Adjustment Disorders

Group 1

Adjustment disorder (AD) is a stress-related, short-term, nonpsychotic disturbance. Persons with AD are often viewed as disproportionately overwhelmed or overly intense in their responses to given stimuli. These responses manifest as emotional or behavioral reactions to an identifiable stressful event or change in the person's life; for instance, in the pediatric population, these events could be parental separation or divorce, a new birth in the family, or loss of an attachment figure or object (eg, pets). The disorder is time-limited, usually beginning within 3 months of the stressful event, and symptoms lessen within 6 months upon removal of the stressor or when new adaptation occurs.

Background

Age Although longitudinal data are limited, studies suggest that adults with adjustment disorder (AD) have a good long-term prognosis, while adolescents eventually may develop major psychiatric illnesses.

Risk Factor

Race and sex No findings suggest any racial or sexual predilection for AD. A study by Jones et al found that male patients were more likely than female patients to be diagnosed with an AD than with major depression or dysthymia

Social The most frequent confirmed diagnoses associated with AD were personality disorders, organic mental disorders, and psychoactive substance abuse disorders. AD was least frequently assigned as a diagnosis with schizophrenia and mood disorders.

Economic Evidence indicates that patients with average to better-than-average incomes are more often diagnosed with AD than patients who lack socioeconomic stability.

Clinical
The following 6 types of AD are listed in the DSM-IV-TR2 :

Depressed mood: Symptoms are that of a minor depression. Anxious mood: Symptoms of anxiety dominate the clinical picture. Mixed anxiety and depressed mood: Symptoms are a combination of depression and anxiety. Disturbance of conduct: Symptoms are demonstrated in behaviors that break societal norms or violate the rights of others. Mixed disturbance of emotions and conduct: Symptoms include combined affective and behavioral characteristics of AD with mixed emotional features and AD with disturbance of conduct. This residual diagnosis is used when a maladaptive reaction that is not classified under other ADs occurs in response to stress.

Diagnostic Criteria
The DSM-IV-TR diagnostic criteria for adjustment disorder are as follows2 : The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurs within 3 months of the onset of the stressor(s). These symptoms or behaviors are clinically significant, as evidenced by either of the following: Marked distress in excess of what is expected from exposure to the stressor Significant impairment in social or occupational (academic) functioning The stress-related disturbance does not meet criteria for another specific axis I disorder and is not merely an exacerbation of a preexisting axis I or axis II disorder. The symptoms do not represent bereavement. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months. Specify whether the condition is acute or chronic, as follows: Acute: If the disturbance lasts less than 6 months, it is considered acute. Chronic: If the disturbance lasts 6 months or longer, it is considered chronic. AD is coded according to subtype, which corresponds with the presenting symptoms. The subtypes of AD include depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified. Before the release of the DSM-IV-TR, AD was a time-limited diagnosis that could not exceed 6 months.

Therapy
Treatment of ADs entails psychotherapeutic counseling aimed at reducing the stressor, improving coping ability with stressors that cannot be reduced or removed, and formatting an emotional state and support systems to enhance adaptation and coping. Strain suggests that the goals of psychotherapy should include the following: Analyze the stressors that are affecting the patient, and determine whether they can be eliminated or minimized. Clarify and interpret the meaning of the stressor for the patient. Reframe the meaning of the stressor. Illuminate the concerns and conflicts the patient experiences. Identify a means to reduce the stressor. Maximize the patient's coping skills. Assist patients to gain perspective on the stressor, establish relationships, attend support groups, and manage themselves and the stressor

These are effective for eliciting the expressions of affects, anxiety, helplessness, and hopelessness in relation to the identified stressor: Psychotherapy, crisis intervention family and group therapies cognitive behavioral therapy interpersonal psychotherapy

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