1. Chapter 17: Adjustment Disorders & Life-Cycle Transitions Fall, 2012 Dr. Mary L. Flett, Instructor

2. 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)

3. 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

4. Adjustment Disorders: Symptoms

5. 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

6. 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

7. 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

8. Adjustment Disorders: Symptoms Emotional Turmoil Young people experience more intense & volatile emotions than adults Uncertainty about relationships and roles increases feelings of anxiety

9. 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

10. 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

11. 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

12. Family Transitions: Symptoms Typically involve addition or loss of members Includes marriage Parenting Empty nest Divorce/re-marriage

13. Family Life Cycle

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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)

21. 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

22. Family Transitions: Treatment Cognitive Behavioral Couples Therapy Emphasizes moment-to-moment interactions Styles of communication Strategies for solving problems

23. 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”

24. 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”

25. 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

26. 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

27. 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

28. 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

29. 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!)

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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