Adjustment Disorders

Key Features

Essentials of Diagnosis

• Anxiety or depression in reaction to an identifiable stress, though out of proportion to the severity of the stressor

• Symptoms are not at the severity of a major depressive episode or with the chronicity of a generalized anxiety disorder

General Considerations

• Stress exists when the adaptive capacity of the individual is overwhelmed by events

• The event may be an insignificant one when objectively considered

• Even favorable changes (eg, promotion and transfer) requiring adaptive behavior can produce stress

• For everyone, stress is subjectively defined, and the response to stress is a function of each person's personality and physiologic endowment

• The causes or sources of stress are different at different ages

  • Young adulthood

    • Marriage or parent-child relationship

    • Employment relationship

    • Struggle to achieve financial stability

  • Middle years

    • Changing spousal relationships

    • Problems with aging parents

    • Problems associated with having young adult offspring who themselves are encountering stressful situations

  • Old age

    • Retirement

    • Loss of physical and mental capacity

    • Major personal losses

    • Thoughts of death

• Distressing emotional and behavioral symptoms in response to stress is called adjustment disorder, with the major symptom specified; for example, adjustment disorder with

  • Depressed mood

  • Anxiety

  • Mixed depression and anxiety

  • Disturbance of conduct

  • Mixed disturbance of emotions and conduct

Clinical Findings

Symptoms and Signs

• Common subjective responses

  • Anxiety

  • Sadness

  • Fear

  • Rage

  • Guilt

  • Shame

• Acute and reactivated stress manifestations

  • Restlessness

  • Irritability

  • Fatigue

  • Increased startle reaction

  • A feeling of tension

• Inability to concentrate, sleep disturbances (insomnia, bad dreams), and somatic preoccupations often lead to self-medication, most commonly with alcohol or other CNS depressants

Differential Diagnosis

• Anxiety disorders

• Mood disorders

• Bereavement

• Other stress disorders, such as posttraumatic stress disorder

• Personality disorders exacerbated by stress

• Somatic disorders with psychic overlay

Diagnosis

Diagnostic Procedures

• Obtain history

• Identify precipitating sources of stress

Treatment

Medications

• Judicious use of sedatives (Table 25–1) (eg, lorazepam, 0.5–1 mg two or three times orally daily) for a limited time and as part of an overall treatment plan can provide relief

• Short-term use of selective serotonin reuptake inhibitors targeting dysphoria and anxiety may be useful