Chapter 17: Adjustment Disorders &

Life-Cycle Transitions

Fall, 2012

Dr. Mary L. Flett, Instructor

Overview Upsetting but normal emotions may result from

difficult life events. Adjustment disorders are a response to stress

that, while clinically significant, are not severe enough to be diagnosed as a mental disorder

Other conditions that may be the focus of clinical attention include partner relational problems bereavement phase of life problems

Adult development includes its own challenges Life cycle transitions (adulthood, family transitions, later life)

Adjustment Disorders: Symptoms

Clinically significant symptoms in response to stress, but not severe enough to be diagnosed as a mental disorder Similar to acute stress DSM does not go into detail on these issues Erik Erikson’s Stages of Development

Focus is on resolving conflict of particular stage Is not pathological unless conflict remains unresolved and

causes problems

Adjustment Disorders: Symptoms

Adjustment Disorders: Symptoms Erikson believes resolution of identity crisis

allows young adults to embark on a journey toward achieving long-term life goals (first crisis of adulthood)

One life-goal is forming intimate relationships and true intimacy (second crisis of adulthood)

Third crisis of adult life is generativity vs. stagnation – career and family achievements

Last stage – integrity vs. despair integrity comes from acceptance instead of regret Despair comes from impossible desire to change

the past and yearning for a second chance

Adjustment Disorders: Symptoms Other adult stage theorists focus on social

relationships Daniel Levinson

“Seasons” in a Man’s Life (roughly 20-year intervals) Early adult transition Midlife transition Late adult transition

Caution in interpreting stages of adult development Many factors that influence adult development Transitions may not be so predictable Don’t know when life will “end” so how can transitions be

predicted

Adjustment Disorders: Symptoms

Don’t ask “who am I” until young adulthood Create a life story Resolve identity crisis Changes in roles and relationships

College, career, family Conflicts in parent-child relationships

Individuation Conflicts between moving toward, moving away, moving

against (Horney, 1939) Increased relationships with peers; decreased relationships

(and influence) by parents

Adjustment Disorders: Symptoms

Emotional Turmoil Young people experience more intense & volatile

emotions than adults Uncertainty about relationships and roles

increases feelings of anxiety

Adjustment Disorders: Diagnosis

DSM-III listed “identity disorder” as a mental disorder; DSM-IV demoted it to focus of clinical attention

Frequency of Identity Conflicts Takes longer to become an “adult” than a

generation ago Cultural climate plays role Economics play role

Adjustment Disorders: Diagnosis

Causes of Identity Conflicts Most successful young adults have parents who

continue to provide support and supervision while allow them to increase independence

Identity crisis may be reflection of Western, industrialized societies

Gender roles influence formation of identity Women may form an identity based on relationships rather

than career

Adjustment Disorders: Treatment

Evidence suggests many young adults seek counseling during this time of life, but no one approach has been studied to determine effectiveness

Supportive, non-directive therapy seems to be the best

Family Transitions: Symptoms

Typically involve addition or loss of members Includes marriage Parenting Empty nest Divorce/re-marriage

Family Life Cycle

Family Transitions: Symptoms

Family conflict Marital satisfaction declines after birth of first child Power struggles and intimacy struggles Reciprocity

Positive feelings reflected back; negative feelings overlooked Negative feelings reflected back; positive feelings overlooked

Demand & withdrawal pattern Wife becomes more demanding; husband withdraws Conflicts go unresolved Marital conflicts lead to fights with children

Family Transitions: Symptoms

Emotional Distress How the conflict is expressed

Sharing of anger Use of “you” is predictor of problems; “I” a predictor of

resolution of problems Unresolved conflicts lead to emotional distress

Emotional distress linked with depression Painful part of separation and divorce

Family Transitions: Symptoms

Cognitive Conflicts Changes in family roles cause problems; “Who

am I now?” Role change in divorce; death of spouse

Acceptance and change a must if harmony is to be achieved

Family Transitions: Diagnosis

Families and relationships not in DSM; just individuals Some argue there needs to be categories for

families & partnerships known as relational disorders

Frequency Census Bureau collects information on certain

family transitions Marriage & Divorce Childbirth outside of marriage

Family Transitions: Causes

Psychological Factors Communication includes

verbal and nonverbal behaviors John Gottman identified following styles of

communication as being critical in a relationship Criticism Contempt Defensiveness Stonewalling

Family Transitions: Causes

Psychological Factors Family Roles

“Traditional” roles vs. “Androgynous” Androgynous is happier!

Social Factors Poverty, unemployment, crowded living

conditions, limited social support can cause substantial distress

Teenage pregnancy, non-marital childbirth divorce, family violence

Family Transitions: Causes

Biological Factors Chicken and Egg debate: Does family distress

cause individual distress or vice versa? Onset of menstruation (menarche) has interesting

biological correlation step father in home, earlier menarche mother’s early age of menarche, early age for daughter(s)

Family Transitions: Treatment

Prevention Programs “Couples Weekends” & “Encounter Groups”

Historically run by the Church Few data on couples of color or LGBT couples

Pre-Marital Counseling Work on communication issues, explore values, identify

potential conflicts and learn problem-solving skills Couples Therapy & Family Therapy

Focus is on changing relationships, not individuals Negotiation skills Break cycles of negative interactivity

Family Transitions: Treatment

Cognitive Behavioral Couples Therapy Emphasizes moment-to-moment interactions

Styles of communication Strategies for solving problems

Later-Life Transitions:

When does “old” start? 65 is an arbitrary marker Physical and emotional changes occur in the 40’s

and 50’s Menopause for women

60s typically is a change from working to retired 70’s and 80’s are focused more on physical

ailments and mortality 90s and 100+ typically housed in long-term care

facilities, out of “mainstream”

Later-Life Transitions:

Ageism Form of social prejudice View of elders as stubborn, irritable, bossy, and

complaining Elders “disappear” into 55+ retirement

communities or nursing homes Frequent observations that “I am not useful any

more”

Later-Life Transitions: Symptoms

Physical Functioning and Health Decline with age when disease process is present Physical activity is a good predictor of

psychological well-being Menopause

Average age of onset in US is 51 years “Hot flashes” Mood swings Memory changes Hormonal changes and role changes

Later-Life Transitions: Symptoms Sensation & Physical Movement

Gradual decline of sensory systems throughout life, but most noticeably after age 70 Eyes adapt to darkness or light more slowly Hearing loss Sensitivity to taste, smell, and touch decline

Muscle mass changes 80% of muscle strength retained Bone loss, particularly after menopause, is problem form

women Chronic illness

Arthritis, cardiovascular disease, cancer, diabetes, sleep disorders

Later-Life Transitions: Symptoms

Life Satisfaction, Work & Relationships Psychological well-being remains remarkably

intact, in spite of physical changes Positive relationships Spiritual/Religious beliefs

Greater sense of “mastery” in personal and work relationships

Retirement a “mixed” blessing For those who want to continue to work, it brings more choice For those who have to work, it brings stress For those who can’t work, it brings loss and status changes

Later-Life Transitions: Symptoms

Erikson’s Integrity v. Despair Finding meaning in life

Who am I now? How do I compare to who I thought I was?

Relationships Quality of friendships is important, not number Having a support system Family relationships

Siblings Children Grandchildren

Later-Life Transitions: Symptoms

Relationships Loss of spouse/partner particularly difficult Remarriage/new relationships

Health issues, including HIV Concerns by children; elder abuse

Grief & Bereavement “Grief” is the emotional and social process of

coping with loss “Bereavement” is a specific form of grieving in

response to loss of a loved one (may include pets!)

Later-Life Transitions: Symptoms

Grief & Bereavement Elizabeth Kubler-Ross – 5 stages of dying

denial anger bargaining depression acceptance

Actual experience for most people is not linear, but all stages are experienced universally

Later-Life Transitions: Symptoms

Grief & Bereavement Experience of loss is different at different times of

life Loss of child Unexpected death of “young” person More prepared for death of an elder because “s/he lived a long

life” Bereavement is in DSM as a disorder

Later-Life Transitions: Symptoms

Mental Health Mood and anxiety disorders most common Psychological issues are under-treated in elders Suicide risk is especially high

Rational suicide Assisted suicide

Later-Life Transitions: Diagnosis

Gerontology is the multidisciplinary study of aging Young-old (65-75) Old-old (75-85) Oldest-old (85+) More women in oldest-old

Later-Life Transitions: Frequency

1 in 8 people living in the US is over 65 3.5 million are 85+ Baby boomers will be a wave of aging challenges Poverty rates are higher among elders More women than men; more women living alone Community-dwelling elders are more common

than long-term care/residential care; this is changing

Later-Life Psychological Problems: Causes

Good physical health is most important contributor to feelings of life satisfaction

Health behavior associated with better outcomes Exercise, good diet, moderate Etoh consumption All tied to improved cognitive functioning Not about longevity; healthy active life until death

Spiritual belief and practices very important Help to deal with loss Help to cope with decline in physical functioning

Later-Life Psychological Problems: Treatment

Good medical care and collaboration among providers is key Behavioral gerontology

Focus is on maintaining or improving quality of life End of life issues