How do I evaluate a patient for adjustment disorder?

Evaluation of Adjustment Disorder

Begin by establishing that emotional or behavioral symptoms developed within 3 months of an identifiable stressor and are causing clinically significant functional impairment—this temporal relationship and impairment threshold are essential for diagnosis. 1, 2

Core Diagnostic Criteria

The diagnosis requires three fundamental elements:

• Temporal criterion: Symptoms must emerge within 3 months of the identifiable stressor 1, 2
• Symptom manifestation: Look for low mood, tearfulness, hopelessness, anxiety, nervousness, worry, or separation anxiety 1, 3
• Functional impairment: Symptoms must cause significant impairment in social, occupational, or other important areas of functioning that exceeds what would be expected from the stressor alone 1, 2

Comprehensive Clinical Assessment

Your evaluation must systematically address six key domains:

• Nature and severity of distress related to the identified stressor 1, 3
• Behavioral and psychological symptoms, including risk-taking behavior, substance use, sleep disturbances, and appetite changes 3
• Psychiatric history and any pre-existing mental health conditions 1, 3
• Current medication use and potential drug interactions 3
• Physical symptoms and their impact on functioning 1, 3
• Suicide risk assessment—this is mandatory in every evaluation 1, 3

Functional Impact Assessment

Evaluate how symptoms affect:

• Work performance and attendance 3
• Social relationships and activities 3
• Self-care abilities 3
• For children: school functioning, attention, and developmental milestones 3

Standardized Assessment Tools

Use the Distress Thermometer with a cutoff score ≥4 as your primary screening tool, as it is specifically recommended for identifying clinically significant distress in adjustment disorder 1, 2, 3

• Brief Symptom Inventory-18 (BSI-18) can quantify symptom severity once screening is positive 1, 2, 3

Critical Differential Diagnoses

Distinguishing from Generalized Anxiety Disorder (GAD)

If anxiety symptoms have persisted less than 6 months and are directly linked to the stressor, diagnose adjustment disorder rather than GAD 2

• GAD requires ≥6 months of excessive worry, whereas adjustment disorder is time-limited and stressor-linked 2
• When anxiety appears immediately after a serious health event and has lasted <6 months, adjustment disorder with anxiety is the appropriate diagnosis 2

Distinguishing from Major Depressive Disorder

The key is whether symptoms meet full criteria for MDD—if they do, MDD takes diagnostic precedence 3, 4

Distinguishing from PTSD

PTSD requires exposure to actual or threatened death or serious injury with specific intrusion, avoidance, and arousal symptoms 3

Normal Stress Response vs. Adjustment Disorder

A critical pitfall is diagnosing normal adaptive stress responses as adjustment disorder—symptoms must be clinically significant and cause functional impairment beyond what is expected from the stressor alone 2

Special Population Considerations

Children and Adolescents

• Assess family functioning and parental adjustment, as parental distress impairs children's sense of safety 3
• Look for neurodevelopmental symptoms: developmental delay, age-regressed behavior, toileting concerns 3
• Obtain collateral information from parents, though recognize they may underestimate their child's distress 3

Medical Populations

Adjustment disorder is one of the most common depressive and anxiety-related conditions in patients with serious medical illnesses like cancer 2, 3

Interview Technique

Create an emotionally safe environment using open-ended questions, as patients may avoid discussing the stressor or their reactions 3

• Be fully present during the interview 3
• Recognize avoidance behaviors as potential diagnostic indicators 3
• Obtain collateral information from family members when possible 3

Comorbidity Assessment

Pre-existing psychiatric disorders do not exclude an adjustment disorder diagnosis—individuals with bipolar disorder or GAD can still develop adjustment disorder 2

• When comorbid conditions exist, identify which disorder causes the greatest functional impairment to guide treatment prioritization 2, 3
• Evaluate for substance abuse, personality disorders, and suicidal behavior, which commonly co-occur 4

Common Diagnostic Pitfalls to Avoid

• Missing the 3-month onset window: Symptoms beginning >3 months after the stressor generally do not qualify 2
• Applying diagnostic criteria poorly: This is a well-documented problem in clinical practice 4
• Medicalizing normal problems of living: Ensure true functional impairment exists 4
• Overlooking suicide risk: This must be assessed in every case 1, 3
• Neglecting family assessment in children: Family dysfunction significantly impacts presentation 3