What is the approach to taking a history and treating adjustment disorder?

History Taking for Adjustment Disorder

Begin by identifying the specific stressor that occurred within 3 months of symptom onset, as this temporal relationship is essential for diagnosis, then systematically assess emotional/behavioral symptoms, functional impairment, suicide risk, and rule out other psychiatric conditions. 1, 2

Essential Components of the Clinical Interview

Identify the Precipitating Stressor

• Establish the temporal relationship: Symptoms must have developed within 3 months of an identifiable stressor 1, 2
• Ask directly: "What significant life event or change occurred before these symptoms began?" 1
• Common stressors include: job loss, divorce/separation, medical diagnosis (especially cancer), relocation, interpersonal conflicts, or bereavement 3, 4
• Document the specific nature, timing, and patient's subjective appraisal of the stressor 5

Characterize Core Symptoms

Systematically inquire about the following symptom domains 1, 2:

• Mood symptoms: Low mood, tearfulness, feelings of hopelessness 1, 2
• Anxiety symptoms: Nervousness, worry, separation anxiety 1, 2
• Behavioral changes: Risk-taking behavior, substance use, social withdrawal 6
• Somatic complaints: Sleep disturbances, appetite changes, physical symptoms without clear medical cause 6
• Cognitive symptoms: Difficulty concentrating, intrusive thoughts about the stressor 1

Assess Functional Impairment

• Evaluate impact on daily functioning: Ask specifically about work performance, social relationships, self-care, and role obligations 1, 2
• Determine if impairment is significant enough to meet diagnostic criteria—symptoms must cause clinically significant distress or functional impairment 1, 2
• Use structured questions: "How have these symptoms affected your ability to work/maintain relationships/care for yourself?" 6

Evaluate Suicide Risk

• Directly assess suicidal ideation, intent, plan, and access to means—adjustment disorder carries elevated suicide risk 4
• This is a critical component that must not be omitted from any adjustment disorder assessment 1, 2

Structured Assessment Tools

Utilize standardized instruments to quantify symptom severity 1, 2:

• Distress Thermometer (DT): Use cutoff ≥4 to identify clinically significant distress 1, 2
• Brief Symptom Inventory-18 (BSI-18): Evaluates anxiety, depression, and somatization 1, 2
• These tools provide objective measurement and facilitate monitoring of treatment response 1

Differential Diagnosis Considerations

Rule Out Other Psychiatric Conditions

Adjustment disorder is a diagnosis of exclusion—symptoms must not meet criteria for other mental disorders 3, 4:

• Major Depressive Disorder: Requires specific symptom count and duration; adjustment disorder is diagnosed longitudinally based on stressor context, while MDD is cross-sectional based on symptom numbers 3
• Generalized Anxiety Disorder: Characterized by excessive worry not limited to the stressor 2
• PTSD: Requires exposure to actual/threatened death or serious injury, with specific intrusion, avoidance, and arousal symptoms 6
• Normal stress reaction: Adjustment disorder must cause significant impairment beyond expected reactions 3, 5

Assess for Comorbidities

• Screen for co-occurring psychiatric disorders, as adjustment disorder frequently presents with comorbid conditions 1, 2
• When comorbidities exist, prioritize treatment based on which condition causes greatest functional impairment 1, 2

Additional History Elements

Psychiatric and Medical History

• Document prior psychiatric diagnoses, treatments, and responses 1, 2
• Review current medications that may contribute to symptoms 1, 2
• Assess for medical conditions, particularly in consultation-liaison settings where prevalence is 10-35% 3

Psychosocial Context

• Evaluate social support systems, coping resources, and prior stress responses 1
• Identify cultural factors that may influence symptom expression and help-seeking 1
• For children/adolescents, assess family functioning and parental adjustment, as parental distress can impair children's sense of safety 6

Interview Technique Considerations

Informant Involvement

• Obtain collateral information from family members or close contacts when possible, particularly for children where parents may underestimate distress 6
• Family members can provide valuable observations about functional changes and behavioral symptoms 6

Addressing Avoidance

• Recognize that patients may actively avoid discussing the stressor or their reactions—this is a core feature that can make diagnosis challenging 6
• Many symptoms (intrusive thoughts, emotional distress) are not externally observable, requiring direct inquiry 6
• Create a safe environment: "This is a safe place where you can discuss difficult feelings" 6

Common Diagnostic Pitfalls

• Premature diagnosis of major depression when symptoms are actually stress-related and time-limited 4
• Failure to identify the temporal relationship between stressor and symptom onset 1, 2
• Overlooking suicide risk despite elevated rates in adjustment disorder 4
• Missing the diagnosis entirely because better-known disorders (depression, anxiety) are considered first 4
• Relying solely on observable behaviors rather than directly inquiring about internal experiences 6
• Underestimating symptom severity in children, as adults often overestimate resilience 6