contrast, the term 'symptomatic' should be applied to all psychiatric syndromes presenting with functional symptoms in which cerebral pathology can be inferred with reasonable certainty. Symptomatic disorders often occur in people who are unaware that they are physically ill and the disorders consequently assume special significance as the initial manifestation of an illness that has not yet declared itself. They can take the form of any functional disorder but depressive and anxiety disorders are the commonest .They emphasise the importance of a thorough physical examination in all psychiatrically ill patients. Mood disorders should be suspected of being symptomatic of an underlying physical illness especially in the following circumstances :
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