Adjustment Disorder

Adjustment disorder is a psychological response to an identifiable stressor. The condition by emotional or behavioral symptoms that develop within 3 months of exposure, and do not last more than 6 months. Adjustment disorder is a diagnosis of exclusion, which means that they are not diagnosed if the patient meets the criteria for any other psychiatric disorder or if their symptoms are better explained by substance use or withdrawal. The 1st line of treatment is psychotherapy.

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Overview

Definition

Adjustment disorder is a psychological and physical response (feeling sad, stressed, or hopeless, and certain physical symptoms) to an identifiable stressor (death of a loved one, divorce, life changes, illness, family problems, school problems, or sexual issues).

Epidemiology

  • Lifetime prevalence: approximately 2%–8% of the general population
  • Women are twice as likely to be diagnosed as men.
  • One of the most common psychiatric diagnosis for patients hospitalized for any other medical/surgical reason

Etiology

  • Precipitated by 1 or multiple stressors
  • Severity of stressor does not predict prognosis.
  • Personality of the patient as well as societal norms contribute to the pathologic reactions to the stressors.

Diagnosis

Adjustment disorder is difficult to diagnose as it shares symptoms with other mental disorders.

History and physical exam elicit the following criteria:

  • Development of psychological symptoms in response to identifiable stressor
  • Occurring within 3 months of the onset of stressor
  • Symptoms or behaviors are clinically significant, causing marked distress and decline in function.
  • Once stressor is removed, symptoms do not last more than 6 months.

Adjustment disorder cannot be diagnosed if symptoms:

  • Meet criteria of any other psychiatric disorder 
  • Are explained by substance use disorder or withdrawal 
  • Last over 6 months after the stressor
  • Cause no decline in patient functioning or marked distress
  • Represent normal bereavement

Management

Psychotherapy

  • 1st-line therapy
  • Different modalities, such as CBT, can help the patient to cope with the stressors.
  • Group therapy may be useful, especially among patients undergoing similar stressors.

Crisis intervention

Crisis intervention may be help provide timely reassurance and support to prevent sentinel outcome.

Pharmacotherapy

  • Generally not indicated but may help treat comorbid symptoms 
  • Severe anxiety may be treated with long-acting benzodiazepines (e.g., diazepam).  
  • Antipsychotics if showing symptoms of psychosis 
  • Antidepressants (selective serotonin reuptake inhibitors (SSRIs)) may be useful adjuncts.

Differential Diagnosis

  • Acute stress disorder: stress reactions that present after an individual has experienced a life-threatening event. Symptoms last > 3 days and < 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders, irritability, hyperarousal, and poor memory and concentration. The traumatic event must have occurred within 1 month and last < a month.
  • Bereavement/grief: emotions or thoughts and actions in response to the death of someone close to the patient. The duration and form of expression vary based on the patient’s culture and customs.  Depression of mood as well as a feeling of loss can be expected. Unlike in adjustment disorder, bereavement causes no significant impairment in function. Bereavement is not pathological. 
  • Generalized anxiety disorder (GAD): a psychiatric disorder marked by chronic multiple worries, usually about things that are not important. Associated with fatigue, low concentration, restlessness, irritability, and sleep disturbance. These symptoms last for > 6 months. The diagnosis of GAD does not require a trigger event causing its symptomatology, unlike adjustment disorder. 

References

  1. Sadock BJ, Sadock VA, Ruiz P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 11, Trauma and stressor-related disorders, pages 446-450. Philadelphia, PA: Lippincott Williams and Wilkins.
  2. Zelviene P, Kazlauskas E. (2018). Adjustment disorder: current perspectives. Neuropsychiatr Dis Treat. 14:375-381. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5790100/ 
  3. O’Donnell ML, Agathos JA, Metcalf O, Gibson K, Lau W. (2019). Adjustment Disorder: Current Developments and Future Directions. Int J Environ Res Public Health. 16(14):2537. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6678970/

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