Day # 101: Adjustment Disorder

We are continuing our current theme of trauma and stressor related disorders. This includes adjustment disorder, persistent complex bereavement disorder, acute stress disorder, and posttraumatic stress disorder (PTSD). Today we will discuss adjustment disorder.

Today's Content Level: Beginner, Intermediate

INTRODUCTION 1

• Adjustment disorders occur when there is development of behavioral/emotional symptoms after a stressful life event.

• Unlike PTSD and acute stress disorder, the stressful event is not life threatening (no exposure to actual or threatened death, serious injury, or sexual violence). Common stressors include divorce or the end of a romantic relationship, loss of a job, financial difficulties, legal stressors, death of a loved one, or a new medical diagnosis.

• Individuals experience emotional symptoms, maladaptive behaviors, or a decrease in functioning but the symptoms do not reach the level of another diagnosis (ex: MDD).

DIAGNOSTIC CRITERIA 2

• Development of emotional or behavioral symptoms.

• Symptoms develop within 3 months of an identifiable stressful life event.

• Symptoms resolve within 6 months after the stressor has terminated. If symptoms persist this is sometimes called "chronic adjustment disorder".

• Must experience either:

  • 1) distress that is > normally expected after such an event or

  • 2) significant impairment of daily functioning (social, occupational, etc.).

• Symptoms do not represent normal bereavement and is not merely an exacerbation of a preexisting mental disorder. Symptoms do not meet criteria for another mental disorder.

• Specifiers to further clarify nature of response:

  • Depressed mood (low mood, tearfulness, hopelessness)

  • Anxiety (nervousness, worry)

  • Mixed anxiety and depressed mood

  • Disturbance of conduct (such as aggression)

  • Mixed disturbance of emotions and conduct

  • Unspecified

EPIDEMIOLOGY / PATHOGENESIS 3, 4, 5

• Prevalence of adjustment disorders vary depending on the setting. Estimates of 2% in the general population; 1-18% in primary care settings; 5-20% in outpatient mental health clinics; 15-20% in psychiatric ED; and ~10% in inpatient psychiatry.

• It is the most common diagnosis in inpatient psychiatric consultation settings (frequently reaching 50% of consults) and is 3x as common as MDD in medically ill inpatients (~14% vs 5%). Two studies showed a prevalence between 12% and 35% of adjustment disorder in patients with head/neck cancer and breast cancer respectively.

• May occur at any age and gender.

• Risk factors include recent stressor (obviously), history of trauma or adverse childhood events, and there is some evidence for increased risk in women.

• Associated with an increased risk of suicide attempts and completed suicide. Notably there is a shorter interval between the appearance of symptoms and suicide attempts compared to other disorders, often less than one month.

• It should be noted that there are some experts in the field that question many aspects of this diagnosis. Some state there is a lack of scientific evidence to differentiate adjustment disorder from a normal response to stressors. Could this be another example of the increased medicalization of life-problems?

• Others agree that adjustment disorder is a helpful clinical paradigm but that it lacks evidence-based specificity in regards to its symptom criteria, duration, and required magnitude of stressor.

• An important unanswered question involves why some individuals develop an adjustment disorder in response to a stressful event while others do not.

CLINICAL PEARLS 6, 7

• The stressor may be a single event such as divorce, the end of a romantic relationship, death of a loved one, or a new medical diagnosis. It may also result from a combination of events.

• It may also be a recurrent or continuous stressor such as enduring financial difficulties, chronic illness, unsafe home/neighborhood environment, marital problems, becoming a parent, and more.

• Keep in mind that adjustment disorder can be diagnosed following the death of a loved one when it is not a normal grief reaction, but also not meeting criteria for persistent complex bereavement disorder (discussed later in this theme).

• Another important note is that adolescents diagnosed with adjustment disorder may be at an increased risk of developing major psychiatric illness compared to adults. Only 44% of adolescents were well at a 5 year follow up vs 71% of adults.

• Examples of screening questions: Since the stressful problem how often have you felt sad, nervous, or restless? Since the event have you been scared of or avoided doing certain things? Full example of a screener is the Adjustment Disorder – New Module 20 questionnaire (ADNM-20).

• Other important features of the clinical interview include:

  • Screen for additional stressful events or trauma.

  • Substance history.

  • Family history of psychiatric disorders and suicide.

  • Suicide risk assessment.

  • The presence of a primary disorder takes precedence. Rule out normal stress reaction, depressive disorders, anxiety disorders, acute stress disorder, PTSD, normal bereavement, persistent complex bereavement, and anxiety/panic/depression due to another medical condition. Also consider personality disorders, but adjustment disorder can still be diagnosed acutely in patients with comorbid personality disorder.

TREATMENT 8, 9, 10

• Adjustment disorders may present with primarily depressive features, anxious features, disturbance of conduct, or mixed. Thus, due to the diversity of presentations there is no single treatment approach. The primary goals of treatment are to relieve symptoms and achieve a level of adaptive functioning that is comparable to their ability to function before the stressor.

• Psychotherapy: Psychotherapy is the first-line treatment of choice. Supportive therapy is most commonly used, however there is no clear evidence for a specific type of therapy in these cases. Commonly used modalities include supportive therapy, cognitive behavioral therapy (CBT), group therapy, problem-solving techniques, and psychodynamic interventions. Many authors argue it is important to help the patient to better understand the meaning of the stressor and why it may have overwhelmed their coping mechanisms. Goals of therapy include exploring the stressor itself and ways to reduce the stressor, reducing maladaptive responses, promoting coping/resilience utilizing their skills/strengths, and helping them utilize family and community resources.

• Pharmacotherapy: Occasionally pharmacotherapy is used to treat associated symptoms such as insomnia, anxiety, or depression, however there is no strong empirical support for this practice. If used, these treatments should generally occur in a time-limited approach and always include psychotherapy. SSRIs are the mostly commonly used.

CONCLUSION

Congrats on finishing day 2 of the trauma and stressor related disorders theme. Next post we will discuss normal bereavement (acute grief) and compare that with persistent complex bereavement.

Resources for today's post include Kaplan and Sadock's Comprehensive Psychiatry, Pocket Psychiatry, DSM-5, and First Aid for Psychiatry.

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