Adjustment Disorder

Basics

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

Diagnosis

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).

Treatment

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.

Inpatient 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

Ongoing Care

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

Additional Reading

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

  • Codes

    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)

    Clinical Pearls

    • 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.

    Authors


    Elizabeth Hoy, MD, MS, MSPH
    Gabriel Sánchez, MD
    Eduardo Camps-Romero, MD

    Bibliography

    1. Carta MG, Balestrieri M, Murru A, et al. Adjustment disorder: epidemiology, diagnosis and treatment. Clin Pract Epidemiol Ment Health. 2009;5:15.  [PMID:19558652]
    2. Casey P. Adjustment disorder: epidemiology, diagnosis and treatment. CNS Drugs. 2009;23(11):927–938.  [PMID:19845414]
    3. 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]
    4. 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]
    5. 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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