What is adjustment disorder?

Adjustment Disorder: Definition, Diagnosis, and Management

Adjustment disorder is characterized by emotional or behavioral symptoms that develop within 3 months of an identifiable stressor, causing significant distress and functional impairment that is out of proportion to the severity of the stressor. 1, 2

Clinical Features

Adjustment disorder presents with various symptoms depending on the subtype:

• Emotional symptoms:

  • Low mood, tearfulness, feelings of hopelessness
  • Anxiety, nervousness, worry, jitteriness
  • Separation anxiety

• Behavioral symptoms:

  • Sleep problems (difficulty falling/staying asleep, nightmares)
  • Eating problems (loss of appetite or increased eating)
  • Withdrawal from previously enjoyed activities
  • Difficulty concentrating or learning new information
  • Substance abuse (alcohol, tobacco, other substances)
  • Risk-taking behavior (increased sexual behavior or other risky actions)
  • Somatic complaints without physical cause
  • Developmental or social regression 1

Diagnostic Criteria

To diagnose adjustment disorder, the following criteria must be met:

1. Symptoms develop within 3 months of an identifiable stressor
2. Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning
3. Symptoms are out of proportion to the severity of the stressor
4. Symptoms do not meet criteria for another mental disorder
5. Symptoms typically resolve within 6 months after the stressor or its consequences have ended 1, 2

According to DSM classification, adjustment disorder may be classified as adjustment disorder with mixed anxiety and depressed mood (diagnostic code 309.28) 1.

Differential Diagnosis

It's crucial to distinguish adjustment disorder from:

• Normal stress reactions: These are proportionate to the stressor and don't cause significant functional impairment
• Major depressive disorder: Adjustment disorder is based on longitudinal course of symptoms in context of a stressor, while major depression is diagnosed cross-sectionally based on symptom count 3
• Posttraumatic stress disorder (PTSD): PTSD requires exposure to actual or threatened death, serious injury, or sexual violence and has specific symptom clusters 1

Prevalence and Risk Factors

Adjustment disorder is common across all age groups and cultures:

• 11-18% prevalence in primary care settings
• 10-35% prevalence in consultation liaison psychiatry 3

Risk factors include:

• Recent significant life changes (job loss, relationship changes, health diagnoses)
• Multiple concurrent stressors
• History of childhood trauma
• Limited social support 2

Treatment Approaches

Psychotherapy (First-Line Treatment)

• Cognitive-Behavioral Therapy (CBT): Addresses maladaptive thought patterns and develops coping strategies
• Brief Dynamic Psychotherapy: Explores underlying conflicts related to the stressor
• Mindfulness-Based Interventions: Helps manage distress through present-moment awareness
• Group Therapy: Provides peer support and normalization of experiences 2

Psychotherapy typically ranges from 8-12 sessions and should focus on:

• Addressing the underlying stressor
• Developing effective coping strategies
• Building resilience for future stressors 2

Pharmacotherapy (Adjunctive, Symptom-Based)

For moderate to severe cases with significant functional impairment:

• Short-term benzodiazepines (2-4 weeks) for anxiety symptoms, with caution due to dependence risk
• SSRIs for depressive symptoms, though evidence is limited 2, 4

Medication should be:

• Time-limited
• Used alongside ongoing psychotherapy
• Discontinued when symptoms resolve or effective coping strategies develop 2

Prognosis

While adjustment disorder is often considered mild and self-limiting:

• Many patients maintain the diagnosis or develop another mental health disorder months to years after initial diagnosis
• Patients with adjustment disorder tend to show symptom improvement at higher rates than those with other disorders
• Some studies suggest increased risk for subsequent development of physical conditions 5

Common Pitfalls to Avoid

• Overlooking the time-limited nature of adjustment disorder
• Failing to address the underlying stressor
• Using antidepressants as first-line treatment without evidence of efficacy
• Not distinguishing adjustment disorder from major depression or normal stress reactions
• Prolonged use of benzodiazepines leading to dependence 2

Regular follow-up is essential to assess treatment response and adjust interventions as needed, particularly to monitor for development of more severe psychiatric conditions.