Management Identifying cases

A major difficulty in delivering treatment to people with adjustment disorders is the difficulty in identifying cases. There are several self-report questionnaires, which may be used to screen for patients with mood disorder. They are useful for alerting staff to the presence of mood symptoms, but their positive predictive value is too low to allow for accurate use in identifying those who need referral to specialist services. Their use is also difficult to integrate into routine clinical practice, and response rates outside research studies are usually low. (16> Their use is best restricted to specialist services where the medical staff are clear about what response they will make to a high score. There are no useful standardized instruments for the detection of other problems with adjustment.

Instead, clinicians should be encouraged to consider the possibility of psychiatric disorder when there is a gap between impairment and handicap, so that the patient is doing worse in rehabilitation than the severity of their disease would suggest they should be, when there are multiple complaints that are difficult to explain, or when multiple drug treatments are being administered without conspicuous benefit. The clinical interview is the mainstay of diagnosis.

There are a number of common reasons for failing to recognize adjustment disorders. First, the questions simply are not asked, or attempts by the patient to introduce the topic of psychological problems are blocked or side-stepped. Second, questions may be asked, but in circumstances where it is difficult for the patient to answer honestly—when there is no privacy, or the person asking is obviously too busy to listen to any but a conventional answer. Third, expressions of distress may be normalized, and thus dismissed: 'Of course it's natural you will feel like that' means to the patient 'So please don't mention it again'.

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