Adjustment Disorder

Description

Adjustment disorder (AD)

• Development of emotional/behavioral symptoms due to an identifiable stressor(s) and occurring within 3 months of onset of stressor(s) (1)
• Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) overview:
  • Various types
    • With depressed mood—feelings of depression, tearfulness, or feelings of hopelessness
    • With anxiety—nervousness, worry, or jitteriness, or, in children, fears of separation from major attachment figures
    • With mixed anxiety and depressed mood—a combination of depression and anxiety
    • With disturbance of conduct—there is violation of the rights of others, major age-appropriate societal norms, and rules
    • With mixed disturbance of emotions and conduct
    • Unspecified includes maladaptive reactions that are not classified as one of the other subtypes.

Epidemiology

Incidence

• Varies among population
• High incidence during times of disaster and in patients with chronic illnesses
• Common diagnosis in clinical setting

Prevalence

• Varies among population
• 11–18% among primary care (2)
• 10–35% in consultation liaison psychiatry (2)

Etiology and Pathophysiology

• Individual vulnerability and risk play a greater role in AD than in other psychiatric disorders (3).
• Factors that lead to development of AD in children and adolescents are similar to those found in adults and are adjusted for stage of life.

Risk Factors

• Women > men (3)
• Younger age
• High rate of stressors
• Other mental health problems
• Unstable family environment, divorce
• Military service
• Natural disasters

General Prevention

• Good coping mechanisms to stressors
• Establishing support

Commonly Associated Conditions

• Personality disorders previously linked to AD (Few studies show a true correlation.)
• Suicide attempts and completed suicide
• Substance abuse

History

DSM-5 requires:

• Occurs within 3 months after onset of stressor(s)
• Marked by distress that is in excess of what would be expected within context, given the nature of the stressor, and/or by significant impairment in social, occupational, or other important areas of functioning
• Do not diagnose if the disturbance meets criteria for another mental disorder and is not an exacerbation of a preexisting mental disorder.
• Does not represent normal bereavement
• Does not persist for more than an additional 6 months once the stressor or its consequences have terminated

Pediatric Considerations

• Excludes separation anxiety disorder of childhood
• Can present with divorce, unstable family environment, or peer victimization
• Bereavement reaction must be out of proportion or inconsistent with age-appropriate norms.
• More prevalent among adolescents than adults
• Adolescents with AD often show presence of suicidal thoughts and behaviors (4).
• Reports of suicidal tendency in adolescents with AD more prevalent in girls than boys (4)[B]

Geriatric Considerations
Excludes normal bereavement

Physical Exam

Complete physical exam. Focus on pulmonary, cardiac, neurologic, and psychiatric components.

Differential Diagnosis

• Posttraumatic stress disorder
• Acute stress disorder
• Major depressive disorder
• Personality disorders
• Normative stress reactions
• Bereavement

Diagnostic Tests & Interpretation

• Clinical diagnosis made by DSM-5 criteria
• Rule out depression or other Axis I disorder.
• No questionnaire type currently exists for AD diagnosis (1).

General Measures

• Treatment for AD is under investigation, although brief psychological interventions are preferred.
• Symptoms resolve after resolution of stressor(s) and its consequences.

Medication

• Psychotherapy has most clinical evidence.
• Psychotropics, antidepressants, and benzodiazepines may be effective for specific subtypes.
• There are few trials specifically directed to the pharmacologic treatment of AD.

First Line
Psychotherapy in groups or individually

• Cognitive-behavioral therapy
• Dialectical behavioral therapy
• Mindfulness therapy (5)[A]

Second Line

• Antidepressants are commonly prescribed for AD types with depressed mood. Selective serotonin reuptake inhibitors are more often recommended.
• Anxiolytics may be used for AD subtype with anxiety. Benzodiazepines may be used to treat symptoms of AD relating to insomnia, anxiety, and panic attacks.

Admission, Inpatient, and Nursing Considerations

• AD alone, without associated types, is not an indication for admission.
• Inpatient care is indicated for AD patients at risk for suicide/homicide and for comorbid conditions.
• Discharge criteria
  • Depressive symptoms resolve.
  • Suicidal symptoms resolve.
  • Appropriate outpatient follow-up

Patient Education

Coping skills for life stressors

Prognosis

Short term: improvement within 6 months of elimination of stressor and consequences

Complications

• Increase risk of attempts and completed suicide
• Low quality of life

ICD-10

• F43.20 Adjustment disorder, unspecified
• F43.21 Adjustment disorder with depressed mood
• F43.22 Adjustment disorder with anxiety
• F43.23 Adjustment disorder with mixed anxiety and depressed mood
• F43.24 Adjustment disorder with disturbance of conduct
• F43.25 Adjustment disorder with mixed disturbance of emotions and conduct
• F43.29 Adjustment disorder with other symptoms

ICD-9

• 309.0 Adjustment disorder with depressed mood
• 309.24 Adjustment disorder with anxiety
• 309.28 Adjustment disorder with mixed anxiety and depressed mood
• 309.29 Other adjustment reactions with predominant disturbance of other emotions
• 309.3 Adjustment disorder with disturbance of conduct
• 309.4 Adjustment disorder with mixed disturbance of emotions and conduct
• 309.82 Adjustment reaction with physical symptoms
• 309.89 Other specified adjustment reactions
• 309.9 Unspecified adjustment reaction

SNOMED

• 17226007 Adjustment disorder (disorder)
• 192063005 Adjustment reaction with physical symptoms (disorder)
• 47372000 Adjustment disorder with anxious mood (disorder)
• 55668003 Adjustment disorder with mixed emotional features (disorder)
• 57194009 Adjustment disorder with depressed mood (disorder)
• 66381006 Adjustment disorder with mixed disturbance of emotions AND conduct (disorder)
• 84984002 Adjustment disorder with disturbance of conduct (disorder)