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A 4-year-old boy, who was seriously injured in a motor vehicle collision, is transferred to a pediatric
rehabilitation unit after being stabilized over a 2-week period at a level 1 hospital. His rehabilitation team
consults child psychiatry due to concerns about a possible anxiety disorder. Staff report he becomes worried
whenever his parents are not able to stay with him, gets anxious about pending medical procedures, and
struggles with getting to sleep. He has no premorbid psychiatric history. Which of the following is the most
likely diagnosis?

AAdjustment disorder with anxietyCorrect Answer

BGeneralized anxiety disorder
CPost-traumatic stress disorderYour Answer
DSeparation anxiety disorder
ESpecific phobia, blood-injection-injury type

Correct Answer ( A )
Explanation:

Adjustment disorder with anxiety is the most likely diagnosis in a child with no premorbid psychiatric history
who presents with 2 weeks of anxiety symptoms after being seriously injured in a motor vehicle collision.
Criteria for adjustment disorder are rather vague, basically requiring the development of emotional or
behavioral problems within 3 months of an identifiable stressor, distress out of proportion to the context
or significant functional impairment, and symptoms that do not meet criteria for another psychiatric
disorder. Specifiers are available to indicate the predominant symptoms (e.g., anxiety, depressed mood,
conduct). Studies have indicated that adjustment disorder is the most common diagnosis (up to 50%) in the
setting of psychiatric consultation on inpatient medical units. A significant change in the DSM-5 was to include
adjustment disorders within the category of trauma- and stressor-related disorders, all of which are based on a
specific etiology (acute stress disorder, post-traumatic stress disorder, reactive attachment disorder, disinhibited
social engagement disorder). However, due to the vagueness of the symptom criteria and excessive reliance on
clinical judgment as to what reactions are out of proportion to specific stressors under particular circumstances,
the validity and reliability of the diagnosis are less than desirable. Given the heterogeneity of the disorder and
lack of clear definition, there is also a lack of evidence-based research on appropriate treatment. Various
psychotherapies (e.g., supportive, cognitive behavioral, problem-solving) are usually the first-line interventions.
Medications are most commonly used for insomnia, moderate to severe depressive symptoms, and short-term for
acute anxiety. Treatment is based on the particular symptom presentation and the expectation that the condition
will resolve within 6 months of the stressor or its consequences. Although this is supported in the literature in the
adult population, youth appear to have longer-lasting symptoms and a higher risk of transition into other
psychiatric disorders and associated morbidity. Research has consistently shown that there is an increased risk of
suicidality in individuals with adjustment disorders, especially adolescents.

Generalized anxiety disorder (B) is characterized by at least 6 months of excessive anxiety and worry about a
number of events or activities, difficulty controlling the worry, and at least three associated symptoms (e.g.,
fatigue, irritability, muscle tension) in adults or at least one associated symptom in children. For children under
the age of 7 years, a diagnosis of post-traumatic stress disorder (C) requires the child directly experienced,
witnessed, or heard about specific major traumatic events happening to a parent or a caregiving figure. The child
must also experience or exhibit more than a 1-month duration of manifestations from specific symptom
categories, including intrusive symptoms, avoidant symptoms or negative alterations in cognition, and
alterations in arousal and reactivity. Separation anxiety disorder (D) refers to developmentally inappropriate
and excessive fear or anxiety about being separated from a primary attachment figure, and it requires at least
three manifestations of this fear or anxiety for at least 4 weeks in children. Specific phobia, blood-injection-
injury type (E), is characterized by at least 6 months of marked fear or anxiety about needles, blood, injections,
injury, or other medical care.

Question: True or false: arctic hysteria is a psychosis experienced by explorers in the Arctic Circle due to the
lack of diverse stimuli in the snow-clad surroundings.

Reveal Answer: False. White-out syndrome is the correct designation for this condition. Whether arctic hysteria
is a real syndrome is controversial, and it was not included in the DSM in the most recent version.
Trauma- and Stressor-Related Disorders

Etiological requirements

Reactive attachment disorder and disinhibited social engagement disorder

Experiences of pathogenic care in childhood
Social neglect or deprivation
Repeated changes in primary caregivers
Rearing in unusual setting (high child to caregiver ratios in institutions)
Acute stress disorder and post-traumatic stress disorder
Exposure to actual or threatened death, serious injury, or sexual violence (includes sexual
exploitation)
Directly experiencing the traumatic event
Witnessing, in person, the event as it occurred to others
Learning a traumatic event occurred to a close family member or friend
Experiencing repeated or extreme exposure to aversive details of traumatic events (e.g., first
responders)
Adjustment disorders
Any identifiable stressor occurring within 3 months of the onset of Sxs
Stressor may include severe stressors required for PTSD or acute stress disorder
In the presence of severe stressors, as required for PTSD or acute stress disorder, differentiating an
adjustment disorder from acute stress disorder or PTSD is dependent on the clinical manifestations

References:

1. 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
American Psychiatric Publishing; 2013.
2. 2. Katzman JW, Geppert CMA. Adjustment disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan &
Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Wolters Kluwer; 2017:(Ch) 25.

Reviewed February 2021

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Category: Adjustment Disorders

Subcategory: Adjustment Disorders

Question: 107312
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 A. A 74%
B. B 1%
C. C 3%
D. D 20%
E. E 2%

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Normal Lab Values

25-hydroxyvitamin D, serum 25–80 ng/mL 62–200 nmol/L
Activated partial thromboplastin time (APTT) 25–35 seconds 25–35 seconds
Adrenocorticotropic hormone (ACTH) 9–52 pg/mL 2–11 pmol/L
Alanine aminotransferase (ALT) 0–35 U/L 0–0.58 µkat/L
Albumin 3.5–5.5 g/dL 35–55 g/L
Alkaline phosphatase 45–115 U/L (men), 30–100 U/L (women) 0.75–1.92 µkat/L (men), 0.50–1.67 µkat/L
(women)
Ammonia 40–80 µg/dL 23–47 µmol/L
Amylase 0–130 U/L
Anion Gap 8–16 mEq/L 8–16 mmol/L
Aspartate aminotransferase (AST) 0–35 units/L 0–0.58 µkat/L
Bands < 1 x 10,000/µL < 1 x 10,000/mm3
Bicarbonate 23–28 mEq/L 23–28 mmol/L
Bilirubin, direct/conjugated 0–0.3 mg/dL 0–5.1 µmol/L
Bilirubin, total 0.3–1.2 mg/dL 5.1–20.5 µmol/L
Blood urea nitrogen (BUN) 8–20 mg/dL 2.9–7.1 mmol/L
B-type natriuretic peptide (BNP) <100 pg/mL < 100 ng/L
Calcium (ionized, adult) 4.5–5.6 mg/dL 1.05–1.3 mmol/L
Calcium (total) 9–10.5 mg/dL 2–2.6 mmol/L
Ceruloplasmin 16–31 mg/dL (men), 19–39 mg/dL (women)
Chloride 98–106 mEq/L 98–106 mmol/L
Cholesterol (Total: Adult) 150–199 mg/dL 3.88–5.15 mmol/L
COHb (%) Non Smoker: < 2% Smoker: <9% Non Smoker: < 2% Smoker: <9%
Copper 63.7–140.12 µg/dL 12–22 µmol/L
Cortisol (bedtime) 3–13 µg/dL 83–359 nmol/L
Cortisol (free, urine) < 50 µg/24 h 138 nmol/24 h
Cortisol (morning) 10–20 µg/dL 275.88–551.76 nmol/L
C-peptide - serum 0.5–2.0 ng/mL 0.17–0.66 nmol/L
C-reactive protein (CRP) < 5 mg/L
Creatine kinase (CK) 30–170 U/L 0.50–2.84 µkat/L
Creatinekinase – MB fraction (CK-MB) 0–7 ng/mL 0–7 µg/L
Creatinine 0.7–1.3 mg/dL 61.9–115 µmol/L
CSF Cell count 0-5 cells/µL 0-5 × 10⁶ cells/L
CSF Glucose 40–80 mg/dL 2.2–4.4 mmol/L
CSF Opening pressure 7-20 cm of H20
CSF Protein 15–50 mg/dL 150–500 mg/L
D-dimer < 0.5 µg/mL < 500 ng/mL
Erythrocyte sedimentation rate (ESR) 0–15 mm/hr (men) 0–20 mm/hr (women)
Estradiol (female, day 1-10) 14–27 pg/mL 50–100 pmol/L
Estradiol (female, day 11-20) 14–54 pg/mL 50–200 pmol/L
Estradiol (female, day 21-30) 19–41 pg/mL 70–150 pmol/L
Estradiol (male) 10–30 pg/mL 37–110 pmol/L
Ferritin, serum 15–200 ng/mL 15–200 µg/L
Fibrinogen, plasma 150–350 mg/dL 1.5–3.5 g/L
Follicle-stimulating hormone (female, follicular/luteal phase) 5–20 mU/mL 5–20 U/L
Follicle stimulating hormone (female, midcycle) 30–50 mU/mL 30–50 U/L
Follicle stimulating hormone (female, postmenopausal) > 35 mU/mL > 35 U/L
Follicle stimulating hormone (male) 5–15 mU/mL 5–15 U/L
Free Thyroxine (T4), serum 0.9–2.4 ng/dL 12–31 nmol/L
Free Triiodothyronine (T3), serum 2.3 - 4.2 pg/mL 0.04-0.06 pmol/L
Gastrin 0–180 pg/mL 0–86.58 pmol/L
GGT level 0 to 30 IU/L
Glucose (fasting) 70–100 mg/dL 3.9–5.6 mmol/L
Glycosylated hemoglobin 4%–5.9% 4%–5.9%
Haptoglobin 50–150 mg/dL 500–1500 mg/L
HDL (Men) ≥ 40 mg/dL 1.0 mmol/dL
HDL (Women) ≥ 50 mg/dL 1.3 mmol/dL
Hematocrit (Hct) (Female) 36–47% 0.36–0.47
Hematocrit (Hct) (Male) 41–51% 0.41–0.51
Hemoglobin (Hgb) (Female) 12–16 g/dL 120–160 g/L
Hemoglobin (Hgb) (Male) 14–17 g/dL 140–170 g/L
Insulin - serum < 25 mU/L < 174 pmol/L
Iron 60–160 µg/dL 11–29 µmol/L
Lactate dehydrogenase (LDH) 60–100 units/L 1.00–1.67 µkat/L
Lactic acid 6–16 mg/dL 0.67–1.8 mmol/L
LDL < 100 mg/dL
Lipase < 95 U/L < 1.59 µkat/L
Luteinizing hormone (female, follicular/luteal phase) 5–22 mU/mL 5–22 units/L
Luteinizing hormone (female, midcycle) 30–250 mU/mL 30–250 units/L
Luteinizing hormone (female, postmenopausal) > 30 mU/mL > 30 units/L
Luteinizing hormone (male) 3–15 mU/mL 3–15 units/L
Lymphocytes 1,000–4,000/µL (20–40%) 1,000–4,000/mm3 (20–40%)
Magnesium 1.5–2.4 mg/dL 0.62–0.99 mmol/L
Mean corpuscular hemoglobin concentration (MCHC) 32–36 g/dL 320–360 g/L
Mean corpuscular hemoglobin (MCH) 28–32 pg 0.4–0.5 fmol/cell
Mean corpuscular volume (MCV) 80–100 fL/red cell
Metanephrines (urine) < 1.2 mg/24 hours < 6.1 mmol/24 hours
Monocytes 100–700/µL (2–8%) 100–700/mm3 (2–8%)
Neutrophils 2500–8000/µL (55–70%) 2500–8000/mm3 (55–70%)
Parathyroid hormone (PTH) 10–65 pg/mL 10–65 ng/L
PCO₂ 35–45 mm Hg 4.7–6 kPa
pH 7.35-7.45 7.35-7.45
Phosphorus 3–4.5 mg/dL 0.97–1.45 mmol/L
Platelets 150,000–350,000/µL 150–350 × 10⁹/L
PO₂ 80–100 mm Hg 10.6–13.3 kPa
Potassium 3.5–5.0 mEq/L 3.5–5.0 mmol/L
Procalcitonin (adults and children > 72 hours old) < 0.15 ng/mL
Prolactin (Men) < 15 ng/mL < 15 µg/L
Prolactin (Nonpregnant women) < 20 ng/mL < 20 µg/L
Prolactin (Pregnant women) 36–372 ng/mL 36–372 µg/L
Protein C 65 to 135 IU dL-1
Prothrombin time (PT) 11–13 seconds 11–13 seconds
Pyruvate 300–900 µg/dL 34068.00–102204.00 µmol/L
Red blood cells (RBC) 4.7–6.1 x 10⁶/µL (men), 4.2–5.4 x 10⁶/µL (women)
Red cell distribution width (RDW) 11.6–14.6% 11.6–14.6%
Reticulocytes 0.5%–1.5% 0.5%–1.5%
Reverse Triiodothyronine (T3), serum 10–24 ng/dL 10–24 ng/dL
Sodium 136–145 mEq/L 136–145 mmol/L
Testosterone (adult male) 300–1200 ng/dL 10–42 nmol/L
Testosterone (female) 20–75 ng/dL 0.7–2.6 nmol/L
Thyroid-stimulating hormone (TSH) 0.5–5.0 µU/mL 0.5–5.0 mU/L
Total iron-binding capacity (TIBC) 250–460 µg/dL 45–82 µmol/L
Total Serum Protein 6.0–7.8 g/dL 60–78 g/L
Total Thyroxine (T4), serum 5–12 µg/dL 64–155 nmol/L
Total Triiodothyronine (T3), serum 70–195 ng/dL 1.1–3.0 nmol/L
Transferrin 200–360 mg/dL 24.60–44.28 µmol/L
Transferrin saturation 20–50% 20–50%
Triglycerides <150 mg/dL < 1.69 mmol/L
Troponin I 0–0.5 ng/mL 0–0.5 μg/L
Troponin T 0–0.10 ng/mL 0–0.10 µg/L
Tryptase < 11.5 ng/mL < 11.5 ng/mL
Urea 17–43 mg/dL 2.8–7.2 mmol/L
Uric acid, serum 2.5–8 mg/dL 0.15–0.47 mmol/L
White blood cells (WBCs) 4,000–10,000/µL 4.0–10.0 x 10⁹/L