Johns Hopkins Psychiatry Guide

Adjustment Disorder

Rachna Lal, M.D., Dean F. Mackinnon, M.D.

DEFINITION

  • Persistent maladaptive emotional or behavioral reaction within several months of an identifiable stressful event or change in a person’s life

EPIDEMIOLOGY

  • Prevalence in patients in outpatient mental health treatment ranges from 5-20%.
  • Prevalences in a hospital psychiatric consultation setting frequently reach 50% or higher.
  • Common in children and adolescents, where the response tends to be behavioral (acting out) rather than emotional (e.g., low mood)
  • Equally prevalent in males and females
  • Variable in course and manifestations across cultures

DIAGNOSIS

Clinical Presentation

  • The presence of emotional or behavioral symptoms in response to an identifiable stressor is the essential feature.
    • These symptoms are out of proportion to the severity or intensity of the stressor (taking into account the external context and the cultural factors that might influence symptom severity and presentation).
    • This leads to impairment in social, occupational, or other important areas of functioning.
    • Patient may have depressed mood, anxiety, or maladaptive behaviors, but does not have a cluster of symptoms that meet criteria for another mental disorder.
  • The stressor may be a single event (e.g., a termination of a romantic relationship, diagnosis with a disabling or life-threatening medical condition), or there may be multiple stressors (e.g., marked business difficulties and marital problems).
  • Stressors may be recurrent (e.g., seasonal business crises, unfulfilling sexual relationships, recurrent hospitalizations for a medical illness) or continuous (e.g., a persistent painful illness with increasing disability, living in a crime-ridden neighborhood).
  • Stressors may affect a single individual, an entire family, or a larger group or community (e.g., a natural disaster).
  • Some stressors may accompany specific developmental events (e.g., going to school, leaving or returning to the parental home, getting married, becoming a parent, failing to attain occupational goals, developing age-related medical ailments, retirement).
  • May be diagnosed following the death of a loved one when the intensity, quality, or persistence of grief reactions exceeds what normally might be expected, when cultural, religious, or age-appropriate norms are taken into account
  • Associated with an increased risk of suicide attempts and completed suicide
  • Development and Course
    • By definition, the disturbance in adjustment disorders begins within 3 months of onset of a stressor and lasts no longer than 6 months after the stressor or its consequences have ceased.
    • If the stressor is an acute event (e.g., being fired from a job), the onset of the disturbance tends to be immediate (i.e., within a few days) but for a relatively brief duration.
    • If the stressor persists, the reaction to stress may persist as well.

Tests and Procedures

  • Adjustment disorder is a clinical diagnosis based on history and mental status examination, without a diagnostic laboratory test.
  • Tests to rule out medical illnesses include CBC, BMP, LFTs, TSH, B12, folate, vitamin D, RPR, blood alcohol level, urinalysis, urine toxicology.

Differential Diagnosis

  • Major depressive disorder
  • Bipolar disorder
  • Persistent depressive disorder (dysthymia)
  • Posttraumatic stress disorder
  • Acute stress disorder
  • Personality disorders
  • Normative stress reactions
  • Grief
  • Psychological factors affecting other medical conditions
    • This refers to psychological symptoms and behaviors that may exacerbate a medical condition (put the patient at risk for medical illness or worsen an existing condition).
    • In contrast, an adjustment disorder is a reaction to the stressor (i.e., having the medical illness).

TREATMENT

General

  • The main goals of treatment are symptom relief/cessation of disturbed conduct and restoration to baseline function (or better).

Pharmacotherapy

  • Medications are generally not indicated to alleviate adjustment disorder, though they may alleviate some specific accompanying symptoms.
    • However, physicians should be especially careful of over-prescribing medications for symptoms of mild to moderate situational anxiety or depression, as symptom suppression may diminish the capacity or incentive to adjust to or change problematic situations.

Psychotherapy

  • Psychotherapy is the treatment of choice for demoralization and adjustment disorders. The form of psychotherapy will vary from patient to patient and from clinician to clinician, including supportive coaching to address life stressors, behavioral approaches to remodel maladaptive habits, and insight-oriented approaches to strengthen psychic defenses.
  • Some individuals may also benefit from family therapy, especially if the situation is family-related or the patient is an adolescent.
  • Couples therapy may also be appropriate when the disorder is negatively affecting a romantic relationship.

WHEN TO REFER

FOLLOW UP

Demoralized patients may exhibit a rapid apparent recovery after initiating treatment, stimulated by the prospect of psychotherapeutic relief, without also undergoing a significant change in attitude or situation. A full, planned course of a time-limited therapy, or additional visits after the symptoms have resolved, may help ensure continued resolution.

References

  1. American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  2. Casey P et al: Can adjustment disorder and depressive episode be distinguished? Results from ODIN. J Affect Disord 92:291, 2006  [PMID:16515807]
  3. Popkin MK et al: Adjustment disorders in medically ill inpatients referred for consultation in a university hospital. Psychosomatics 31:410, 1990  [PMID:2247569]
  4. Portzky G, Audenaert K, van Heeringen K: Adjustment disorder and the course of the suicidal process in adolescents. J Affect Disord 87:265, 2005  [PMID:16005078]
  5. Strain JJ et al: Adjustment disorder: a multisite study of its utilization and interventions in the consultation-liaison psychiatry setting. Gen Hosp Psychiatry 20:139, 1998  [PMID:9650031]
  6. Strain JJ, Friedman MJ: Considering adjustment disorders as stress response syndromes for DSM-5. Depress Anxiety 28:818, 2011  [PMID:21254314]
Adjustment Disorder is a sample topic from the Johns Hopkins Psychiatry Guide.

To view other topics, please or purchase a subscription.

Johns Hopkins Guides provide diagnosis, management, and treatment guidance for infectious diseases, diabetes, and psychiatric conditions. Learn more.

Last updated: November 21, 2014