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Stat Consult: Adjustment Disorder

Background

  • Adjustment disorder is an emotional and behavioral response to a psychosocial stressor that is disproportionate to the stressor’s severity, resulting in impaired emotional, social, occupational, and other functioning
  • Prevalence of 1% to 2% reported in the general population, but estimates vary widely based on patient reporting of symptoms and provider assessment
  • With appropriate treatment, most patients return to their prior level of functioning within 3 to 6 months, unless the stressor itself is prolonged
  • Chronic adjustment disorder is associated with increased risk of declining quality of life, progression to more severe psychiatric disorders, and increased risk of self-harm and suicide

Types

  • Acute adjustment disorder: symptoms last less than 6 months
  • Chronic adjustment disorder: symptoms last 6 months or more if the duration of the stressor is prolonged
  • DSM-5 recognizes 6 subtypes; adjustment disorder with
    • Depressed mood (low mood, tearfulness, hopelessness)
    • Anxiety (nervousness, jitteriness, separation anxiety)
    • Mixed anxiety and depressed mood (combination of depression and anxiety)
    • Disturbance of conduct (violation of age-appropriate social norms or others’ rights)
    • Mixed disturbance of emotions and conduct (depression/anxiety with disturbance of conduct)
    • Unspecified  

Risk Factors

  • Female sex, younger age, higher education, and being single
  • Residing in postconflict regions or socioeconomically disadvantaged settings
  • Chronic medical illnesses and/or psychiatric disorders
  • Psychosocial stressors   
    • Traumatic events (threatened death, illness, natural disaster, epidemic, or terror attack)
    • Trauma due to financial difficulties, divorce, safety concerns, or illness/death of a loved one
    • Nontraumatic events (retirement or other major life changes)

Pathogenesis

  • Pathogenesis is unclear; typical determinants of psychopathology such as personality, coping strategies, and structural brain abnormalities do not predict adjustment disorder

History of Present Illness

  • Ask about emotional manifestations, such as
    • Excessive worry/sadness
    • Distressing thoughts
    • Constant rumination
    • Depressed mood
    • Anxiety
    • Hopelessness
  • Ask about physical symptoms
    • Sleep issues
    • Concentration
    • Weight gain/overeating
    • Palpitations, dizziness, trembling, gastrointestinal upset
  • Evaluate level of daily functioning, loss of interest in work or social life
  • Ask about thoughts of self-harm or suicide  
  • To differentiate adjustment disorder from posttraumatic stress disorder (PTSD), determine severity of stressor and duration of symptoms
    • Stressors associated with adjustment disorder typically are not as intense as events associated with PTSD/acute stress disorder  
    • Symptoms of PTSD usually last more than 1 month, symptoms of acute stress disorder typically occur within 1 month of the stressor and last between 2 days and 4 weeks

Past Medical History and Social History

  • History or current diagnosis of psychiatric disorders
  • History of self-harm, suicidal ideation, and/or suicide attempt
  • Increased consumption of food or alcohol/other substances
  • Change in sleep quality or quantity

General Physical

  • Usually without physical findings unless symptoms are prolonged enough to bring physical changes

Evaluation

  • Suspect adjustment disorder in patients with emotional or behavioral symptoms (anxiety, depression, or maladaptive behaviors) within 1 to 3 months following an identifiable stressor; these symptoms  
    • Are disproportionate to the severity of the stressor
    • Contribute to impaired social, occupational, or other functioning
    • Do not meet criteria for another psychiatric disorder
  • Diagnosis is generally clinical and based on self-report, history, and mental status exam
  • Screening tools:
    • Diagnostic Interview for Adjustment Disorder (DIAD)  
    • Adjustment Disorder-New Module (ADNM) 
    • 7-item generalized anxiety disorder scale (GAD-7)
    • 9-item patient health questionnaire (PHQ-9)

Management Overview

  • Adjustment disorder usually resolves with appropriate management
  • Goals of management focus on symptom relief, restored functioning, and prevention of progression to severe psychiatric conditions and maladaptive behaviors
  • Stepped care approach for management includes
    • Watchful waiting/active monitoring
    • Low-intensive psychological interventions
    • Psychotherapies with or without medications
    • Crisis interventions
  • Watchful waiting/active monitoring (supervision from general practitioner) likely sufficient for most patients due to the generally self-limited course of this disorder

Low-Intensive Psychological Interventions

  • Adjustment disorder may be responsive to low-intensity interventions, including
    • Bibliotherapy/self-help
      • Manual that addresses preoccupation and failure to adapt  
      • Modules for screening, education, and self-assessment
    • Behavioral activation helps with coping and occupational functioning
    • Electronic health interventions: internet-based models specific to adjustment disorder, such as “EMMA’s world,” BADI (Brief Adjustment Disorder Intervention)  
    • Other interventions often used in conjunction with mental health services include
      • Support groups, informal peer support 
      • Mindfulness and relaxation techniques  

Psychotherapies for Adjustment Disorder

  • Rely on those established for other psychiatric disorders; few psychotherapies have been validated specifically for adjustment disorder
  • Individual or group psychotherapy is often recommended and may include brief psychopharmacologic treatment for severe symptoms 
  • Group psychotherapy may be useful for individuals who share a common stressor (such as medical illness, divorce)
  • Approaches for specific subtype per DSM-5
    • Adjustment disorder with depressed mood: cognitive behavioral therapy (CBT) or interpersonal therapy
    • Adjustment disorder with anxiety: CBT and relaxation techniques
    • Adjustment disorder with disturbance of conduct (common in children and adolescents): problem-solving and parent training
    • Adjustment disorder as subthreshold of PTSD: imaginative exposure for intrusive preoccupation with stressor
  • Eye movement desensitization and reprocessing (EMDR)
    • Type of CBT used in PTSD to densensitize patients
    • Patient tracks clinician’s moving finger back and forth while recalling trauma
  • Interventions during public health crisis may help distinguish between normal and pathologic responses
    • Distress from public health crises (such as the COVID-19 pandemic) involves anxiety, agitation, preoccupation, insomnia, grief, isolation, and fear associated with potential loss of health
    • Treatment includes verbal support, education, and skill development with
      • General counseling
      • Behavioral strategies (relaxation techniques, meditation, exercise)
      • Problem-solving skills
      • Cognitive therapies
      • General wellness education
  • Considerations for electronic health during a pandemic  
    • Low-intensive psychological interventions may be more appropriate than medications  
    • Issues difficult without proper and frequent assessment include
      • Substance abuse issues/outpatient detoxification
      • Suicidal and self-injurious individuals
      • Patient requests for new controlled substances or dosage adjustments

Medications

  • Pharmacologic agents are generally not indicated for adjustment disorder due to insufficient evidence of efficacy, however, they have been prescribed for specific symptoms
  • Although benzodiazepines are prescribed for anxiety reduction, clinical guidelines advise against use of benzodiazepines for treatment of PTSD; as adjustment disorder is similarly a trauma/stressor-related condition, it is advisable to avoid use of benzodiazepines

Prognosis

  • With appropriate treatment, most patients return to prior level of functioning within 3 to 6 months unless the stressor is prolonged
  • Chronic adjustment disorder can lead to substantial decline in quality of life, progression to severe psychiatric disorders, and increased risk of self-harm

Kendra Church MS, PA-C, is a physician assistant at Dana-Farber Cancer Institute/Brigham & Women’s Hospital, and is also a senior clinical editor for DynaMed, an evidence-based, point-of-care database. 

Sources

1. Bachem R, Casey P. Adjustment disorder: a diagnosis whose time has comeJ Affect Disord. 2018;227:243-253. doi:10.1016/j.jad.2017.10.034

2. O’Donnell ML, Agathos JA, Metcalf O, Gibson K, Lau W. Adjustment disorder: current developments and future directionsInt J Environ Res Public Health. 2019;16(14):2537. doi:10.3390/ijerph16142537full-text

3. Powell AD. Grief, bereavement, and adjustment disorders. In: Stern TA, Fava M, Wilens TE, et al., eds. Mass General Hospital Comprehensive Clinical Psychiatry. 2nd ed. Philadelphia, PA: Elsevier; 2016:428-432.

4. Zelviene P, Kazlauskas E. Adjustment disorder: current perspectivesNeuropsychiatr Dis Treat. 2018;14:375-381. doi:10.2147/NDT.S121072

5. Domhardt M, Baumeister H. Psychotherapy of adjustment disorders: current state and future direction. World J Biol Psychiatry. 2018;19(sup1):S21-S35. doi:10.1080/15622975.2018.1467041

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