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.
- Varies among population
- High incidence during times of disaster and in patients with chronic illnesses
- Common diagnosis in clinical setting
- 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.
- Women > men (3)
- Younger age
- High rate of stressors
- Other mental health problems
- Unstable family environment, divorce
- Military service
- Natural disasters
- 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
- 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
- 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]
Excludes normal bereavement
Complete physical exam. Focus on pulmonary, cardiac, neurologic, and psychiatric components.
- Posttraumatic stress disorder
- Acute stress disorder
- Major depressive disorder
- Personality disorders
- Normative stress reactions
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).
- Treatment for AD is under investigation, although brief psychological interventions are preferred.
- Symptoms resolve after resolution of stressor(s) and its consequences.
- 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.
Psychotherapy in groups or individually
- Cognitive-behavioral therapy
- Dialectical behavioral therapy
- Mindfulness therapy (5)[A]
- 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
Coping skills for life stressors
Short term: improvement within 6 months of elimination of stressor and consequences
- Increase risk of attempts and completed suicide
- Low quality of life
Additional ReadingAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- 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
- 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
- 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)
- Short-term disorder: occurs within 3 months of a stressor(s) and should resolve within 6 additional months from termination of stressor(s) or consequences of stressor(s)
- Suicide risk should be assessed throughout management.
- Most cases respond well to nonpharmacologic treatment.
Elizabeth Hoy, MD, MS, MSPH
Gabriel Sánchez, MD
Eduardo Camps-Romero, MD
- Carta MG, Balestrieri M, Murru A, et al. Adjustment disorder: epidemiology, diagnosis and treatment. Clin Pract Epidemiol Ment Health. 2009;5:15. [PMID:19558652]
- Casey P. Adjustment disorder: epidemiology, diagnosis and treatment. CNS Drugs. 2009;23(11):927–938. [PMID:19845414]
- Fernández A, Mendive JM, Salvador-Carulla L, et al; and DASMAP Investigators. Adjustment disorders in primary care: prevalence, recognition and use of services. Br J Psychiatry. 2012;201:137–142. [PMID:22576725]
- Ferrer L, Kirchner T. Suicidal tendency in a sample of adolescent outpatients with adjustment disorder: gender differences. Compr Psychiatry. 2014;55(6):1342–1349. [PMID:24889338]
- Sundquist J, Lilja Å, Palmér K, et al. Mindfulness group therapy in primary care patients with depression, anxiety and stress and adjustment disorders: randomised controlled trial. Br J Psychiatry. 2015;206(2):128–135. [PMID:25431430]
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