Adjustment disorder

Last updated
Adjustment disorder
Specialty Psychiatry, clinical psychology   OOjs UI icon edit-ltr-progressive.svg
Complications Suicide; [1] Progression to more serious psychiatric disorders, e.g., PTSD or major depressive disorder
Usual onsetTheoretically, within one to three months after a stressful event
DurationTheoretically, up to six months unless the stressor or its consequences continue
TypesMild, moderate, severe
Risk factors History of mental disorder; low social support
Differential diagnosis Rule out PTSD, depressive disorders, & anxiety disorders
TreatmentPsychotherapy; bibliotherapy; structured paraprofessional help
Prognosis Relatively good compared to many other mental disorders, but severity varies

Adjustment disorder is a maladaptive response to a psychosocial stressor. It is classified as a mental disorder. [2] The maladaptive response usually involves otherwise normal emotional and behavioral reactions that manifest more intensely than usual (considering contextual and cultural factors), causing marked distress, preoccupation with the stressor and its consequences, and functional impairment. [3] [4] [5] [6]

Contents

Diagnosis of adjustment disorder is common. Lifetime prevalence estimates for adults range from five percent to 21%. [7] Adult women are diagnosed twice as often as men. Among children and adolescents, girls and boys are equally likely to be diagnosed with an adjustment disorder. [8]

Adjustment disorder was introduced into the Diagnostic and Statistical Manual of Mental Disorders in 1980 (DSM-III). [9] [10]

Other names for adjustment disorder are stress response syndrome (new name as of 2013) and situational depression since it is one of the most common symptoms. [11]

Signs and symptoms

Some emotional signs of adjustment disorder are: sadness, hopelessness, lack of enjoyment, crying spells, nervousness, anxiety, desperation, feeling overwhelmed and thoughts of suicide, performing poorly in school/work etc. [12]

Common characteristics of adjustment disorder include mild depressive symptoms, anxiety symptoms, and traumatic stress symptoms or a combination of the three. According to the DSM-5, there are six types of adjustment disorder, which are characterized by the following predominant symptoms: depressed mood, anxiety, mixed depression and anxiety, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified. However, the criteria for these symptoms are not specified in greater detail. [8] Adjustment disorder may be acute or chronic, depending on whether it lasts more or less than six months. According to the DSM-5, if the adjustment disorder lasts less than six months, then it may be considered acute. If it lasts more than six months, it may be considered chronic. [8] [13] Moreover, the symptoms cannot last longer than six months after the stressor(s), or its consequences, have terminated. [2] : 679  However, the stress-related disturbance does not only exist as an exacerbation of a pre-existing mental disorder. [6]

Unlike major depression, the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation. The condition is different from anxiety disorder, which lacks the presence of a stressor, or post-traumatic stress disorder and acute stress disorder, which usually are associated with a more intense stressor.

Suicidal behavior is prominent among people with adjustment disorder of all ages, and up to one-fifth of adolescent suicide victims may have an adjustment disorder. Bronish and Hecht (1989) found that 70% of a series of patients with adjustment disorder attempted suicide immediately before their index admission and they remitted faster than a comparison group with major depression. [5] Asnis et al. (1993) found that adjustment disorder patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression. [4] According to a study on 82 adjustment disorder patients at a clinic, Bolu et al. (2012) found that 22 (26.8%) of these patients were admitted due to suicide attempt, consistent with previous findings. In addition, it was found that 15 of these 22 patients chose suicide methods that involved high chances of being saved. [3] Henriksson et al. (2005) states statistically that the stressors are of one-half related to parental issues and one-third in peer issues. [14]

One hypothesis about adjustment disorder is that it may represent a sub-threshold clinical syndrome. [6]

The syndrome of occupational burnout is considered to be adjustment disorder by some national health authorities. [15] [16] [17]

Subtypes and their symptoms

Adjustment disorder has six different subtypes, and they are all based on what the main symptoms are. [18] [19]

Those subtypes are as follows: [18]

Risk factors

Those exposed to repeated trauma are at greater risk, even if that trauma is in the past. Age can be a factor due to young children having fewer coping resources and because they are less likely to realize the consequences of a potential stressor. [8]

A stressor is generally an event of a serious, unusual nature that an individual or group of individuals experience. [20] Adjustment disorders can come from a wide range of stressors that can be traumatic or relatively minor, like the loss of a girlfriend/boyfriend, a poor report card, or moving to a new neighborhood. It is thought that the more often the stressor occurs, the more likely it is to produce adjustment disorder. The objective nature of the stressor is of secondary importance. A stressor gains its pathogenic potential when the patient perceives it as stressful. The identification of a causal stressor is necessary if a diagnosis of adjustment disorder is to be made. [21]

There are certain stressors that are more common in different age groups: [22]

Adulthood:

Adolescence and childhood:

In a study conducted from 1990 to 1994 on 89 psychiatric outpatient adolescents, 25% had attempted suicide in which 37.5% had misused alcohol, 87.5% displayed aggressive behaviour, 12.5% had learning difficulties, and 87.5% had anxiety symptoms. [14]

Diagnosis

DSM-5 classification

The basis of the diagnosis is the presence of a precipitating stressor and a clinical evaluation of the possibility of symptom resolution on removal of the stressor due to the limitations in the criteria for diagnosing adjustment disorder. In addition, the diagnosis of adjustment disorder is less clear when patients are exposed to stressors long-term, because this type of exposure is associated with adjustment disorder and major depressive disorder (MDD) and generalized anxiety disorder (GAD). [23]

Some signs and criteria used to establish a diagnosis are important. First, the symptoms must clearly follow a stressor. The symptoms should be more severe than would be expected. There should not appear to be other underlying disorders. The symptoms that are present are not part of a normal grieving for the death of family member or other loved one. [21]

Adjustment disorders have the ability to be self-limiting. Within five years of when they are originally diagnosed, approximately 20–50% go on to be diagnosed with psychiatric disorders that are more serious. [6]

ICD-11 classification

International Statistical Classification of Diseases and Related Health Problems (ICD), assigns codes to classify diseases, symptoms, complaints, social behaviors, injuries, and such medical-related findings.

ICD-11 classifies adjustment disorder (6B43) under "Disorders specifically associated with stress". [24]

Treatment

Individuals with an adjustment disorder and depressive or anxiety symptoms may benefit from treatments usually used for depressive or anxiety disorders. The use of different therapies can be beneficial for any age group. There is also a list of medications that can be used to help people with adjustment disorder whose symptoms are too severe for therapy alone. If a person is considering taking medication, they should talk to their doctor. [18] Specific treatment is based on factors of each individual separately. These factors include but are not limited to age, severity of symptoms, type of adjustment disorder, and personal preference. [18] [19]

Different ways to help with the disorder include:

In addition to professional help, parents and caregivers can help their children with their difficulty adjusting by:

Criticism

Like many of the items in the DSM, adjustment disorder receives criticism from a minority of the professional community as well as those in semi-related professions outside the healthcare field. First, there has been criticism of its classification. It has been criticized for its lack of specificity of symptoms, behavioral parameters, and close links with environmental factors. Relatively little research has been done on this condition. [25]

An editorial in the British Journal of Psychiatry described adjustment disorder as being so "vague and all-encompassing… as to be useless," [26] [27] but it has been retained in the DSM-5 because of the belief that it serves a useful clinical purpose for clinicians seeking a temporary, mild, non-stigmatizing label, particularly for patients who need a diagnosis for insurance coverage of therapy. [28]

In the US military there has been concern about its diagnosis in active duty military personnel. [29]

When the cause of substantial distress is harm caused by unjust social systems, it may be considered that the true disorder requiring intervention lies in the systems causing the problem rather than in the individual who is distressed by them. [30]

In relation to the COVID-19 pandemic

A study was conducted in Poland during the first phase of the pandemic. The study used self-report surveys to measure the prevalence and severity of symptoms of adjustment disorder compared to PTSD, depression, and anxiety. The data was collected in the first quarantine period between 25 March to 27 April 2020. [31]

Results from the study [31]

Related Research Articles

<span class="mw-page-title-main">Major depressive disorder</span> Mental disorder involving persistent low mood, low self-esteem, and loss of interest

Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians in the mid-1970s, the term was adopted by the American Psychiatric Association for this symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and has become widely used since.

<i>Diagnostic and Statistical Manual of Mental Disorders</i> American psychiatric classification

The Diagnostic and Statistical Manual of Mental Disorders is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. It is the main book for the diagnosis and treatment of mental disorders in the United States and is considered one of the principal guides of psychiatry, along with the ICD, CCMD, and the Psychodynamic Diagnostic Manual. However, not all providers rely on the DSM-5 as a guide, since the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions.

<span class="mw-page-title-main">Mood disorder</span> Group of conditions characterised by a disturbance in mood

A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

<span class="mw-page-title-main">Borderline personality disorder</span> Personality disorder of emotional instability

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of intense and unstable interpersonal relationships, distorted sense of self, and strong emotional reactions. Those affected often engage in self-harm and other dangerous behaviors, often due to their difficulty with returning their emotional level to a healthy or normal baseline. They may also struggle with dissociation, a feeling of emptiness, and a fear of abandonment.

<span class="mw-page-title-main">Hypochondriasis</span> Medical condition

Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. Hypochondria is an old concept whose meaning has repeatedly changed over its lifespan. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they have, or are about to be diagnosed with, a serious illness.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses.

Dissociative disorders (DD) are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. People with dissociative disorders use dissociation as a defense mechanism, pathologically and involuntarily. The individual experiences these dissociations to protect themselves. Some dissociative disorders are triggered by psychological trauma, but depersonalization-derealization disorder may be preceded only by stress, psychoactive substances, or no identifiable trigger at all.

<span class="mw-page-title-main">Suicidal ideation</span> Thoughts, ideas, or ruminations about the possibility of ending ones life

Suicidal ideation, or suicidal thoughts, is the thought process of having ideas, or ruminations about the possibility of ending one's own life. It is not a diagnosis but is a symptom of some mental disorders, use of certain psychoactive drugs, and can also occur in response to adverse life events without the presence of a mental disorder.

A major depressive episode (MDE) is a period characterized by symptoms of major depressive disorder. Those affected primarily exhibit a depressive mood for at least two weeks or more, and a loss of interest or pleasure in everyday activities. Other symptoms can include feelings of emptiness, hopelessness, anxiety, worthlessness, guilt, irritability, changes in appetite, difficulties in concentration, difficulties remembering details, making decisions, and thoughts of suicide. Insomnia or hypersomnia and aches, pains, or digestive problems that are resistant to treatment may also be present.

A spectrum disorder is a disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".

The classification of mental disorders is also known as psychiatric nosology or psychiatric taxonomy. It represents a key aspect of psychiatry and other mental health professions and is an important issue for people who may be diagnosed. There are currently two widely established systems for classifying mental disorders:

Child and adolescent psychiatry is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families. It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the pediatric population.

<span class="mw-page-title-main">DSM-5</span> 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In 2022, a revised version (DSM-5-TR) was published. In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. However, not all providers rely on the DSM-5 for planning treatment as the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. The DSM-5 is the only DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the only living document version of a DSM.

Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

Mixed anxiety–depressive disorder (MADD) is a diagnostic category defining patients who have both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some autonomic features. Autonomic features are involuntary physical symptoms usually caused by an overactive nervous system, such as panic attacks or intestinal distress. The World Health Organization's ICD-10 describes Mixed anxiety and depressive disorder: "...when symptoms of anxiety and depression are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately. When both anxiety and depressive symptoms are present and severe enough to justify individual diagnoses, both diagnoses should be recorded and this category should not be used."

<span class="mw-page-title-main">Occupational burnout</span> Type of occupational stress

According to the World Health Organization (WHO), occupational burnout is a phenomenon resulting from chronic work-related stress, with symptoms characterized by "feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy". While occupational burnout may influence health and can be a reason for people contacting health services, it is not itself classified by the WHO as a medical condition or mental disorder. WHO additionally states that "Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life."

Cyclothymia, also known as cyclothymic disorder, psychothemia / psychothymia, bipolar III, affective personality disorder and cyclothymic personality disorder, is a mental and behavioural disorder that involves numerous periods of symptoms of depression and periods of symptoms of elevated mood. These symptoms, however, are not sufficient to indicate a major depressive episode or a manic episode. Symptoms must last for more than one year in children and two years in adults.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

<span class="mw-page-title-main">Prolonged grief disorder</span> Medical condition

Prolonged grief disorder (PGD), also known as complicated grief (CG), traumatic grief (TG) and persistent complex bereavement disorder (PCBD) in the DSM-5, is a mental disorder consisting of a distinct set of symptoms following the death of a family member or close friend. People with PGD are preoccupied by grief and feelings of loss to the point of clinically significant distress and impairment, which can manifest in a variety of symptoms including depression, emotional pain, emotional numbness, loneliness, identity disturbance and difficulty in managing interpersonal relationships. Difficulty accepting the loss is also common, which can present as rumination about the death, a strong desire for reunion with the departed, or disbelief that the death occurred. PGD is estimated to be experienced by about 10 percent of bereaved survivors, although rates vary substantially depending on populations sampled and definitions used.

The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) is a semi-structured interview aimed at early diagnosis of affective disorders such as depression, bipolar disorder, and anxiety disorder. There are different versions of the test that have use different versions of diagnostic criteria, cover somewhat different diagnoses and use different rating scales for the items. All versions are structured to include interviews with both the child and the parents or guardians, and all use a combination of screening questions and more comprehensive modules to balance interview length and thoroughness.

References

  1. ↑ "Adjustment disorders - Symptoms and causes". Mayo Clinic. Retrieved 30 May 2019.
  2. 1 2 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). pp. 271–281.
  3. 1 2 Bolu A, Doruk A, Ak M, Özdemir B, Özgen F (2012). "Suicidal behavior in adjustment disorder patients". Dusunen Adam the Journal of Psychiatry and Neurological Sciences. 25 (1): 58–62. doi: 10.5350/DAJPN2012250107 .
  4. 1 2 Asnis GM, Friedman TA, Sanderson WC, Kaplan ML, van Praag HM, Harkavy-Friedman JM (January 1993). "Suicidal behaviors in adult psychiatric outpatients, I: Description and prevalence". The American Journal of Psychiatry. 150 (1): 108–112. doi:10.1176/ajp.150.1.108. PMID   8417551.
  5. 1 2 Bronisch T, Hecht H (1989). "Validity of adjustment disorder, comparison with major depression". Journal of Affective Disorders. 17 (3): 229–36. doi:10.1016/0165-0327(89)90004-9. PMID   2529290.
  6. 1 2 3 4 Bisson JI, Sakhuja D (July 2006). "Adjustment disorders". Psychiatry. 5 (7): 240–242. doi:10.1053/j.mppsy.2006.04.004.
  7. ↑ Portzky G, Audenaert K, van Heeringen K (August 2005). "Adjustment disorder and the course of the suicidal process in adolescents". Journal of Affective Disorders. 87 (2–3): 265–270. doi:10.1016/j.jad.2005.04.009. hdl: 1854/LU-337403 . PMID   16005078.
  8. 1 2 3 4 "Adjustment Disorders". 8 August 2021.
  9. ↑ "DSM-5 Diagnostic Codes". Psych Central. 2021-05-13. Retrieved 2022-04-10.
  10. ↑ Substance Abuse and Mental Health Services Administration (June 2016). "Table 3.19, DSM-IV to DSM-5 Adjustment Disorders Comparison". www.ncbi.nlm.nih.gov. Retrieved 2022-04-10.
  11. ↑ "What Is Adjustment Disorder?". WebMD. Retrieved 2022-04-10.
  12. ↑ "Adjustment disorders - Symptoms and causes". Mayo Clinic. Retrieved 2022-03-07.
  13. ↑ Carta MG, Balestrieri M, Murru A, Hardoy MC (June 2009). "Adjustment Disorder: epidemiology, diagnosis and treatment". Clinical Practice and Epidemiology in Mental Health. 5: 15. doi:10.1186/1745-0179-5-15. PMC   2710332 . PMID   19558652.
  14. 1 2 Pelkonen M, Marttunen M, Henriksson M, Lönnqvist J (May 2005). "Suicidality in adjustment disorder--clinical characteristics of adolescent outpatients". European Child & Adolescent Psychiatry. 14 (3): 174–180. doi:10.1007/s00787-005-0457-8. PMID   15959663. S2CID   33646901.
  15. ↑ van der Klink JJ, van Dijk FJ (December 2003). "Dutch practice guidelines for managing adjustment disorders in occupational and primary health care". Scandinavian Journal of Work, Environment & Health. 29 (6): 478–487. doi: 10.5271/sjweh.756 . JSTOR   40967326. PMID   14712856.
  16. ↑ Lastovkova A, Carder M, Rasmussen HM, Sjoberg L, Groene GJ, Sauni R, et al. (April 2018). "Burnout syndrome as an occupational disease in the European Union: an exploratory study". Industrial Health. 56 (2): 160–165. doi:10.2486/indhealth.2017-0132. PMC   5889935 . PMID   29109358.
  17. ↑ van Dam A (2021-09-03). "A clinical perspective on burnout: diagnosis, classification, and treatment of clinical burnout". European Journal of Work and Organizational Psychology. 30 (5): 732–741. doi: 10.1080/1359432X.2021.1948400 . ISSN   1359-432X. S2CID   237829018.
  18. 1 2 3 4 "Adjustment Disorders". www.hopkinsmedicine.org. 8 August 2021. Retrieved 2022-04-10.
  19. 1 2 "Adjustment Disorder: All You Need to Know". Psych Central. 2021-08-27. Retrieved 2022-04-10.
  20. ↑ Zelviene P, Kazlauskas E, Maercker A (2020-01-10). "Risk factors of ICD-11 adjustment disorder in the Lithuanian general population exposed to life stressors". European Journal of Psychotraumatology. 11 (1): 1708617. doi:10.1080/20008198.2019.1708617. PMC   6968697 . PMID   32002141.
  21. 1 2 Adjustment Disorders at eMedicine
  22. ↑ Powell AD (2015). "Grief, Bereavement, and Adjustment Disorders". In Stern TA, Fava M, Wilens TE, Rosenbaum JF (eds.). Massachusetts General Hospital Comprehensive Clinical Psychiatry (2nd ed.). Elsevier. pp. 428–32. ISBN   978-0-323-32899-9.
  23. ↑ Casey P, Doherty A (2012). "Adjustment disorder: Diagnostic and treatment issues". Psychiatric Times. 29: 43–46.
  24. ↑ "6B43 Adjustment disorder". ICD-11 - Mortality and Morbidity Statistics. Retrieved 2019-08-28.
  25. ↑ Casey P (January 2001). "Adult adjustment disorder: a review of its current diagnostic status". Journal of Psychiatric Practice. 7 (1): 32–40. doi:10.1097/00131746-200101000-00004. PMID   15990499. S2CID   24932443.
  26. ↑ Casey P, Dowrick C, Wilkinson G (December 2001). "Adjustment disorders: fault line in the psychiatric glossary". The British Journal of Psychiatry. 179 (6): 479–481. doi: 10.1192/bjp.179.6.479 . PMID   11731347.
  27. ↑ Fard K, Hudgens RW, Welner A (March 1978). "Undiagnosed psychiatric illness in adolescents. A prospective study and seven-year follow-up". Archives of General Psychiatry. 35 (3): 279–282. doi:10.1001/archpsyc.1978.01770270029002. PMID   727886.
  28. ↑ Baumeister H, Kufner K (July 2009). "It is time to adjust the adjustment disorder category". Current Opinion in Psychiatry. 22 (4): 409–12. doi:10.1097/YCO.0b013e32832cae5e. PMID   19436201. S2CID   8610912.
  29. ↑ "Discharges for adjustment disorder soar". 29 March 2013. Retrieved 31 July 2018.
  30. ↑ Morris, N. P. (1 December 2022). "Injustice Disorder". The New England Journal of Medicine. 387 (22): 2017–2019. doi:10.1056/NEJMp2211154. ISSN   0028-4793.
  31. 1 2 Dragan M, Grajewski P, Shevlin M (2021-01-01). "Adjustment disorder, traumatic stress, depression and anxiety in Poland during an early phase of the COVID-19 pandemic". European Journal of Psychotraumatology. 12 (1): 1860356. doi:10.1080/20008198.2020.1860356. PMC   8725738 . PMID   34992743.

Further reading

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.