Adjustment Disorder

Overview

Definition

Adjustment disorder is a psychological and physical response (feeling sad, stressed, or hopeless, and certain physical symptoms) to an identifiable stressor (death of a loved one, divorce, life changes, illness, family problems, school problems, or sexual issues).

Epidemiology

• Lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: approximately 2%–8% of the general population
• Women are twice as likely to be diagnosed as men.
• One of the most common psychiatric diagnosis for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship hospitalized for any other medical/surgical reason

Etiology

• Precipitated by 1 or multiple stressors
• Severity of stressor does not predict prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas.
• Personality of the patient as well as societal norms contribute to the pathologic reactions to the stressors.

Diagnosis

Adjustment disorder is difficult to diagnose as it shares symptoms with other mental disorders.

History and physical exam elicit the following criteria:

• Development of psychological symptoms in response to identifiable stressor
• Occurring within 3 months of the onset of stressor
• Symptoms or behaviors are clinically significant, causing marked distress and decline in function.
• Once stressor is removed, symptoms do not last more than 6 months.

Adjustment disorder cannot be diagnosed if symptoms:

• Meet criteria of any other psychiatric disorder 
• Are explained by substance use disorder or withdrawal 
• Last over 6 months after the stressor
• Cause no decline in patient functioning or marked distress
• Represent normal bereavement

Management

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

• 1st-line therapy
• Different modalities, such as CBT, can help the patient to cope with the stressors.
• Group therapy Group therapy A form of therapy in which two or more patients participate under the guidance of one or more psychotherapists for the purpose of treating emotional disturbances, social maladjustments, and psychotic states. Psychotherapy may be useful, especially among patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship undergoing similar stressors.

Crisis intervention

Crisis intervention may be help provide timely reassurance Reassurance Clinician–Patient Relationship and support to prevent sentinel outcome.

Pharmacotherapy

• Generally not indicated but may help treat comorbid symptoms 
• Severe anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder may be treated with long-acting benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines (e.g., diazepam Diazepam A benzodiazepine with anticonvulsant, anxiolytic, sedative, muscle relaxant, and amnesic properties and a long duration of action. Its actions are mediated by enhancement of gamma-aminobutyric acid activity. Benzodiazepines).  
• Antipsychotics if showing symptoms of psychosis 
• Antidepressants ( selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors Serotonin Reuptake Inhibitors and Similar Antidepressants ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants)) may be useful adjuncts.

Differential Diagnosis

• Acute stress disorder Acute stress disorder Acute stress disorder describes stress reactions displayed after an individual has experienced a traumatic event. Symptoms last more than 3 days but less than 1 month and include re-experiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Acute Stress Disorder: stress reactions that present after an individual has experienced a life-threatening event. Symptoms last > 3 days and < 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders, irritability, hyperarousal, and poor memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment and concentration. The traumatic event Traumatic event An emotionally painful, shocking, stressful, and sometimes life-threatening experience. It can result from witnessing distressing events such as natural disasters, physical or sexual abuse, and terrorism or other acts of violence. Posttraumatic Stress Disorder (PTSD) must have occurred within 1 month and last < a month.
• Bereavement/grief: emotions or thoughts and actions in response to the death of someone close to the patient. The duration and form of expression vary based on the patient’s culture and customs.  Depression of mood as well as a feeling of loss can be expected. Unlike in adjustment disorder, bereavement causes no significant impairment in function. Bereavement is not pathological. 
• Prolonged grief disorder: a persistent, pervasive grief response which causes impairment or distress for > 12 months after the loss of a loved one. It is characterized by intense longing for and preoccupation Preoccupation Body Dysmorphic Disorder with the deceased, as well as emotional pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways. The duration and intensity of grief must exceed usual social, religious, or cultural norms. The diagnosis is made based on clinical criteria. Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy is the preferred management.
• Generalized anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder ( GAD GAD Generalized anxiety disorder (GAD) is a common mental condition defined by excessive, uncontrollable worrying causing distress and occurring frequently for at least 6 months. Generalized anxiety disorder is more common in women. Clinical presentation includes fatigue, low concentration, restlessness, irritability, and sleep disturbance. Generalized Anxiety Disorder): a psychiatric disorder marked by chronic multiple worries, usually about things that are not important. Associated with fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia, low concentration, restlessness, irritability, and sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep disturbance. These symptoms last for > 6 months. The diagnosis of GAD GAD Generalized anxiety disorder (GAD) is a common mental condition defined by excessive, uncontrollable worrying causing distress and occurring frequently for at least 6 months. Generalized anxiety disorder is more common in women. Clinical presentation includes fatigue, low concentration, restlessness, irritability, and sleep disturbance. Generalized Anxiety Disorder does not require a trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation event causing its symptomatology Symptomatology Scarlet Fever, unlike adjustment disorder.