Vignette Analysis

Vignette Analysis
Name of the Student
Professor’s Name
Abstract
The prevalence of psychiatric disorders across aged individuals is a growing concern among healthcare professionals, family members, public health authorities, and the society at large. The present article reflects vignette analysis on one such stress-related disorder known as “Adjustment Disorder.” Adjustment Disorder (AD) is a type of stress-related disorder that stems from the presence or exposure to stressful events. The disorder is most common in individuals who fail to cope or adjust to such events at any point in their life. The case vignette deals with an individual named Mr. Elliot who has just retired from a responsible position from a big company. The individual is finding it difficult to adapt to his social settings post-retirement. The case vignette reflects that Mr. Elliot was suffering from “Adjustment Disorder with mixed disturbance of emotions and conduct.” Such conclusion regarding the diagnosis of Mr. Elliot was based on the diagnostic criteria and sub-criteria for “adjustment disorders” as framed by the DSM-V and ICD-10 guidelines. According to such criteria, the case vignette falls under the code 309.4.F43.24 (AD with mixed disturbance of emotions and conduct.). The separate criterion for an AD with anxiety refers to the act of nervousness, jitteriness, and separation anxiety. On the other hand, the separate standard for an AD with depressed mood signifies low mood, tearfulness, or feeling of hopelessness.

Cognitive behavioral therapy might ne helpful in managing individuals suffering from the AD.
Keywords: Attachment Disorder, DSM-V, Vignette, Cognitive Behavioral Therapy, ICD-10
Vignette Analysis
Introduction
Background
The prevalence of psychiatric and psychological disorders across aged individuals is a growing concern among healthcare professionals, family members, public health authorities, and the society at large. Moreover, the presence of psychiatric and psychological disorders is itself debilitating for the affected individuals. Such disorders not only decrease their quality of life (QOL) but also predispose the risk of accidental harm and accidental falls in concerned stakeholders. The aged and the geriatric communities are at increased risk of psychiatric or psychological disorders. Different factors contribute to the genesis of such disorders across the respective target populations. Most of these factors stem either within the family or from the community or at the workplace of the respective individual. Under certain circumstances, the individuals themselves are accountable for such debilitating disorders. Although the presence of comorbid or chronic clinical condition is a determining factor for the genesis of psychological disorders, however; the former causes are more common than the organic causes. The major types of psychiatric disorders that are commonly witnessed in the adult and geriatric community are depressive disorders, anxiety, and stress-related disorder. The present article reflects the pathophysiology, etiology and clinical management of one such stress-related disorder known as “Adjustment Disorder.” Adjustment Disorder (AD) is a type of stress-related disease that stems from the presence or exposure to stressful events. The disorder is most common in individuals who fail to cope or adjust to such events at any point in their life. The disorder is often accompanied by other comorbid disorders such as anxiety and depression (O’Connor & Zeanah, 2003). This article is based on a case-study approach of an individual named Mr. Elliot. This vignette analysis would help relevant stakeholders to diagnose and manage the projected diseased condition at their respective professional settings.
The Case Vignette
The case study is about Mr. Elliot, a 67-year old man who recently retired from the position of President of a large company. Mr. Elliot was associated with the company for last 25 years and served in different positions. His able leadership helped the company to thrive through harsh periods and overcome the economic crisis. The Board of Trustees organized a cordial farewell for Mr. Elliot and wished him a peaceful and enjoyable retired life. However, in that very meeting, one of the Board members passed a sarcastic comment about the quality of life of Mr. Elliot during his retirement phase. In fact, the audience too laughed to such a comment. Such an act could have jeopardized the self-respect, dignity, and professional attitude of Mr. Elliot at that very moment. Mr. Elliot continued to work for the company during the transition period till his day of retirement. However, he noted that the staff and his peers exhibited a cold and indifferent attitude towards him. Instead, they were getting to the exit of Mr. Elliot and welcoming of their new President. Although such a situation is quite natural in a corporate professional setting, however; Mr. Elliot seemed unprepared for such professional behavior and indifferent attitude of his peers, colleagues, and subordinates.
Perhaps, Mr. Elliot expected the same attitude from them that he was accustomed to during the past 25 years. Mr. Elliot finally bid farewell to the company and returned home with a depressed mood and was anxious regarding his voyage through the retirement phase. The case study further reflected that Mr. Elliot received the same behavior from his peers and friends within social settings. The sarcastic and humiliating comments at the workplace and within his community left Mr. Elliot depressed, irritable, and restless. Mr. Elliot found it difficult to fall asleep and exhibited little appetite. Mr. Elliot started avoiding his friends, colleagues, and peers for several weeks. Such behavior of Mr. Elliot reflects that he wanted to avoid all such cues that kindled the thoughts of different benefits, cherishes, quality of life parameters, and challenges that he enjoyed in his professional and personal life before his retirement. Perhaps, Mr. Elliot thought that staying away from such cues would help him to overcome such memories. Mr. Elliot’s attitude was evident to his wife, and she was sorry for the condition in which he had to go through. She suggested the Mr. Elliot should go for a vacation or pay a visit to their children. However, such suggestions did not touch Mr. Elliot, and his agony continued. Suddenly, one day Mrs. Elliot suggested that Mr. Elliot should get engaged in a productive manner. Although Mt. Elliot initially rebuked such an idea, however; he later nodded to her suggestions.
Every behavior of Mr. Elliot suggested that he was unprepared to accept and cope with his destined lifestyle post-retirement. The position from which Mr. Elliot retired was filled with responsibilities and challenges. A professional individual always rises to such difficulties and feel great satisfaction in overcoming them. The perks, perquisites, and financial losses are mere misnomers for individuals such as Mr. Elliot. The vignette aptly highlighted the mental agony of an individual who stays away from productive engagement. In fact, different studies suggest that productive involvement can reduce the severity of depression and improve QOL parameters across concerned stakeholders. However, the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) and ICD-10 have classified such condition as “Adjustment Disorder with anxiety and depression.” The detailed classification and diagnostic criteria for such disorders are highlighted in the following section.
Part 1: Diagnosis Section
Guidelines: DSM-V and ICD-10
The case vignette reflects that Mr. Elliot was suffering from “Adjustment Disorder with mixed disturbance of emotions and conduct.” Such conclusion regarding the diagnosis of Mr. Elliot was based on the diagnostic criteria and sub-criteria for “adjustment disorders” as framed by the DSM-V and ICD-10 guidelines. The latest literature on Adjustment Disorders classifies it as a stressor-related disorder which is caused by a specific stressor. The DSM-V guidelines (Code 309) state that an individual should be diagnosed with Adjustment Disorder if he or she exhibits emotional and behavioral disturbance to specific and identifiable stressor/stressors. Such symptoms of emotional and behavioral disturbance should be clinically relevant such as marked distress that is out of proportion to the severity and intensity of the stressor and taking into account the external context and cultural deliverables that might aggravate or mitigate the severity and presentation of such symptoms. The respective individual should also exhibit significant impairment in social and occupational functioning. The DSM-V further states that an individual should be diagnosed with an AD if the stress-related symptoms do not fall under other psychiatric or mental disorders and it should neither be an exacerbation of a preexisting mental disorder (Zeanah & Gleason, 2010).
Moreover, such symptoms should not either mimic or align with normal bereavement behavior of the respective individual. On the other hand, once the stressor is removed or alleviated, the symptoms should not relapse or persist for at least next six months. The DSM-V further went onto state that such disorders may be classified as either acute or chronic depending on the time of their development or presentation or manifestation. By comorbid presentations, the DSM-V guidelines further classified AD into six categories. According to such criteria, the case vignette falls under the code 309.4.F43.24 (AD with mixed disturbance or emotions and conduct.) The terminology “mixed disturbances” signifies symptoms of depression and anxiety, while a disturbance of conduct is also predominant. The separate criterion for an AD with anxiety refers to the act of nervousness, jitteriness, and separation anxiety. On the other hand, the separate criterion for an AD with depressed mood signifies low mood, tearfulness, or feeling of hopelessness. The case vignette reflects that Mr. Elliot satisfies all the three separate criterion for an AD with anxiety, AD with depressed mood, and AD with disturbance of conduct. Hence, it can be concluded that Mr. Elliot is suffering from AD with mixed disturbance or emotions and conduct (Zeanah & Gleason, 2010).
Likewise the most recent version of the ICD (International Classification of Diseases) with a diagnostic draft (ICD-10 and ICD-11) published by the WHO classifies Adjustment Disorder as a maladaptive reaction to identifiable psychosocial stressors or life changes that are featured by a preoccupation with the given stressor and a failure to exhibit adaptation to such stressors. The collapse in adaptation could be manifested as an array of different symptoms that interferes with the daily functions of the respective individual. For example, sleep disturbance and difficulty in concentrating can be considered as symptoms that impair everyday functioning in an individual. The ICD-11 draft further states that “individuals with AD often present with symptoms of anxiety, depression, impulse control, and conduct problems and such symptoms emerge within one month after onset of the stressor and tend to culminate within six months unless the stressor persists for a longer duration.” It is contended that for a conclusive diagnosis of AD, the respective individual must exhibit significant distress and impairment in personal, social, educational, professional, and other contextual functioning. AD is also referred as culture shock and grief reaction. However, like the DSM-V guidelines, the ICD-11 also rules out symptoms of childhood attachment disorder from AD (Zeanah & Gleason, 2010).
The ICD-11 classifies Attachment Disorder as “states of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event. Moreover, the stressor should have affected the social network or a wider system of social supports and values about such individual. Such disorder might also stem from major developmental transitions or crisis. The ICD-11 further went onto state that “individual predisposition or vulnerability plays a significant role in the genesis and manifestations of the symptoms of AD, however; such predisposition should always be associated with an identified stressor/s.” The manifestations of AD vary from one individual to another and include low mood, anxiety, or worry or a combination of all three. The concerned stakeholder exhibits an inability to cope, plan, or overcome the situation. On the other hand, conduct disorders may present as an associative feature mainly in adolescents. According to the ICD-11 guidelines, AD is predominantly featured by a brief or prolonged depression reaction, or a disturbance of other emotions and conduct (Zeanah & Gleason, 2010).
Etiology and Models of AD
Kocalevent et al. (2014) stated that Adjustment disorders (ADs) are defined as stress response syndrome. The authors said that continuing stressful events and unpleasant experiences are the primary overriding factors for Ads and no AD develop without such factors. The respective individual exhibits maladaptive response and impaired social functioning. Erstwhile, symptoms of ADs or other stress-related disorders were linked to models that underpin Post Traumatic Stress Disorder (PTSD). Such constructs were based on the etiology and manifestations of ADs. To recall, PTSD is a psychiatric disorder that is featured by recurrent thoughts of a traumatic event even in the absence of such events. It is contended that depression is the predisposing factor for bipolar disorders or comorbid psychiatric disorders. Such theory also holds true for PTSD and ADs. Hence, ADs were mainly associated with PTSD. On the other hand, the DSM-V and ICD-10 guidelines suggest that ADs might or might not be associated with depression or anxiety. The disorder is a mere reaction to an ongoing or recent stressful event. However, unlike PTSD, the recurrent thoughts of a stressful event or traumatic event usually do not persist after six months from its occurrence. On the other hand, the symptoms of ADs could be well-explained from the perspectives of neurophysiology. Low mood or depressive symptoms might stem from the unavailability of serotonin in the neuronal synapses of the reward-punishment pathway of the brain. The increased reuptake of serotonin by the pre-synaptic neurons gives rise to the symptoms of depression. On the other hand, the flight or fight response that is a hallmark of General Adaptation Syndrome (GAS) is responsible for the features of anxiety. To recall, GAS is a homeostatic physiological reaction to a stressor/s. Increased activation of the sympathetic nervous system is responsible for increased heart rate or palpitation that may accompany individuals affected with ADs. Finally, conduct disorders stem from the inability of the respective individual to cope with the specific stressor as a function of emotional disturbance. Hence, pharmacological and non-pharmacological interventions are tailored to address the organic basis of ADs. However, studies suggest that non-pharmacological interventions could play a significant role in alleviating the symptoms of AD by removing the cues that act as stressors to the concerned individual.
The prevalence of ADs markedly differs within a nation and from one nation from another. The authors stated that the incidence of ADs varies between 0.9% and 2.3% in Germany. Likewise, the prevalence of AD in Switzerland and China is 3.7%and 2.3%. The authors further stated that the prevalence of AD is significantly higher across individuals belonging to the age range of 60 years to 95 years. Such epidemiological data on AD reflects that post-retirement phase or a lack of productive engagement predisposes the risk of ADs across concerned individuals. Epidemiological data further suggests that the QOL parameters in individuals affected with ADs were higher compared to other psychiatric disorders. However, the QOL parameters were significantly less compromised in AD-affected individuals compared to their counterparts suffering from the somatic disorders. Moreover, the QOL parameters of women affected with AD was significantly lower than their male counterparts. Such findings suggest that the severity of symptoms of AD is more pronounced in women compared to their male counterparts.
Empiric data suggest that the prevalence of self-perceived stress scores were higher in individuals who were affected with AD compared to their counterparts who suffered from anxiety or other mental disorders. Till date, the cognitive models of AD are based on the genesis of PTSD. Such cognitive models emphasize on three constructs for the genesis of AD. These three constructs of AD include successful completion, chronic cognitive processing, and inhibition of cognitive processing. A recent study explored the genesis of AD based on the theoretical constructs of a cognitive model. The model concluded that AD is a specific form of distress response syndrome where intrusion, avoidance of reminders, and failure to cope with life events were considered the central processes for the genesis of ADs. Such models emphasize in understanding stress as a function of the direct effects of the resources on the perception of stress and the indirect effects on health-related aspects. Kocalevent et al. (2014) constructed a model of AD based on the transactional model of stress. The authors contended that the total effect of resources on mental health is postulated to be decomposed into direct effect of resources on mental health and the indirect effect mediated by stress. The authors conducted an observational study in 108 individuals who were admitted with ADs. The authors explored emotional distress, stress perception, and mental health variants, and resources on the development and manifestation of ADs. The authors highlighted that the primary psychiatric components pertained to the presence of a stressor.
Part 2: Theory Section
Psychotherapy: Curative factors and mechanisms of change
Although the case vignette reflects that the individual might benefit from pharmacological interventions, however; non-pharmacological interventions should be extended either alone or in combination with pharmacological interventions. The non-pharmacological interventions that could be beneficial include different modalities of psychotherapy. In this present case vignette, the individual may be managed with Cognitive Behavioral Therapy (CBT). To recall, CBT is a psycho-social intervention that focuses on developing coping strategies for an individual to overcome his or her mental health issues (Hollon and Beck, 2013). This domain of therapy integrates the behavioral and cognitive theories in psychotherapy to change negative patterns in cognition, behavior, and emotional regulation towards positive patterns (Persons & Tompkins, 1999).
Clinician’s Perspective
Although CBT was initially implemented for managing depression and depressive disorders, however; presently it is endorsed across a wide array of mental health disorders. Since the management plan of ADs is similar to that of depressive and anxiety disorders, hence; CBT would be ideal for managing the mental health condition of Mr. Elliott. Brewin (1999) highlighted that CBT effectively combines the concept of cognitive and behavioral therapies of psychotherapy for managing different mood and anxiety disorders. CBT aims to build a set of skills that help an individual to be more aware of his or her thoughts and emotions and identification of such situations, thoughts, and behaviors and the ways by which they influence one’s emotive feelings to change the dysfunctional thoughts and behaviors (Hayes et al., 2011).
From a clinician’s perspective, CBT should alleviate the symptoms of anxiety, depression, and misconduct in Mr. Elliott. Different studies have highlighted that CBT is effective in managing depression, bipolar disorders, panic disorder, post-traumatic stress disorder, and anxiety disorder (Chiang et al., 2017, Wykes et al., 2007). Hence, CBT would be a useful psychotherapeutic modality in managing individuals suffering from ADs with mixed emotion and conduct disorders. On the one hand, the role of a clinician should be to manage the symptoms of anxiety, depression, and misconduct. On the other hand, the clinician should try to alleviate the stressors from which such thoughts, emotions, and feelings that play a pivotal role in exacerbating the symptoms of anxiety, depression, mood disorders, and misconduct.
Goals of Therapy and Role of the Therapist
The goals of therapy would be specific for each case vignette. In this present case vignette, the goals of therapy should be tailored as per the social, physical, and psychological constructs of Mr. Elliot. First of all, the clinician should undertake a person-centric approach in identifying the stressors in Mr. Elliot. Although it is evident that all the symptoms in Mr. Elliott stem from his detachment from the organization for which he was working. However; the physician should try to rule out or rule in the possibilities of other stressors too. Once the stressors are identified, the physician should help the respective individual to overcome such stressors. A person-centric approach would be ideal for identifying the coping strategies within an individual to overcome such stressors. The case vignette reflects that Mr. Elliott was employed in a responsible position and is well aware regarding the norms of employment. Hence, the physician should try to make Elliott understand that retirement is a natural phenomenon for any professional and one has to accept it. However, retirement from a present position does not take away one’s skills or abilities or experience to be engaged productively. Hence, the physician should help Mr. Elliott to explore the options for productive engagement. To recall, when Mrs. Elliot suggested that Mr. Elliot should be involved in the productive engagement, Mr. Elliott did agree to such suggestion. The second goal of therapy should be to minimize the symptoms of anxiety and depression in Mr. Elliott. The pathophysiology of depression states that “depression is a mood disorder that stems from an inappropriate response of the reward-punishment pathway of the brain.”
Such philosophy is strongly aligned with the first goal of therapy. This is because the presence of stressors could have modulated the reward-punishment pathway in Mr. Elliott. Hence, decreased serotonergic transmission at the neuronal synapses in the reward-punishment pathway in the brain might have translated into the depressive symptoms in Mr. Elliott. Likewise, the pathophysiology of anxiety is underpinned by increased activation of the sympathetic nervous system by different stressors. Hence, once the stressors are minimized in Mr. Elliot, the symptoms of anxiety or depression could be automatically alleviated. The final goal of therapy would be to rehabilitate Mr. Elliott successfully in his social and family settings. Such objectives could be achieved by addressing the conduct problems in Mr. Elliott. Once again, Mr. Elliott would be made to realize the impact of his behavior on his family, friends, and society. However, such an initiative would be challenging for any physician. On the contrary, it is apparent that the conduct problems in Mr. Elliott stemmed from his state of anxiety and depression. Hence, once the symptoms of anxiety and depression are addressed in Mr. Elliot, it is contended that the episodes of misconduct would also decrease. Under such circumstances, Mr. Elliot could be successfully rehabilitated either in his professional or his personal (family/social) settings.
Structure and Orientation of the Therapy Process
The therapeutic process would be structured based on the combined principles of Brief Cognitive Behavioral therapy (BCBT) and Stress Inoculation Training (SIT). BCBT is a variant of the cognitive behavioral therapy where the average number of sessions is reduced from 12-20 sessions to 4-8 sessions. During BCBT, the primary focus would be to address limited and major problems of a patient. This is because BCBT has to be delivered under time-constraints. However, the time constraints do not always stem from the unavailability of a physician. It may also stem from the time-constraints in a patient itself. For example, in the present case vignette, it seems unlikely that Mr. Elliott would devote adequate time for therapy. This is because Mr. Elliot has been a productive individual and he may perceive such lengthy CBT sessions as unproductive. As a result, Mr. Elliott might not comply with the regime of the CBT. On the other hand, different studies have contended that time-restricted therapies provide additional incentives for both patients and their therapists. However, there are no stringent regulations on the length of the different sessions of BCBT, and the therapist is flexible to tailor such sessions as per the time limitations and needs of the patient (Rudd, 2012). The BCBT sessions that would be administered to Mr. Elliot is presented in Table 1.
Number of sessions Content of the sessions
Session 1 Orienting Mr. Elliott towards CBT
Assessing the concerns (identification of the stressors) of Mr. Elliot. Setting initial treatment plan and goals for Mr. Elliot.
Session 2 Assessing the concerns (identification of the stressors) of Mr. Elliot. Setting initial treatment plan and goals for Mr. Elliot. Initiating early treatment interventions through person-centric approach.
Session 3 Continuing with the treatment interventions and reassessment of therapeutic/treatment outcomes or goals.
Session 4 Continuation of interventions or refinement of interventions
Session 5 Continuation of interventions or improvement of interventions
Session 6 Continuation of interventions or refinement of interventions
Session 7 Continuation of interventions or refinement of interventions. Voicing for the end of treatment in consultation with Mr. Elliot and his family members.
Session 8 Ending the treatment and helping Mr. Elliot to maintain the changes that helped him to overcome the stressors and exhibit a positive behavior towards himself, his family, and to his society at large.
SIT is a type of psychotherapy that blends cognitive, behavioral, and humanistic approaches to alleviate the stressors in the concerned individual. Such approaches help an individual to cope with their stress and anxiety upon confronting the stressful event or post-stressful event. SIT is administered through a three phases, an interview phase (that includes cognitive testing, self-monitoring, and exposure to an array of reading materials), a skill acquisition phase (the individual rehearses the appropriate behavior that he or she should exhibit upon confronting the stressor), and an application phase (the way the individual should appropriately react to such stressors in real life situations). The interview phase allows the therapist to tailor the process of training as per the needs of the client. The goal of therapy is to help clients identify their mental health problem as emotion-focused or problem-focused. Such realization is essential for overcoming the negative thought processes or emotions stemming out from the defined stressors. The interview phase prepares the client to confront and reflect upon their reactions towards such stressors. During the second phase, the therapist teaches specific skills in the respective individual that would help them to overcome the stressors. The individual practices such skills in clinical settings. The major skills that are taught during this phase include skills on self-regulation, problem-solving, decision-making, and communication. The final phase deals with the application of coping skills that are learned in Phase two. This phase includes role-playing sessions and visual imageries on the likely or anticipated stressors. (Meichenbaum, 1996)
Part 3: Intake Report and Treatment plan
Identifying information The case vignette deals with an individual named Mr. Elliot who has just retired from a responsible position from a big company. The individual is finding it difficult to adapt to his societal settings post-retirement. The primary stressor the individual is facing is the lack of productive engagement and humiliation of friends and peers for going about without any productive engagement. The respective individual seems jittery at times, exhibits impaired social functioning, exhibit symptoms of anxiety and depression, and also exhibit conduct disorders. He cannot accept the fact that that he is without any productive engagement and the cold attitude of his peers bothers him the most. The case vignette also reflects that Mr. Elliot is trying to avoid his place of work or professional peers with whom he once interacted. In fact, he also cherishes to become socially excluded and also prefers to stay away from social gatherings. Such attitude is detrimental and could further aggravate the mental health condition of Mr. Elliot.
Presenting concerns Mr. Elliot often presents with symptoms of anxiety, depression, and jitteriness. The person also exhibits signs of avoidance both in his professional and personal settings.
Situational stressors The situational stressors include humiliating comments from his professional peers and friends about his retired life. Moreover, the recurrent thoughts within Mr. Elliot that he is no more with the company or respectable position could be itself a potent stressor to him. Finally, the retrenchment of fringe benefits, perks, and perquisites that he once enjoyed could also act as stressors to Mr. Elliot. There could also be a possibility that the QOL (Quality of life) parameters must have become compromised in Mr. Elliot. Although it seems unlikely that the QOL parameters have been constrained due to financial limitation, however; it might be very well possible that Mr. Elliot might have defined QOL parameters for himself. Amongst such defined QOL parameters, productive engagement and professional status might be some of them that have been jeopardized in Mr. Elliot. Hence, a deterioration of the defined QOL parameters could be considered as further stressors for Mr. Elliot.
Mental Status examination/observations (symptoms of impaired functioning) The symptoms of Mr. Elliot indicate that he is suffering from a major depressive disorder and also from PTSD which is classified as Attachment Disorder. Such conclusions could be drawn from the DSM-V diagnostic tools (Beck Depression Inventory) for MDD. First of all, the case vignette reflects that Mr. Elliot finds no pleasure in doing things that are apparently enjoyable (for example playing golf, interacting with peers or friends or paying a visit to his children or going to a vacation) for several weeks now. Such symptoms itself quality Mr. Elliot for a candidate of MDD. On the other, his symptoms of depression are confirmed by an inability to concentrate while watching television, sleep disturbance (difficulty in falling asleep), and eating disturbances (anorexia). A combination of such symptoms places Mr. Elliot at a scale of Moderate Depression. On the other hand, the jitteriness, conduct behaviors, and inability to concentrate parameters also qualify Mr. Elliot as a candidate for anxiety disorders as per the State-Trait anxiety scale. Finally, there is also a definite element of post-traumatic stress disorder in Mr. Elliot. This is evident from his avoidance behaviors to his professional peers. It seems incredibly likely that Mr. Elliot’s mental health condition deteriorates after recurrent thoughts of attachment with his company for which it once worked. However, the present case vignette reflects that symptoms of anxiety and depression persist with exposure to the specific or allied stressors. Hence,
Client’s strength and assets The client’s greatest strength is that he is knowledgeable and aware of the cues that caused his emotional disturbances. Moreover, the client already gave indications that productive engagement might help him to overcome his present mental condition.
Diagnosis The case vignette reflects that Mr. Elliot was suffering from “Adjustment Disorder.” Adjustment Disorders classifies it as a stressor-related disorder which is caused by a specific stressor. The DSM-V guidelines (Code 309) state that an individual should be diagnosed with Adjustment Disorder if he or she exhibits emotional and behavioral disturbance to specific and identifiable stressor/stressors. Such symptoms of emotional and behavioral disturbance should be clinically relevant such as marked distress that is out of proportion to the severity and intensity of the stressor and taking into account the external context and cultural deliverables that might aggravate or mitigate the severity and presentation of such symptoms. The respective individual should also exhibit significant impairment in social and occupational functioning. The DSM-V further states that an individual should be diagnosed with AD if the stress-related symptoms do not fall under other psychiatric or mental disorders and it should neither be an exacerbation of a preexisting mental disorder. The case vignette reflects that Mr. Elliot satisfied all the diagnostic criteria of Adjustment disorders as per DSM-V and ICD-10.
Differential diagnosis The case vignette reflects that Mr. Elliot was suffering from “Adjustment Disorder with mixed disturbance or emotions and conduct.” Such conclusion regarding the diagnosis of Mr. Elliot was based upon the diagnostic criteria and sub-criteria for “adjustment disorders” as framed by the DSM-V and ICD-10 guidelines. According to such criteria, the case vignette falls under the code 309.4.F43.24 (AD with mixed disturbance or emotions and conduct.) The terminology “mixed disturbances” signifies symptoms of depression and anxiety, while a disturbance of conduct is also predominant. The separate criterion for AD with anxiety refers to the act of nervousness, jitteriness, and separation anxiety. On the other hand, the separate criterion for AD with depressed mood signifies low mood, tearfulness, or feeling of hopelessness.
Theory-based conceptualization The theoretical constructs should be based on cognitive and behavioral theories of psychotherapy. This is because Mr. Elliot must perceive the benefits of his present position. It is only then his behavioral modification could take place. In simple terms, Mr. Elliot’s reward-punishment pathway has to be aligned regarding reward. Such reward could be either extended as a productive engagement or inculcation of successful coping strategies.
Treatment plan Pharmacological; Selective serotonin reuptake inhibitors (SSRIs) may be administered to ensure the availability of serotonin in the neuronal synapses of Mr. Elliot. Anxiolytics may be co-administered to reduce the symptoms of anxiety. Benzodiazepines may be planned to enhance the quality of sleep in Mr. Elliot.
Non-pharmacological: Cognitive behavioral therapy through BCBT and SIT.
Part 4: Critique of DSM-V guidelines
Although the DSM-V and ICD-10 guidelines have categorized the mental health condition that was witnessed in the present case vignette as Adjustment Disorder with mixed disturbance or emotions and conduct, however; there was no need to frame a separate section for such type of mental health condition in addition to those that already exist for anxiety disorders, stress-disorders, or depressive disorders. The diagnostic criteria of both DSM-V and ICD-10 guidelines have put particular emphasis on the generation of symptoms of anxiety, depression, and misconduct as a function of stressors. However, it is well-known that most forms of anxiety or depression do not have an organic basis. Instead, they stem from stressors to which an individual was once exposed or are persistently exposed. Such philosophies should be reconsidered by the DSM-V and ICD-10 guidelines before categorizing “Adjustment Disorder with mixed disturbance or emotions and conduct” as a separate psychiatric disorder. On the contrary, such classification could jeopardize or underestimate the severity of anxiety or depression that the individual is exposed. In fact, both these guidelines projected the state of depression as altered mood or jitteriness. A critique of this case vignette and the existing diagnostic criteria of DSM-V and ICD-10 on ADs imply that ADs should not be classified as a separate psychiatric disorder. Instead, ADs should be ranked as a combined state of anxiety, depression, and PTSD. On the contrary, it is well-known that depression is the most common underlying cause of various psychiatric disorders (including GAD and PTSD). Hence, therapeutic guidelines must emphasize primarily on the management of depression or depressive disorders in patients who present symptoms of Attachment Disorders. Such a shift in therapeutic orientation would translate into active management of ADs.
References
Brewin C (1996). “Theoretical foundations of cognitive-behavioral therapy for anxiety and depression.” Annual Review of Psychology. 47, 33–57
Chiang, Kai-Jo; Tsai, Jui-Chen; Liu, Doresses; Lin, Chueh-Ho; Chiu, Huei-Ling; Chou, Kuei-Ru (2017). “Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials”  PLOS ONE. 12 (5), e0176849
Hayes, Steven C.; Villatte, Matthieu; Levin, Michael; Hildebrandt, Mikaela (2011). “Open, Aware, and Active: Contextual Approaches as an Emerging Trend in the Behavioral and Cognitive Therapies.” Annual Review of Clinical Psychology. 7(1), 141–68
Hollon SD, Beck AT (2013). “Chapter 11: Cognitive and Cognitive-Behavioral Therapies”. In MJ Lambert. Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (6th ed.). Hoboken, NJ: John Wiley & Sons., 393–394.
Kocalevent R-D, Mierke A, Danzer G, Klapp BF (2014) Adjustment Disorders as a Stress-Related Disorder: A Longitudinal Study of the Associations among Stress, Resources, and Mental Health. PLoS ONE 9(5), e97303. 
 Meichenbaum, D (1996). “Stress Inoculation Training for Coping with Stressors.” The Clinical Psychologist. 69, 4–7
O’Connor TG, Zeanah CH (2003). “Attachment disorders: assessment strategies and treatment approaches” Attach Hum Dev. 5 (3), 223–44
Persons J. B. & Tompkins M. A. (1999). Cognitive-behavioral case formulation. In Ells, T. (Ed.). Handbook of psychotherapy and case formulation. New York: Guilford Press; 314-339
Rudd, M. David (2012). “Brief cognitive behavioral therapy (BCBT) for suicidality in military populations.” Military Psychology. 24 (6), 592–603
Wykes, T.; Steel, C.; Everitt, B.; Tarrier, N. (2007). “Cognitive Behavior Therapy for Schizophrenia: Effect Sizes, Clinical Models, and Methodological Rigor”  Schizophrenia Bulletin. 34 (3), 523–537
Zeanah C, and Gleason M (2010) REACTIVE ATTACHMENT DISORDER: A REVIEW FOR DSM-V, American Psychiatric Association.