From the Guidelines
Adjustment disorder is diagnosed when a person experiences emotional or behavioral symptoms within three months of an identifiable stressor that are more severe than expected and cause significant impairment in functioning, as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR) classification of mental disorders 1. The diagnostic criteria for adjustment disorder include symptoms that develop in response to a stressor, marked distress that is out of proportion to the severity of the stressor, significant impairment in social or occupational functioning, and symptoms that don't meet criteria for another mental disorder.
- Symptoms must also resolve within six months after the stressor ends
- The stressor can be a single event or a series of events, and the symptoms can vary in severity and duration
- A comprehensive evaluation, including a psychiatric history, use of medications, pain, fatigue, sleep disorder, cognitive impairment, and other physical symptoms, is essential for accurate diagnosis 1
Treatment for adjustment disorder primarily involves psychotherapy, particularly cognitive-behavioral therapy (CBT) and brief psychodynamic therapy, which help patients develop coping skills and process their emotional responses to stressors.
- Supportive counseling and group therapy can also be beneficial
- Medications are generally not first-line treatments but may be used short-term to address specific symptoms, such as SSRIs like fluoxetine 1 for anxiety or depressed mood, or benzodiazepines like alprazolam 1 for severe anxiety
- However, benzodiazepines should be limited to 2-4 weeks due to dependency risk
The prognosis for adjustment disorder is generally good, with most people recovering within months as they adapt to the stressor or after the stressor is removed, though some may develop more persistent conditions if not properly treated.
- Early intervention and treatment can significantly improve outcomes and reduce the risk of complications
- A multidisciplinary approach, including psychiatrists, psychologists, nurses, advanced practice clinicians, and social workers, can provide comprehensive care and support for patients with adjustment disorder 1
From the Research
Diagnostic Criteria for Adjustment Disorder
The diagnostic criteria for adjustment disorder are not explicitly defined in the DSM-IV, but it is characterized by the presence of a causal stressor and symptoms that vary and include those found in other common psychiatric disorders 2. The diagnosis of adjustment disorder is based on the longitudinal course of symptoms in the context of a stressor, whereas a diagnosis of major depression is a cross-sectional one based on symptom numbers 2.
Key Characteristics
- The presence of a causal stressor is essential before a diagnosis of adjustment disorder can be made 2
- Symptoms vary and include those found in other common psychiatric disorders 2
- Adjustment disorders are difficult to distinguish from normal responses to life's stressors 2
- The distinction from major depression also poses a classificatory conundrum since both are conceptually different 2
Treatment Options
- Treatments consist mainly of brief interventions, while pharmacotherapy is limited to the symptomatic management of anxiety or insomnia 2
- Psychotherapy seems indicated for mildly symptomatic adjustment disorder 3
- Psychotropic agents such as benzodiazepines, antidepressants, or etifoxine may be considered for adjustment disorder with severe symptoms 3
- Cognitive behavioral therapy (CBT) components are commonly used in psychological therapies for adjustment disorder 4
Challenges in Diagnosis and Treatment
- Adjustment disorder is under-researched, possibly due to the failure of some common diagnostic tools to allow for the diagnosis of adjustment disorder 2
- The concordance between the clinical and interview diagnosis is very poor, with the diagnosis being made more commonly in clinical practice than the diagnostic tools allow for 2
- There are no robust studies demonstrating benefits from antidepressants 2
- The quality of the evidence for positive effects of all psychological and pharmacological treatments on symptoms of adjustment disorder was ranked as low to very low 4