Adjustment Disorders

Updated: Nov 01, 2016
  • Author: Julia B Frank, MD; Chief Editor: David Bienenfeld, MD  more...
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Overview

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. [1] Demoralization is a common element of adjustment disorders that may provide grounds for effective treatment interventions, either problem-solving approaches or psychotherapy. [1]

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 [2] :

  • 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 [3]
  • Crisis intervention
  • Family and group therapies [4]
  • Support groups specific to the stressor
  • Cognitive-behavioral therapy (CBT)
  • Interpersonal psychotherapy
  • Mindfulness-based therapy (including group) [5]
  • Internet-based therapy (being tested) [6]

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 [7]
  • 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. [8]

See Treatment and Medication for more detail.

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Background

Adjustment disorder is a stress-related, short-term, nonpsychotic disturbance. Persons with this condition are impaired in some element of their general functioning because of their emotional or behavioral response to an identifiable stressful event or change in the person’s life. In the pediatric population, such events could be parental separation or divorce, a new birth in the family, or loss of an attachment figure or object (eg, a pet). In adults, typical stressors include disruptions in relationships, loss of a job or job-related difficulties, bankruptcy, undesired changes (eg, moves for a spouse’s career), or diagnosis or worsening of a serious health condition. Adjustment disorders may develop in reaction to traumatic stressors such as natural disasters or violence, with or without concomitant PTSD. [9]

The disorder usually begins within 3 months of the stressful event and should subside when the stressor resolves or the person has adapted to the change, usually within 6 months. The condition may persist when the stressor condition itself is prolonged. Although adjustment disorder is by definition self-limited, the associated discomfort, distress, turmoil, and anguish are significant, and the consequences, including the possibility of suicide, are extremely important. [10]

Diagnostic criteria (DSM-5)

The American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), [2] lists adjustment disorders in the category of trauma- and stress-related disorders, a group of conditions for which one of the explicit criteria is exposure to a traumatic or stressful event. 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)
  • The symptoms or behaviors are clinically significant, as evidenced by one or both of the following: (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 (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: [2]

  • With depressed mood - Symptoms of depression (low mood, loss of motivation, reduced enjoyment) dominate the clinical picture
  • With anxious mood - Symptoms of anxiety (worry, overestimation of negative possibilities, helplessness or feeling overwhelmed) dominate the clinical picture
  • With mixed anxiety and depressed mood - Predominant symptoms reflect a combination of depression and anxiety
  • With disturbance of conduct - Behaviors that break societal norms or violate the rights of others dominate the clinical picture (e.g., binge eating, excessive drinking or drug use, outbursts of anger, efforts to punish or seek revenge on others)
  • With mixed disturbance of emotions and conduct - Predominant symptoms consist of a combination of emotional symptoms (e.g., depression or anxiety) and conduct disturbances
  • Unspecified - Maladaptive reactions occurring in response to stress that do not fall into the other subtypes of adjustment disorders

DSM-5 also lists a separate category, other specified trauma- and stressor-related disorder, which is used when the clinician chooses to communicate the specific reason why the presentation does not meet the criteria for any specific trauma- and stressor-related disorder. Presentations that can be assigned to this category include the following:

  • Adjustmentlike disorders with delayed onset of symptoms (>3 months after the stressor)
  • Adjustmentlike disorders of prolonged duration (>6 months) without prolonged duration of the stressor
  • Persistent complex bereavement disorder
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Pathophysiology

The pathology of adjustment disorders varies depending on the quality of the stressor (brief, prolonged, interpersonal, material, etc.) and upon which symptoms predominate. Human life involves constant adaptation to change, and human beings have multiple redundant stress response systems. Distress and disorder occur when the need to adapt exceeds the person’s capacity to maintain psychological or physiological equilibrium. Adaptation at the physiological level involves the activity of monoamine neurotransmitters, hormones, and other neuromodulators exerting their effects in multiple brain regions and upon different body organs. Stress reactions may affect many elements of behavior, including sleep, impulsivity or behavioral constriction, autonomic functions like heart rate and blood pressure, digestion, movement and sensitivity to pain. Any of these may be disrupted by an uncontrolled or excessive stress response.

In a study evaluating the relation of blood serotonin concentrations to underlying psychiatric disorders, Rao et al observed that patients with adjustment disorders had a significantly higher maximal binding capacity of the platelet serotonin-2A receptor. [11] These findings were consistent with those in other psychiatric patients who were suicidal and suggested that loss of control over suicidal impulses may be associated with a reduction in the availability of serotonin and an upregulation of the serotonin-2A receptors.

Di Rosa et al conducted a study that analyzed serum levels of protein carbonyl groups and nitrosylated proteins, which are biologic markers of oxidative stress. [12] These biomarkers were higher in 19 individuals who experienced psychological abuse and suffered from workplace mobbing−associated adjustment disorders, in comparison to 38 healthy subjects; this finding suggested a direct role of oxidative stress in adjustment disorders.

These and other physiological processes are mediated by the meaning a person attaches to a stressor and influenced by the quality of the helping relationships and resources that may influence the person's ability to adapt and recover. Helplessness, hopelessness, and social isolation or alienation typically worsen stress responses.

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Etiology

In humans, the meaning of an event or circumstance often mediates the degree to which an individual views it as a stress. Factors that contribute to the meaning of a stressor and, thus, to adjustment disorder, include the genetic qualities that affect a person's patterns of neurochemical activity and response, preexisting personality, past personal history, stage of development, psychological qualities (cognitive capacities, typical coping patterns,), and overall constitution. The form and presentation of the stressor also contribute to the individual’s reaction. What may be perceived as a minor irritant by one person could be the stressor that challenges both the resources and coping skills of another.

The factors that contribute to the development of adjustment disorder in children and adolescents are similar to those found in adults, adjusted for stage of development. In 1996, Tomb identified the following 4 factors that may contribute to the development of adjustment disorders in children [13] :

  • Nature of the stressor
  • Vulnerabilities of the child
  • Intrinsic factors - Age; sex; intellectual, emotional, and ego development; coping skills; temperament; and past experiences
  • Extrinsic factors - Parents and support systems; expectations, understanding, skills, maturity, and support available from the child’s larger environment

The most important factor in the development of adjustment disorder in a child is his or her degree of vulnerability, which depends on the characteristics of both the child and the child’s environment.

Psychosocial factors related to comorbidity

A study of 686 patients with confirmed diagnoses of adjustment disorder reported that those who were significantly more likely to have a comorbid psychiatric diagnosis were married, employed full time, and not living alone. [14] This finding suggests that mental illnesses predispose people who would otherwise be resilient to adjustment disorders. The most frequent comorbid diagnoses associated with adjustment disorder were personality disorders, organic mental disorders, and psychoactive substance abuse disorders; the least frequent were schizophrenia and mood disorders. In another study, the presence of a comorbid disorder was one of the factors that increased the risk of suicidal ideation and attempts. [15]

A separate cross-sectional, case-control designed studydetermined associations between personal and psychosocial factors. [16] A vast majority of patients with adjustment disorders defined themselves as “insecurely attached” and tended to “keep a larger interpersonal distance from self-images, family members, and significant others,” in addition to having “low self-esteem, self-efficacy, and poor social support from family, friends, and significant others.”

Kienlen et al found that nonpsychotic “stalkers” tended to meet diagnostic criteria for either major depression or adjustment disorder in addition to personality disorders. [17]

Social factors related to suicidality

Polyakova et al, in a study comparing the characteristics of the suicide attempts of 69 patients experiencing major depression with those of 86 patients with adjustment disorders, found no significant differences in suicide methods between the 2 groups but did find several social and demographic differences. [18]

The suicidal patients with adjustment disorders had less education and lower social status than the patients with major depression; in addition, they were more likely to be unmarried. [18] More than half of the patients who attempted suicide in the group with adjustment disorders reported unstable parental families, being orphaned at an early age, and emotional deprivation during childhood. Less than 35% of the patients with major depression reported such experiences.

In a study by Pelkonen et al that included 89 patients who received a diagnosis of adjustment disorder, those who made suicide attempts, voiced suicidal threats, or disclosed suicidal ideation (as compared with those who had the same diagnosis but no suicidal tendencies) were characterized by previous psychiatric treatment, poor psychosocial functioning at treatment entry, suicide as a stressor, dysphoric mood, and psychomotor restlessness. [15]

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Epidemiology

The reported frequency of adjustment disorder varies widely, depending on the population studied and the assessment methods used. A number of studies have reported rates around 12% across a variety of populations. In clinical patient populations, rates as high as 23% have been recorded. [14, 19, 20, 21, 22] Depressed mood was the most common subtype assigned (11.6%), followed by anxious mood, mixed anxiety and depressed mood, and disturbance of conduct. [14]

In a survey of mental health−related hospitalizations in the US Armed Forces between 2000 and 2012, 49,790 of 192,317 hospitalizations of active duty personnel (38%) were related to adjustment disorder. [23]

According to DSM-5, a principal diagnosis of adjustment disorder is made in approximately 5-20% of individuals undergoing outpatient mental health treatment. In the setting of a hospital psychiatric consultation service, adjustment disorder is often the most common diagnosis, with frequencies as high as 50%. [2]

Most studies report no significant differences in prevalence among age groups. [24, 25] Rates of adjustment disorder do not clearly vary by race or sex in current studies. [24] A study by Jones et al found that female patients were significantly more likely to be diagnosed with major depression or dysthymia than with an adjustment disorder. [26]

As many as 70% of patients with adjustment disorder in adult medical settings of general hospitals receive comorbid psychiatric diagnoses, such as personality disorders, anxiety disorders, affective disorders, and psychoactive substance abuse disorders.

In a study of refugees in Ethiopia, Algeria, Gaza, and Cambodia, Dobrisk et al identified posttraumatic stress disorder (PTSD) as a comorbid condition in about 53–70% of adjustment disorder cases. [9] These individuals had experienced a high number of both traumatic and non-traumatic life events, and expressed a range of reactions. The high comorbidity between adjustment disorder and PTSD indicates that the 2 conditions constitute a continuum of a stress-responses. [9] (When using DSM-5 to make a clinical (as opposed to research diagnosis), PTSD is presented as something to be differentiated from adjustment disorder, although one does not explicitly preclude the other.)

Adjustment disorder has been reported in as many as one third of patients with cancer. [27] Although this number may be something of an overestimation, a meta-analysis of 94 interview-based studies by Mitchell et al found that the prevalence of adjustment disorder was approximately 15.4% in palliative-care settings and approximately 19.4% in oncologic and hematologic settings. [28]

Overall, the literature suggests that the incidence of adjustment disorder increases in other major illnesses as a consequence of the upsetting nature of a life-changing diagnosis or event. [29, 30] For instance, one study demonstrated that 61.5% of burn victims referred for psychiatric consultation suffered from adjustment disorder. [31]

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Prognosis

Although longitudinal data are limited, studies suggest that adults with adjustment disorders have a good long-term prognosis, whereas adolescents are at increased risk to develop major psychiatric conditions later on.

No clear correlation exists between adjustment disorder and mortality; however, research findings suggest morbidity and mortality are increased in patients with adjustment disorder.

Gradus et al examined all of the 9612 suicides recorded in Denmark from 1994 to 2006. [32] For each case, as many as 30 controls were matched on the basis of gender, date of birth, and calendar time. Conditional logistic regression analyses revealed that those diagnosed with adjustment disorder had a 12-fold higher rate of suicide than those without such a diagnosis.

Mitrev et al found that suicide risk was higher in patients with chronic adjustment disorder and in individuals with previous suicide attempts. [33] Patients aged 15-19 years demonstrated the highest suicide risk. The suicide risk for women increased with age.

In a study comparing the characteristics of the suicide attempts of 69 patients experiencing major depression with those of 86 patients who had adjustment disorders, Polyakova et al found that the interval from the first symptoms to the suicide attempt was shorter in the group with adjustment disorder than in the group with major depression. [18] Furthermore, suicide attempts of people with adjustment disorder frequently were not planned.

Runeson et al evaluated 58 consecutive suicides among individuals aged 15-29 years through psychologic autopsy and study of the suicidal process, finding that the median interval from the first suicidal communication to the suicide was less than 1 month for persons with adjustment disorder. [34] Portzky et al also confirmed that the suicidal process in adjustment disorder was significantly shorter and evolved more rapidly without any previous indications of emotional or behavioral problems. [35]

A more recent study by Casey et al. found that suicidal ideation and behavior was as common and as dangerous in patients with adjustment disorder as in those with a major derpessive episode. The presence of depressive symptoms within the adjustment disorder raised the risk of suicidal ideation and behavior. The suicidal behavior was more impulsive in the patients with adjustment disorder.

These studies underscore the importance of assessing suicidal risk in patients diagnosed with adjustment disorder and for considering adjustment to a stressor as an important contributor to any expression of suicidal thought or suicidal behavior. Psychiatric assessment of patients with adjustment disorder should include careful monitoring for nonsuicidal self-harm and harm to others.

Patients with adjustment disorder engage in deliberate self-harm at a rate that surpasses those seen in most other disorders. An emergency department (ED) study of individuals who engaged in deliberate self-harm determined that a clinical diagnosis of adjustment disorder was made in 31.8% of those interviewed. [36, 37]

In a study by Vlachos et al examining 548 patients referred for deliberate self-harm, self-poisoning accounted for most of the deliberate self-harm behaviors, and adjustment disorder or acute reaction to stress was the most common psychiatric diagnosis. A study by Mitrev et al found that in cases of deliberate self-poisoning among persons with adjustment disorder, suicidal thoughts persisted in only 11% of patients. [33]

Individuals with adjustment disorder may also be at increased risk for substance abuse disorders. However, some evidence suggests that the instability associated with the misuse of drugs and alcohol confounds the diagnoses of adjustment disorder. Addictions and their consequences are often the cause rather than the result of stress. One study revealed that 59% of individuals diagnosed primarily with adjustment disorder were relabeled on discharge with a primary diagnosis of substance abuse. [38]

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Patient Education

Patients and families benefit from the explanation that  adjustment disorder occurs when a psychological stressor exceeds an individual’s capacity for coping. The stressor can be anything that is important to the patient.

Every individual reacts differently to situations, depending on the importance and intensity of the event, the personality and temperament of the person, and the person’s age and well-being. Thus, adjustment disorder may result from a single event, or it may result from a string of events that deplete individual resources. The patient should be encouraged to acknowledge the personal significance of the stressful event(s).

Patients and families should be reassured that the emotional and physical effects of stressful events are understandable and often self-limited. Patients can generally expect to return to previous levels of functioning, even if their initial symptoms were severe. Patients should be encouraged to identify relatives, friends, and community resources that can provide support during the acute period.

The following Web sites provide useful resources for patient education:

For other patient education resources, see the Depression Center, as well as Depression, Post-traumatic Stress Disorder (PTSD), and Suicidal Thoughts.

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