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Adjustment Disorders

Adjustment disorder is a stress-related, short-term, nonpsychotic disturbance.

Persons with adjustment disorder are often viewed as disproportionately
overwhelmed or overly intense in their responses to given stimuli. The disorder is
time-limited, and symptoms lessen upon removal of the stressor or when new
adaptation occurs.

Because of insufficient behavioral criteria for patients with adjustment

disorder, reliability and validity of this disorder remain problematic.

Diagnosis is constructed to allow for the classification of psychiatric conditions

that are clinically significant but do not meet major criteria for major syndromes. In
1998, Strain et al asserted that the diagnostic construct for patients with adjustment
disorder is "clinically significant and deemed to be in excess of a normal reaction to
the stressor in question, and not solely the result of a psychosocial problem
requiring medical attention."

A problem with this diagnostic construct is apparent in the Diagnostic and

Statistical Manual, Fourth Edition (DSM-IV) description of adjustment disorder as a
"maladaptive reaction to an identifiable psychosocial stressor, or stressors, that
occurs within 3 months after onset of that stressor." The definition of maladaptive
reaction is potentially broad and systemically relative depending on the racial,
ethnic, and cultural identifications of the patient and psychiatrist. No guidelines are
provided to help identify a psychosocial stressor. Additionally, the delineation
between adjustment disorder, anxiety not otherwise specified, and depression not
otherwise specified are unclear. Studies have examined the constructs of stress-
related and non–stress-related diagnoses, but interpretations of the results have not
been conclusive.

The pathology of adjustment disorder is not clear. Adjustment disorders are

caused by a disruption of the process of adaptation to stressful occurrences.
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Psychiatric symptoms result from the disruption of normal functioning caused by

stress. Stress is thought to be the common antecedent to adjustment disorder.
Cohen suggests that acute and chronic stress differ in psychologic and physiologic
terms and that the meaning of stress is influenced by ecologic modifiers (eg, support
systems, resilience).
Age: Although longitudinal data are limited, studies suggest that adults with
adjustment disorder have a good long-term prognosis, while adolescents eventually
may develop major psychiatric illnesses. Most studies report no significant
differences in prevalence of adjustment disorder among different age groups.

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

Adjustment disorder and other subthreshold syndromes can include

substantial psychopathology, such as suicidal ideation and other behaviors that
should be documented and treated. The following 6 types of AD are listed in the
DSM-IV:

• Adjustment disorder with depressed mood: Symptoms are that of a minor

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

The DSM-IV diagnostic criteria for adjustment disorder are as follows:

• 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:
o Marked distress in excess of what is expected from exposure to the
stressor
o Significant impairment in social or occupational (academic) functioning
• The stress-related disturbance does not meet criteria for another specific
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.

Adjustment disorders are located on a continuum between normal stress

reactions and specific psychiatric disorders. Symptoms are not likely a normal
reaction if the symptoms are moderately severe or if daily social or occupational
functioning is impaired. If a specific stressor is involved and/or the symptoms are not
specific but are severe, alternate diagnoses (eg, posttraumatic stress disorder,
conduct disorder, depressive disorders, anxiety disorders, depression or anxiety due
to a general medical condition) are unlikely.

Clinical treatments are important for the alleviation of symptoms of adjustment

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disorder. Because no randomized clinical trials have been conducted to help direct
the choice of treatment modalities, Strain states that treatment choices "remain a
clinical decision influenced by consensus." That said, no official consensus has
been reached on the optimal treatment for adjustment disorders.

Because AD originates from a psychological reaction to a stressor, the

stressor must be identified and communicated by the patient. The nonadaptive
response to the stressor may be diminished if the stress can be "eliminated,
reduced or accommodated".

Therefore, treatment of adjustment disorders 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.

Psychotherapy, crisis intervention, family and group therapies, cognitive

behavioral therapy, and interpersonal psychotherapy are effective for eliciting the
expressions of affects, anxiety, helplessness, and hopelessness in relation to the
identified stressor(s).