History and Physical Examination

Adjustment disorder can include substantial psychopathology, such as suicidal ideation and other self-damaging behaviors, that should be documented and treated.

Symptoms typically include low mood, sadness, worry, anxiety, insomnia, and poor concentration following a recent stressful occurrence.^[25]In a retrospective study of 60 children and adolescents (aged 5-17 years) affected by depressive disorder and adjustment disorder, approximately half of the patients with adjustment disorder suffered from depressed/irritable mood (59%), sleep disturbances (48%), and poor performance in school (48%).^[39]

No physical findings correlate with adjustment disorder. The “more severe than expected” wording of the diagnostic criteria allows demarcation between early or temporary states, when the clinical presentation is vague, and the morbid state that warrants clinical attention. The various aspects of the diagnostic construct for adjustment disorder, including stressor severity, the maladaptive reaction, the accompanying mood and features, and the time and relationship between the stressor and the psychological response to it, are difficult to measure or compare across individuals.

In a study by Grassi et al, 57% of patients with adjustment disorders displayed criteria for abnormal illness behavior (ie, disease phobia, health anxiety, thanatophobia, nosophobia, and illness denial), 37% met criteria for somatization, and 20-30% displayed demoralization, alexithymia, and irritable mood.^{[20, 40]}Maercker et al also proposed that adjustment disorders are “particular forms of stress response syndromes, in which instructions, avoidance of reminders, and failure to adapt are core symptoms.”^[41]

The absence of a diagnostic decision tree for adjustment disorder limits the validity and reliability of the diagnosis. The development of the Impact Thermometer for use in combination with the Distress Thermometer as a brief screening tool for adjustment disorder and major depression has proved useful for identifying patients with adjustment disorder; however, the inability of these measures to distinguish between adjustment disorder and other depressive disorders limits their usefulness for differential diagnosis.^{[42, 43]}

A reliable and valid survey instrument for this disorder is needed. Adjustment disorders constitute a diagnostic category that lies between health and pathology. Prompt treatment may prevent worsening of symptoms; suicidal behavior; and social, relational, academic, and occupational impairment. Although the adjustment disorder diagnosis has not been studied extensively in controlled treatment trials, the potential sequelae remain serious, and treatment, though lacking specificity, is important.

Physical Examination

By itself, the presence of an adjustment disorder may not require a physical examination. However, the presence of physical symptoms including pain, fatigue, insomnia, GI distress, or autonomic symptoms warrants medical evaluation appropriate to the symptom. Measurement of vital signs is advisable, as stress may affect blood pressure and heart rate. Stress may also worsen the physical findings of preexisting chronic diseases, particularly movement disorders (e.g., essential tremor), metabolic conditions (e.g., diabetes), and automimmune conditions.

Complications

As noted, the most serious complications of adjustment disorders are behaviors such as suicide, self-harm, and harm to others. Disruption of relationships, occupational or school-related failures, interruption of normal development, and exacerbation of preexisting medical or psychiatric conditions may occur. Progression from adjustment disorder to a depressive or anxiety disorder is not uncommon. Worsening substance abuse, including use of alcohol, relapse into smoking, and resort to illicit drug use, are all seen in stress-related disorders, including adjustment disorders.

Differential Diagnoses

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