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Answer 3
  1. Adjustment disorder with anxiety. The diagnosis of adjustment disorder is warranted when a patient experiences symptoms and functional impairment in close proximity to an identifiable stressor. Diagnosis of generalized anxiety disorder requires that symptoms be present more than 6 months and that the patient be worried about more than one problem. This patient’s symptoms are not characteristic of panic attacks, excluding the diagnosis of panic disorder without agoraphobia. Both acute stress disorder and posttraumatic stress disorder require that the precipitating stress imply a grave threat to the patient’s (or close associate’s) life or physical well-being and that the patient respond with horror or helplessness. Also, the patient with acute stress disorder or posttraumatic stress disorder must have intrusive symptoms (eg, forced recollection, nightmares, flashbacks), avoidance symptoms (eg, loss of emotional range, loss of interest in activities, estrangement), and arousal (eg, disrupted sleep, irritability, enhanced startle, decreased sleep). Acute stress disorder further requires dissociative symptoms and subsides within 1 month.1 Although this patient has some of these symptoms, divorce per se is not considered a traumatic stress. If the patient describes being in fear for his life because of his partner’s reaction to divorce or having been subjected to domestic violence during the marriage, posttraumatic stress disorder could be considered. These fears occur more frequently in women than in men, and the presence of any anxiety, especially in a woman, should prompt screening for domestic violence.2

    1.  Nesse RM, Zamorski MA: Anxiety disorders in primary care. In Primary Care Psychiatry. Knesper DJ, Riba MB, Schwenk TL, eds. Philadelphia: WB Saunders, l997:32-163.

    2. Frank JB, Radowski MF: Review of psychological issues in victims of domestic violence seen in emergency settings. Emerg Med Clin North Am 1999;17:657-677.

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