Adaptation disorder

Adaptation disorder (a disorder of adaptive reactions) arises from significant changes in the way of life caused by the emergency. According to the Diagnostic and Statistical Manual of Mental Disorders, an adjustment disorder that can trigger stressors of varying intensity has different manifestations.

An adjustment disorder usually occurs after a transitional period. In most cases, various depressive disorders are observed in duration and structure, in some patients depression is manifested as a subjective feeling of reduced mood, hopelessness and hopelessness in the context of an adjustment disorder.

Outwardly the victims look older than their age. There is a decrease in skin turgor, early appearance of wrinkles and graying of hair. They do not actively join the conversation, they barely support the conversation, they speak in a low voice, the rate of speech is slowed down. Victims pay attention that it is difficult for them to gather their thoughts, any initiative seems impossible, it takes a strong-willed effort to do something. They note the difficulty of concentrating on one issue, the difficulty in making decisions, and then putting it into practice. The victims, as a rule, realize their inadequacy, but try to hide it, coming up with various reasons to justify their inaction.

Almost always there are violations of sleep (difficulty falling asleep, frequent nocturnal spills, early waking up in anxiety), lack of vivacity in the morning, regardless of the total duration of sleep. Sometimes nightmares are noted. During the day, the mood is lowered, eyes are easily "tucked up" on a minor occasion.

Observe the fluctuations in blood pressure that appear before the change of the weather, the earlier attacks of tachycardia, sweating, cold extremities and palpitation, deviations in the digestive system (loss of appetite, discomfort in the abdomen, constipation). In some cases, individuals who suffer from adjustment disorder are at the forefront, along with a subjectively low perceived decrease in mood, a sense of anxiety appears.

Outwardly, the victims look tense, during the conversation they are sitting in a "closed position": leaning slightly forward, shifting their legs to their legs and crossing their arms over their chests. In the conversation they enter reluctantly, wary. Initially, they do not express their complaints, but after the conversation begins to touch on the "actual topic", the pace of speech accelerates, a "metallic tint" appears in the voice. During the conversation they hardly follow the canvas of the conversation, they can not wait until the interlocutor expresses his opinion, constantly interrupting it. Answers to questions are often superficial, ill-conceived. Easily suggestible and quickly amenable to persuasion. For the task entrusted with a great responsibility, but in the future, due to the difficulty of concentration, can not track the sequence of the execution of orders, make gross mistakes and either do not bring it to the end, or complete it with a great delay.

There is also a disturbance of sleep, however, unlike the representatives of the previous group, the difficulty of falling asleep in these cases is primarily expressed in the fact that before a dream "a variety of disturbing thoughts come to mind" concerning significant issues. From the side of the cardiovascular system, as in the previous group, the increase in blood pressure is observed (however, it is more stable and less dependent on changing weather conditions), deviations in the digestive system (loss of appetite, moving with a feeling of "hunger, often accompanied by the absorption of large amounts of food).

Some people with an adjustment disorder, along with a subjectively perceived decrease in mood, develop anxiety. And in the early morning hours immediately after awakening, an alarming mood prevails, which "does not make it possible to laze in bed." Then within 1-2 hours it decreases, and the clinical picture begins to be dominated by melancholy,

During the day, the victims of this group are inactive. On their own initiative, they do not apply for help. During the conversation, they complain about a reduced mood, apathy. To alarm the representatives of this group complain only if they are examined in the evening or in case the doctor pays attention to it.

The alarm builds up in the evening and gradually decreases by midnight. The victims themselves are precisely this period of time considered "the most stable and productive", when there is no feeling of anguish and anxiety. Many of them emphasize, realize that during this period of the day you need to rest, but they begin to do household chores or watch an "interesting film" on TV, and they lie only deep after midnight.

In some cases, the adjustment disorder manifests itself in a change in lifestyle. Sometimes a person subconsciously disclaims responsibility for the well-being and health of family members. In some cases, the victims believe that it is necessary to change the place of residence. Often they move to a new place of residence, where they also can not adapt to the conditions of life. Representatives of this group begin to abuse alcohol, gradually breaking ties with the family and adjoining the environment with lower social demands and needs. Sometimes, subconsciously taking off responsibility for the well-being and health of members of their family, they are adjacent to sects. As the victims themselves explain in these cases, "new friends help to forget the old grief".

In a number of people with disabilities, adaptation is manifested by neglecting the generally accepted norms of behavior. In this case, it is not that a person considers an unseemly act unacceptable, but "necessity makes one do this", but that it is consciously defined as "completely permissible". In these cases, it is a question of reducing individual moral criteria of the individual.

[1], [2]

Adaptation disorder and grief reaction

Disorders of adaptation include the pathological reaction of grief.

Before describing the clinical picture of the pathological reaction of grief, it is advisable to state how the uncomplicated grief reaction (the emotional and behavioral response of the organism to an irreplaceable loss) is associated with loss.

Initially, the word "loss" (loss) was understood as a personal experience associated with the loss of a loved one. Somewhat later, the divorce and other types of rupture began to refer to the loss with a loved one. In addition, the loss refers to the loss of ideals and the former way of life, as well as amputation of the body part and loss of an important body function due to somatic disease. There is a special form of loss observed in people with chronic illness. For example, in chronic diseases of the cardiovascular system, a person is forced to lead a half-disabled life, to which he gradually adapts, and then gets used to it. After performing the necessary surgical operation and restoring the function, a grief reaction may occur over a limited life. 

There are losses and some other type that can also provoke a grief reaction: loss of social status, membership in a certain group, work, housing. A special place among the losses (mainly among lonely people) is the loss of beloved pets.

The loss is not only the loss of a loved one. A significant loss may be the loss of the ideals or lifestyle of the individual.

The reaction of grief is, to a certain extent, a natural reaction to loss. According to S.T. Wolff and RC Simons, the "appointment" of the grief reaction is the release of the personality from the connections with the individual who is no longer there.

The intensity of the grief reaction is more pronounced with a sudden loss. However, the degree of severity of the reaction of grief is affected by family relations with the deceased. As is known, in 75% of cases couples who lost children for a certain period of time cease to function as a single family, and subsequently the family often disintegrates. Among these couples are frequent cases of depression, suicidal attempts, alcoholism and sexual problems.

When a person is killed, not only the parents suffer. Surviving siblings not only feel guilty about remaining alive, but also perceive the torment of parents as confirmation that the dead children were loved more.

The external expression of the reaction of grief (mourning) largely determines the cultural affiliation. Ethnocultural traditions (rituals) either contribute to the weakening of the grief reaction, or prohibit it from showing.

In the grief reaction, three phases are conventionally isolated. The first phase is the phase of protest. It is characterized by a desperate attempt of the individual to restore relations with the deceased. This is expressed in the first reaction of the type "I do not believe that it happened." Some of the individuals can not accept what happened and continue to behave as if nothing had happened. Sometimes the protest is manifested in the subjective feeling of dulling of all feelings (they do not hear anything, see nothing and do not feel anything). As some authors point out, such a blocking of the surrounding reality at the very beginning of the protest phase is a kind of massive defense against loss perception. Sometimes, realizing that the individual has died, close relatives seek to return him unrealistically, for example, the wife, embracing the body of her deceased husband, turns to him with the words: "Come back, do not abandon me now." The stage of protest is characterized by sobbing and lamentation. In this case, quite often there is a marked hostility and anger, often directed at doctors. The protest phase can last from a few minutes to several months. Then it gradually gives way to the phase of disorganization (the phase of awareness of loss). In this phase, there is an awareness that a loved one is no longer there. Emotions are very intense and painful. The basic mood is deep sadness with the experience of loss. A person can also experience anger and guilt, but the deepest sadness remains the predominant affect. It is essential to note that. In contrast to depression, the reaction of grief self-esteem of the individual is not reduced.

The reaction of grief is accompanied by various physical sensations, which can provoke the environment. These include:

• loss of appetite:
• feeling of emptiness in the stomach:
• sensation of constriction in the throat;
• feeling of lack of air:
• feelings of weakness, lack of energy and physical exhaustion.

They can also be provoked by surrounding events. Sometimes these memories are subjectively transferred so hard that the individual tries to avoid them. 

One of the manifestations of the adaptation disorder is the reluctance of communication and the reduction of contacts with the surrounding microsocial environment. Patients become introvert, they are unable to show to others spontaneity and their inherent warmth.

Persons with a grief response often indicate a sense of guilt towards a deceased close person. At the same time, they may show irritability and hostility. Individuals with a reaction of grief from their relatives want to hear the words "I will help you get it back," and not words of sympathy.

In general, in this phase of grief reaction, the patient notes disorganization, aimlessness and anxiety. The individuals themselves, assessing this time in retrospect, say that everything they did was "done automatically, without feelings, and this required a lot of effort."

In this phase, the individual gradually begins to recognize the loss. He often remembers the deceased, about his last days and minutes. Many try to avoid these memories, because they are very painful: the individual understands that this connection is no more.

Many individuals dream of seeing the deceased in a dream. Some quite often see the deceased in a dream alive. For them, waking up (returning to real life) is often extremely painful. Sometimes in the daytime, individuals have auditory hallucinations: "someone tiptoed down the corridor and slammed the window," "the deceased calls by name." These hallucinations often cause a pronounced fear and force you to turn to specialists for help because of fears of "going insane". It should be noted that, as some researchers believe, the fear of going insane in individuals with an adjustment disorder does not apply to adaptation disorders and does not entail the development of serious diseases.

The phase of disorganization is followed by a phase of reorganization, lasting from several weeks to several years. In this phase, the person again turns his face to reality. The individual begins to remove from the prominent places objects belonging to the deceased. By this time, unpleasant memories associated with the death of a loved one are gradually turning pale, and pleasant memories associated with the deceased are beginning to emerge in memory.

In the third stage, the individual often begins to show interest in a new area of activity and at the same time restore old ties. At times, a person may feel guilty about the fact that he is alive and enjoying life when the deceased is absent. This syndrome in its time was described as a survivor's syndrome. It should be noted that the emerging sense of guilt is sometimes expressed quite strongly and can sometimes be projected onto a new person who has appeared in the life of an individual.

Despite the fact that much is changing, most people with an adjustment disorder have some common patterns of attitude toward the deceased:

• memories of the deceased;
• the internal maintenance of fantasies about reunion with the deceased (the idea of such a possibility is maintained by the majority of religions in the future);
• the connection with the deceased is maintained through the process of identification (in time people gradually begin to identify themselves with the deceased by habits, values and activities, for example, the wife begins to continue her husband's business in the same vein, sometimes completely unaware of it).

Finally, it should be said that a person who has experienced a loss (test) becomes more mature and wise. If an individual has adequately experienced the reaction of grief without loss, he has new values and habits, which allows him to become more independent and better cope with life's troubles.

[3], [4], [5],

Pathological reaction of grief

The most severe manifestation of the pathological reaction of grief is the absence of the reaction of grief as such: individuals who have lost a loved one do not experience any pain, sadness, or memories of the deceased. They do not show any somatic adaptation disorders. Sometimes after the loss of a loved one, the individual expresses anxiety and fear for his health due to the presence of a real chronic disease.

Often, in the pathological disorder of adaptation, the individual begins to realize his loss only after 40 days or after the anniversary of the death of a loved one. Sometimes the loss of a loved one begins to be taken very seriously after another significant loss. A case is described when the individual died a wife, after the death of which he began to mourn his mother, who died 30 years ago.

Sometimes a person begins to grieve for his close, who died at the same age as the individual has attained at the moment.

In some cases, progressive social isolation can develop, when the individual practically ceases to communicate with the surrounding microsocial environment. Social isolation can be accompanied by constant hyperactivity.

The deep sadness and guilt of the survivor can gradually turn into a clinically pronounced depression with a feeling of self-hatred. Often simultaneously, there are hostile feelings towards the deceased, which are unacceptable both for the individual himself and for the surrounding microsocial environment. Occasionally, in persons with pronounced hostility, paranoid reactions subsequently develop. Especially in relation to the doctors who treated the deceased.

Among those with an adaptation disorder, mortality and morbidity with loss of the second half during the first year of mourning is increased compared to the general population.

In some cases, people with an adjustment disorder continue to mentally communicate (talk) with the deceased and in their fantasies believe that everything they do, they do the same as they did with the deceased. At the same time, they realize that a loved one is no longer alive.

Currently, there is no single classification of adaptation disorders related to emergencies. In different classifications, the concepts of flow type (acute and chronic) are treated differently and differently determine the duration of a syndrome.

According to ICD-10, in the disorder of adaptation, "symptoms exhibit a typical mixed and changing picture and include an initial state of deafness with some narrowing of the field of consciousness and a decrease in attention, inability to adequately respond to external stimuli and disorientation." This condition can be accompanied by a further departure from the surrounding reality (up to dissociative stupor), or agitation and hyperactivity (reaction of flight or fugue). Often there are vegetative signs of panic anxiety, partial or complete dissociative amnesia of the episode is possible.

When there is an opportunity to eliminate the stressful situation, the duration of acute adaptation disorder does not exceed several hours. In cases where the stress lasts or by its nature can not stop, the symptoms begin to disappear after 24-48 hours and are reduced to a minimum within three days. At the same time, according to the diagnostic criteria of the adjustment disorder, the response of a person who has been exposed to a traumatic event includes intense fear, helplessness, or horror.

During the impact of the distress event (stressor) or after it, the individual must have three or more of the following adaptation disorders:

• subjective feeling of numbness, alienation or lack of emotional resonance;
• Reduction of the perception of the surrounding reality (the state of "deafness" or "dumbfounded");
• derealization;
• depersonalization;
• dissociative amnesia (inability to recall important aspects of trauma).

Personality is constantly re-experiencing a traumatic event, at least in one of the options:

• recurrent ideas, thoughts, dreams, illusions, flashback episodes; o feeling of revitalizing the experience;
• Distress when exposed to reminiscent moments of a traumatic event.

Observe the avoidance of stimuli that evoke memories of a traumatic event: thoughts, feelings, conversation, activity, the place of the event, people who took part. There are severe symptoms that cause anxiety and exacerbation: sleep difficulties, irritability, difficulty concentrating, supervigilance, excessive fright reaction, motor anxiety.

The existing adjustment disorder causes clinically significant distress or the inability to perform various functions.

The adjustment disorder lasts a minimum of two days, but not more than four weeks.

As can be seen from the above data, the classification of the OBM-GU-TI itself is more detailed. However, it differs significantly from ICD-10. First, acute stress disorder of adaptation includes a part of the symptoms that are referred to ICD-10 diagnostic criteria for SDP. Secondly, the duration of the acute reaction to stress, according to the ICD-10, "is reduced to a minimum within three days, even in those cases when the stress continues or by its nature can not stop." According to ICD-10, "if the symptomatology persists, then the question arises of changing the diagnosis." Thirdly, according to OBM-GU-TI, if the symptoms of acute stress disorder last more than 30 days, the diagnosis of "acute stress disorder of adaptation" should be replaced by the diagnosis of "SDP". Therefore, according to OBM-GU-TI, the AKP as a diagnosis can be exhibited only in the first 30 days after a traumatic event.

The diagnosis of the "transition period" does not exist in any classification. Nevertheless, we singled it out for the following reasons:

• in the transitional period, a clinical picture of subsequent psychopathological disorders occurs;
• it is in the transitional period, as a rule, it is possible to provide highly psychological and psychiatric assistance to the victims;
• the volume and quality of psycho-psychiatric care provided and the social activities carried out during the transition period largely determine the effectiveness of the entire range of rehabilitation measures aimed at resocializing the victims.