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Adjustment Disorders

Practice Essentials

Adjustment disorder is a stress-related, short-term, nonpsychotic disturbance. The discomfort, distress, turmoil, and anguish to the patient are significant, and the consequences (eg, suicidal potential) are extremely important.

Signs and symptoms

As the term adjustment disorder implies, symptoms develop when the person is responding to a particular event or situation, for example a loss, a problem in a close relationship, an unwanted move, a disappointment, or a failure. The pathogenic stressors may be single events, or persistently stressful circumstances. They may be recurrent or continous. Typical stressors include disruptions of close relationships (except bereavement), events that disrupt general adaptation (emergencies or disasters), and occupational failures or losses. Characteristic symptoms include the following:

Low mood

Sadness

Worry

Anxiety

Insomnia

Poor concentration

Anger, disruptive behavior

Other typical manifestations – Loss of self esteem, hopelessness, feeling trapped, having no good options, and feeling isolated or cut off from others

Children and adolescents with adjustment disorder commonly exhibit the following:

Depressed/irritable mood

Sleep disturbances

Poor performance in school

No specific physical findings correlate with adjustment disorder, but people may consult a healthcare provider for poor sleep, aches and pains, indigestion, fatigue, and other typical symptoms related to physiological stress responses. The constellation of feelings of helplessness, subjective incompetence and a negative view of the future but without anhedonia have also been described under the term demoralization.
Demoralization is a common element of adjustment disorders that may provide grounds for effective treatment interventions, either problem-solving approaches or psychotherapy.

Use of the Impact Thermometer in combination with the Distress Thermometer can help identify patients with adjustment disorder; however, these measures do not distinguish between adjustment disorder and other depressive disorders, limiting their diagnostic utility.

See Presentation for more detail.

Diagnosis

The specific DSM-5 diagnostic criteria for adjustment disorder are as follows
:

Emotional or behavioral symptoms develop in response to an identifiable stressor or stressors within 3 months of the onset of the stressor(s) plus either or both of (1) marked distress that is out of proportion to the severity or intensity of the stressor, even when external context and cultural factors that might influence symptom severity and presentation are taken into account and/or (2) significant impairment in social, occupational, or other areas of functioning.

The stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder

The symptoms do not represent normal bereavement

After the termination of the stressor (or its consequences), the symptoms persist for no longer than an additional 6 months

The following 6 specifiers are used to identify subtypes of adjustment disorder:

With depressed mood

With anxious mood

With mixed anxiety and depressed mood

With disturbance of conduct

With mixed disturbance of emotions and conduct

Unspecified

Management

Selection of treatments for adjustment disorder is a clinical decision. At present, no official consensus identifies an optimal therapy. Both psychological therapy and pharmacotherapy may be considered.

Because adjustment disorder tends to be time-limited, brief rather than long-term psychotherapy is often sufficient. The goals of brief therapy typically include:

To analyze the stressors affecting the patient and determine whether they can be eliminated or minimized (problem solving)

To clarify and interpret the meaning the patient gives to the stressor

To reframe the meaning of the stressor

To illuminate the concerns and conflicts the patient experiences

To identify a means of reducing the stressor

To maximize the patient’s coping skills (emotional self-regulation, avoidance of maladaptive coping, especially substance misuse)

To help patients gain perspective on the stressor, establish relationships, mobilize support, and manage themselves and the stressor

Approaches that may be helpful include the following:

Supportive psychotherapy

Psychodynamic psychotherapy

Crisis intervention

Family and group therapies

Support groups specific to the stressor

Cognitive-behavioral therapy (CBT)

Interpersonal psychotherapy

Mindfulness-based therapy (including group)

Internet-based therapy (being tested)

Pharmacotherapy may help by improving coping through moderating symptoms such as insomnia, anxiety, or dysphoria. Useful agents include the following:

Benzodiazepines (eg, lorazepam, alprazolam)

A nonbenzodiazepine anxiolytic, etifoxine, has been used in one clinical study in France

Intermittent or time-limited use of sedatives related to benzodiazepines (e.g., zolpidem)

SSRI or SNRI (sertaline, venlafaxine) (note because of their reponse latency, these are most appropriate for symptoms lasting more than a few weeks)

Mildly anxiolytic antihistamines (e.g., hydroxazine)

Sedating plant extracts (e.g., kava-kava and valerian)

Further studies are required to investigate the effectiveness of these and additional novel agents in treating adjustment disorder.

See Treatment and Medication for more detail.

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