Psychiatry · Year 3 · from Psychiatry
Case 3: Adjustment Disorder with Mixed Anxiety and Depressed Mood
Patient Demographics
- Age: 45 years old
- Sex: Male
- Occupation: Sales manager
Chief Complaint
"Since I got laid off 2 months ago, I can't sleep, I can't think straight, and I'm snapping at my family."
History of Present Illness
The patient presents with depressed mood, anxiety, and irritability that began approximately 8 weeks ago following unexpected job loss. After 18 years with the same company, he was informed his position was eliminated due to restructuring. He describes feeling "blindsided" and "lost." He reports persistent low mood with tearfulness, particularly when thinking about his career. He worries constantly about finances, finding a new job, and what others think of him. He has applied to dozens of positions but feels hopeless about his prospects, stating "I'm too old, no one will hire me." He has difficulty falling asleep and wakes frequently, ruminating about his situation. His appetite is decreased, and he has lost 8 pounds. He has become irritable with his wife and teenage children, leading to frequent arguments. He has withdrawn from friends, not wanting to discuss his unemployment. He has stopped exercising, a previously regular habit, and spends most days at home browsing job listings or watching TV. He denies suicidal ideation but admits to feeling like "less of a man" and questions his worth to his family. Notably, his symptoms are focused specifically on his job loss; he is able to enjoy time with his children when not thinking about work.
Mental Status Examination
Appearance: Middle-aged man, appropriate dress but appearing tired, slumped posture
Behavior: Cooperative, occasionally tearful when discussing job loss
Speech: Normal rate and volume, sighing frequently
Mood: "Down" and "worried"
Affect: Dysphoric, anxious, tearful at times, reactive to content
Thought Process: Linear, goal-directed, somewhat ruminative about job loss
Thought Content:
- Preoccupied with unemployment
- Worry about finances and future
- Feelings of worthlessness related to job loss
- No suicidal ideation
- No homicidal ideation
Perceptions: No hallucinations
Cognition: Alert, oriented x4, concentration mildly impaired
Insight: Good - recognizes symptoms are related to job loss
Judgment: Fair - seeking help
Psychiatric Workup
Screening Tools:
- PHQ-9: 14 (moderate depression)
- GAD-7: 13 (moderate anxiety)
- Work and Social Adjustment Scale (WSAS): 22 (moderate impairment)
Diagnostic Considerations:
- Major Depressive Disorder: Does not meet full criteria (still experiences some pleasure, duration 8 weeks but closely tied to stressor)
- Generalized Anxiety Disorder: Worry is focused on specific stressor, not generalized
Diagnosis
Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23)
DSM-5 Criteria:
- Emotional or behavioral symptoms in response to identifiable stressor - present (job loss)
- Symptoms develop within 3 months of stressor onset - present
- Symptoms are clinically significant:
- Distress out of proportion to severity/intensity of stressor - present
- Significant impairment in functioning - present (family relationships, daily activities)
- Symptoms do not meet criteria for another mental disorder - present
- Symptoms do not represent normal bereavement
- Once stressor is resolved, symptoms would not persist >6 months (theoretical)
Specifier: With mixed anxiety and depressed mood (symptoms of both)
Treatment Plan
Psychotherapy (First-line):
- Supportive psychotherapy
- Normalize emotional response to significant loss
- Process feelings about job loss (grief for lost career identity)
- Enhance coping skills
- Problem-solving therapy
- Structured approach to job search challenges
- Practical coping strategies
- Cognitive Behavioral Therapy (brief)
- Address cognitive distortions ("I'm too old," "I'm worthless")
- Behavioral activation (resume exercise, social activities)
Pharmacotherapy:
- Not first-line for adjustment disorder
- Consider if symptoms persist or worsen:
- Start SSRI (sertraline 50 mg) if progresses toward MDD
- Short-term sleep aid if insomnia is impairing function:
- Trazodone 50 mg QHS or melatonin 3-5 mg
Practical Interventions:
- Career counseling referral
- Review finances with financial counselor if needed
- Maintain structure: daily schedule, regular activities
- Continue/resume exercise (proven benefit for mood and anxiety)
Family Support:
- Brief family meeting to discuss impact on family
- Strategies for communication during stressful period
Lifestyle Recommendations:
- Regular sleep schedule
- Daily physical activity
- Limit alcohol (can worsen mood/sleep)
- Stay socially connected (avoid isolation)
- Set realistic job search goals (quality over quantity of applications)
Prognosis:
- Adjustment disorder typically resolves within 6 months of stressor resolution or adaptation
- If patient finds employment, symptoms likely to improve significantly
- Monitor for progression to MDD if symptoms persist or worsen
Follow-up:
- Every 2-4 weeks
- PHQ-9 and GAD-7 monitoring
- Re-evaluate diagnosis if symptoms meet MDD/GAD criteria or persist >6 months