Adjustment Disorders

KEY FEATURES

Essentials of Diagnosis

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

• Symptoms not as severe as a major depressive episode or have 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

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

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

• By definition, an adjustment disorder occurs within 3 months of onset of an identifiable stressor

• 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

CLINICAL FINDINGS

Symptoms and Signs

• An individual reaction to stress include becoming anxious or depressed, developing a physical symptom, running away, drinking alcohol, overeating, or starting an affair

• 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 central nervous system depressants

• 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 anxiety and depressed mood

  • Disturbance of conduct

  • Mixed disturbance of emotions and conduct

  • Unspecified

• Risk and protective factors for developing adjustment disorders during the COVID-19 pandemic

  • Risk factors include

    • Being at risk for severe COVID-19 illness

    • Female gender

    • Old age

    • Poorer general health status

    • History of trauma exposure

    • A mental health disorder

    • Longer exposure to COVID-19 news

  • Protective factors include

    • Higher income

    • Retirement

    • More close social face-to-face contact

  • Pandemic-related stressors include

    • Fear of infection

    • Governmental crisis management

    • Restricted social contact

    • Work-related issues

    • Restricted activity

    • Challenging housing conditions

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

• Even with an identifiable stressor, if the patient meets criteria for another disorder such as major depression, the convention is to diagnose a major depression and not an adjustment disorder with depressed mood

TREATMENT