Adjustment disorder is characterized by an emotional or behavioral response to a stressful life event. It is diagnosed when symptoms begin within 3 months of the stressor and resolve within 6 months of its removal. Common subtypes include depressed mood, anxiety, mixed anxiety and depression, and disturbances in conduct. Adjustment disorder is often seen in primary care and general hospital settings in response to physical illness, interpersonal problems, or life changes. Treatment involves psychotherapy, crisis intervention, and sometimes brief use of medication to target specific symptoms. The diagnosis is criticized for lacking specificity in criteria defining the stressor and symptoms.

1. ADJUSTMENT DISORDER
TOPIC DISCUSSION
Presenter : KRITI JAIN
MPhil CP I Year (2020-’22)
Gwalior Mansik Arogyashala
Date : 17 September, 2021

2. ● HISTORY
● DEFINITION
● EPIDEMIOLOGY
● AETIOLOGY
● DIAGNOSTIC AND CLINICAL FEATURES
● SUBTYPES
● DIFFERENTIAL DIAGNOSIS
● COURSE AND PROGNOSIS
● ASSESSMENT
● TREATMENT
● CRITICISM
● CONCLUSION
CONTENTS

3. HISTORY
o The first recognizable clinical description of an adjustment disorder
and its appropriate treatment is in the 11th century writings of the
Islamic physician-philosopher Avicenna.
o The initial impetus for this came through documentation of severe
wartime stress seen in World War II as well as through the
evolution of crisis intervention theory and practice.
o DSM-I in 1952 described the category of Transient Situational
Personality Disorder. (subtypes of gross stress reaction, adult
situational reaction, adjustment reaction of infancy, adjustment
reaction of childhood, adjustment reaction of adolescence, and
adjustment reaction of late life.)

4. o The diagnosis was modified somewhat in DSM-II, which changed
the concept to Transient Situational Disorder. The subtypes of
gross stress reaction and adult situational reaction were eliminated.
o DSM-III introduced the diagnosis of Adjustment Disorder. The
developmental periods of the earlier diagnostic systems were
eliminated. Instead, the subtypes of adjustment disorder were
categorized based on the predominant affective experience.
o DSM-III-R retained these diagnostic subtypes and added an
additional one involving physical complaints. It also specified that
symptoms of an adjustment disorder could not exceed 6 months.

5. o DSM-IV the subtypes of mixed emotional features, work
inhibition, withdrawal, and physical complaints were eliminated.
The stressor was allowed to persist for an indefinite period of time.
A descriptor of chronicity was specified, whereby symptoms
persisting for greater than 6 months were deemed chronic.
o In DSM-V a newly delineated category of Trauma- and Stressor-
Related Disorders was introduced.
o AD has been incorporated into the ICD classification since the 9th
revision in 1978.

6. DEFINITION
o Characterized by an emotional response to a stressful event.
o Typically, the stressor involves financial issues, a medical illness, or a
relationship problem.
o The symptom complex that develops may involve anxious or
depressive affect or may present with a disturbance of conduct.
o The symptoms must begin within 3 months of the stressor, and must
remit within 6 months of removal of the stressor. If the symptom
complex is less than 6 months in duration it is deemed acute.
Symptoms lasting beyond 6 months of the initial event are coded as a
chronic adjustment disorder.

7. o The symptom complex must not qualify for another Axis I
condition.
o Normal bereavement is an exclusion.
o Subtypes include adjustment disorder with depressed mood, anxious
mood, mixed anxiety and depressed mood, disturbance of conduct,
mixed disturbance of emotions and conduct, and unspecified type.

8. o According to ICD-10
States of subjective distress and emotional disturbance,
usually interfering with social functioning and performance,
and arising in the period of adaptation to a significant life
change or to the consequences of a stressful life event
(including the presence or possibility of serious physical
illness). The stressor may have affected the integrity of an
individual's social network (through bereavement or
separation experiences) or the wider system of social supports
and values (migration or refugee status). The stressor may
involve only the individual or also his or her group or
community.

9. EPIDEMIOLOGY
o None of the major international studies such as
the Epidemiological Catchment Area, the National Co-morbidity
Survey or the National Psychiatric Morbidity Survey included AD
among the conditions examined. Most studies are of smaller or more
discrete samples and have the problem of generalization.
o The prevalence of the disorder is estimated to be from 2 to 8 percent
of the general population. Women are diagnosed with the disorder
twice as often as men.
o Prevalent problem in consultation liaison psychiatry.

10. o In children and adolescents, boys and girls are equally diagnosed
with adjustment disorders. The disorders can occur at any age but
are most frequently diagnosed in adolescents.
o AD is very common in primary care where family practitioners deal
with the long-term impact of physical illness as well as the
consequences of social and Interpersonal problems.
o Furthermore, 10 to 30 percent of mental health outpatients and up to
50 percent of general hospital inpatients referred for mental health
consultations have been diagnosed with adjustment disorders.

11. AETIOLOGY
o By definition, an adjustment disorder is precipitated by one or more
stressors. The severity of the stressor or stressors does not always
predict the severity of the disorder; the stressor severity is a
complex function of degree, quantity, duration, reversibility,
environment, and personal context.
o Personality organization and cultural or group norms and values
also contribute to the disproportionate responses to stressors.

12. Stressor Criteria
Single
Loss of job
Divorce
Multiple
Combined
employment and
marital problem
Death of a person
important to a patient
coinciding with own
physical illness
Recurrent
Seasonal business
difficulties
Continuous
Poverty
Chronic illness

13. o A discordant intrafamilial relationship can produce an AD that
effects the whole family system, or may be limited to the patient.
o It can also occur in a group or community setting, and the stressors
affect several persons, as in natural disaster or in racial, social,
religious persecution.
o The implicit developmental triggers such as beginning school,
leaving home, getting married, becoming a parent, failing to achieve
occupational goals, empty nest syndrome, retiring, etc.

14. Psychodynamic Factors
o An understanding of three factors is necessary: the nature of the stressor,
the conscious and unconscious meanings of the stressor, and the patient's
preexisting vulnerability.
o Loss of a parent during infancy, being reared in a dysfunctional family,
personality disorder or organic impairment may make a person
vulnerable. Actual or perceived support from key relationships can affect
behavioral and emotional responses to stressors.

15. o Psychoanalytic research has emphasized the role of the mother and
the rearing environment in a person's later capacity to respond to
stress. Particularly important was Donald Winnicott's concept of the
good-enough mother, a person who adapts to the infant's needs
and provides sufficient support to enable the growing child to
tolerate the frustrations in life.
o Certain patients commonly place all the blame on a particular event
when a less obvious event may have had more significant
psychological meaning for the patient. It may reawaken past traumas
or disappointments from childhood, so patients should be
encouraged to think about how the current situation relates to similar
past events.

16. o Defense Mechanisms: Because of greater amounts of trauma or
vulnerability, some children have less mature defensive constellations
than other children. This disadvantage may cause them as adults to
react with substantially impaired functioning.
o Psychodynamic theory suggests that it is the lack of an experience of
affect or feelings about the stressor that generates problems.
Individuals may not have the opportunity to experience their feelings
about an event or toward a person because the emergence of these
feelings represented a danger or threat. Individuals develop
psychological defenses to mitigate this anxiety which in themselves
can cause problems.

17. Family and Genetic Factors
o Studies suggest that certain persons appear to be at increased risk both
for the occurrence of these adverse life events and for the development
of pathology once they occur. Findings from a study of more than 2,000
twin pairs indicate that life events and stressors are modestly correlated
in twin pairs, with monozygotic twins showing greater concordance
than dizygotic twins.
o Another twin study that examined genetic contributions to the
development of PTSD symptoms (not necessarily at the level of full
disorder and, therefore, relevant to adjustment disorders) also concluded
that the likelihood of developing symptoms in response to traumatic life
events is partially under genetic control.

18. Biological Factors
o Biological theorists have postulated the role of numerous neurotransmitters in the
generation of pathology in individuals most at risk at the time of a stressful life
event.
o “Allostatic load" of neurochemical networks may relate to individuals resilience in
the face of stressful life events. One prediction is that individuals in the highest
quartile for measures of HPA axis, corticotrophin-releasing hormone (CRH), locus
coeruleus-norepinephrine, dopamine, and estrogen activity, and the lowest quartile
for dehydroepiandrosterone (DHEA), neuropeptide Y, galanin, testosterone,
5HT1A receptor, and benzodiazepine receptor function will have the highest index
for psychobiological allostatic load.
o These neurotransmitters act through brain regions including the amygdala,
hippocampus, locus coeruleus, and prefrontal cortex, deemed critical in the
modulation of a stressful experience.

19. Theory of Associative Network Formation
Stimulus
information
about the
stressor
Information about the
cognitive, behavioral
and physiological
reactions to stressor
Meaning elements
representing basic
assumptions and
violation
Symptoms occur
when reexposed
to an element of
the associative
network
This occurs following a significant stressful experience. The literature
provides an example of meeting one's former boss, and how that may
trigger thoughts about the unexpected dismissal from work and why
this happened. Treatment would be aimed at modifying this
associative network.

20. Realization
that a
stressful
event has
occurred.
Period of
suppression
of this
information.
Alternating
intrusion of the
event and
attempts at
suppressing it.
A working
through of the
information
Integration of
the material
into one's
cognitive
schema or in
symptom
formation.
Model of Processing Stressful Life Experiences

21. Diagnostic and Clinical Features
o Although by definition adjustment disorders follow a stressor, the
symptoms do not necessarily begin immediately. Up to 3 months may
elapse between a stressor and the development of symptoms.
Symptoms do not always subside as soon as the stressor ceases; if the
stressor continues, the disorder may be chronic.
o The disorder can occur at any age, and its symptoms vary considerably,
with depressive, anxious, and mixed features most common in adults.
Physical symptoms, which are most common in children and the
elderly, can occur in any age group.
o Manifestations may also include assaultive behavior and reckless
driving, excessive drinking, defaulting on legal responsibilities,
withdrawal, vegetative signs, insomnia, and suicidal behavior.

22. The onset is usually within 1 month of the occurrence of the stressful
event or life change, and the duration of symptoms does not usually
exceed 6 months, except in the case of prolonged depressive reaction
(F43.21). If the symptoms persist beyond this period, the diagnosis
should be changed according to the clinical picture present, and any
continuing stress can be coded by means of one of the Z codes in
Chapter XXI of ICD-10.
Diagnosis depends on a careful evaluation of the relationship between:
(a)form, content, and severity of symptoms;
(b)previous history and personality; and
(c)stressful event, situation, or life crisis.

23. The presence of this third factor should be clearly established and there
should be strong, though perhaps presumptive, evidence that the
disorder would not have arisen without it. If the stressor is relatively
minor, or if a temporal connection (less than 3 months) cannot be
demonstrated, the disorder should be classified elsewhere, according to
its presenting features.
If the criteria for adjustment disorder are satisfied, the clinical form or
predominant features can be specified by a fifth character:

24. CODES SUBTYPE DESCRIPTION
F43.20 Brief depressive reaction A transient, mild depressive state of duration not exceeding 1 month.
F43.21 Prolonged depressive reaction A mild depressive state occurring in response to a prolonged exposure to a stressful situation
but of duration not exceeding 2 years.
F43.22 Mixed anxiety and depressive reaction Both anxiety and depressive symptoms are prominent, but at levels no greater than specified
in mixed anxiety and depressive disorder (F41.2) or other mixed anxiety disorder (F41.3).
F43.23 With predominant disturbance of other emotions The symptoms are usually of several types of emotion, such as anxiety, depression, worry,
tensions, and anger. Symptoms of anxiety and depression may fulfil the criteria for mixed
anxiety and depressive disorder (F41.2) or other mixed anxiety disorder (F41.3), but they are
not so predominant that other more specific depressive or anxiety disorders can be
diagnosed. This category should also be used for reactions in children in which regressive
behaviour such as bed-wetting or thumb-sucking are also present.
F43.24 With predominant disturbance of conduct The main disturbance is one involving conduct, e.g. an adolescent grief reaction resulting in
aggressive
or dissocial behaviour.
F43.25 With mixed disturbance of emotions and conduct Both emotional symptoms and disturbance of conduct are prominent features.
F43.28 With other specified predominant symptoms
F43.8 Other reactions to severe stress
F43.9 Reaction to severe stress, unspecified

25. DIFFERNTIAL DIAGNOSIS
Other disorders from which adjustment disorder must be differentiated
include:
o Major Depressive Disorder
o Brief Psychotic Disorder
o Generalized Anxiety Disorder
o Somatic Symptom Disorder
o Substance-related Disorder
o Conduct Disorder
o Post Traumatic Stress Disorder
o NOS categories in DSM V and ICD-10 of major mental disorders
These diagnoses should be given precedence in all cases that meet their criteria, even in
the presence of a stressor or group of stressors that served as a precipitant.

26. COURSE AND PROGNOSIS
With appropriate treatment, the overall prognosis of an adjustment
disorder is generally favorable. Most patients return to their previous
level of functioning within 3 months. Some persons (particularly
adolescents) who receive a diagnosis of an adjustment disorder later
have mood disorders or substance related disorders.
Research over the past 5 years has disclosed a risk for suicide,
especially in adolescent patients with adjustment disorder.

27. ASSESSMENT
o Important to collect clinically relevant information through
interview and collateral informant reports.
o Adjustment Disorder module of the MINI- International
Neuropsychiatric Interview.
o Schedules for Clinical Assessment in Neuropsychiatry
o Adjustment Disorder module of the Structure Clinical
Interview for DSM-IV-TR

28. TREATMENT
o PSYCHOTHERAPY
Group therapy can be particularly useful for patients who have had similar stresses.
Individual psychotherapy offers the opportunity to explore the meaning of the
stressor to the patient so that earlier traumas can be worked through.
Psychotherapy can help persons adapt to stressors that are not reversible or time
limited and can serve as a preventive intervention if the stressor does remit.
Psychiatrists must be particularly aware of problems of secondary gain. The illness
role may be rewarding to some normally healthy persons who have had little
experience with illness's capacity to free them from responsibility. Thus, patients
can find therapists' attention, empathy, and understanding, which are necessary for
success, rewarding in their own right, and therapists may thereby reinforce patients'
symptoms.

29. Another therapeutic modality, eye movement desensitization and
reprocessing (EMDR) has been recently studied in patients with AD.
EMDR, a psychotherapeutic technique shown to be effective in the
treatment of post-traumatic stress disorder. Results showed significant
improvement in patients with anxious or mixed features but not in those
with depressed mood. Additionally, those with ongoing stressors did not
show improvement.
o CRISIS INTERVENTION
Crisis intervention and case management are short-term treatments
aimed at helping persons with adjustment disorders resolve their
situations quickly by supportive techniques, suggestion, reassurance,
environmental modification, and even hospitalization, if necessary.

30. o PHARMACOTHERAPY
It may be reasonable to use medication to treat specific symptoms for a
brief time. The judicious use of medications can help patients with
adjustment disorders, but they should be prescribed for brief periods.
Depending on the type of adjustment disorder, a patient may respond to
an antianxiety agent or to an antidepressant. Patients with severe anxiety
bordering on panic can benefit from anxiolytics such as diazepam
(Valium), and those in withdrawn or inhibited states may be helped by a
short course of psychostimulant medication. Antipsychotic drugs may be
used if there are signs of decompensation or impending psychosis.
Selective serotonin reuptake inhibitors have been found useful in treating
symptoms of traumatic grief.

31. But Adjustment disorders have been seen as problematic for a number
of reasons:
1. The diagnostic criteria describe a syndrome in which a stressful event
leads to the development of a symptom complex. However, within the
diagnostic construct, there are no criteria to qualify or quantify the
stressor for an adjustment disorder in any way.
2. The symptom complex that develops has been criticized as lacking
specificity.
3. The temporal course between the stressor and the development of
symptoms lacks rigorous scientific evidence.
4. Difficult in clinical practice to link an event to the development of a
symptom complex.
CRITICISM

32. Wastebasket or After-thought Diagnosis
The criticisms have focused on three main nosological weaknesses.
1. Another manifestation of the increased medicalization of life-
problems as well as the hegemony of biological models in psychiatry
at the expense of social, psychological, cultural, and spiritual
conceptualizations and responses to illness.
2. Failure to present a consistent, coherent, and clear explication of the
essential relationship of an external stressor and internal diathesis.
While the criteria require the stressor to precede the developments of
symptoms in a causative manner, no specific symptoms, duration,
nature, or magnitude of stressor has been delineated.

33. 3. The use of adjustment disorder for clinical presentations that fail to
meet the criteria of other psychiatric diagnose particularly major or
minor depressions. Once the temporal threshold has been met for
another anxiety or mood or even trauma disorder, the diagnosis is
changed, yet the arbitrariness of these time periods is well
recognized. Claiming AD suddenly is transformed into another
entity after 2 weeks or 2 months is not sound science.
This raises one of the central philosophical issues in postmodern
psychiatry: where normality ends and pathology begins.

34. AD is a very common diagnosis in clinical practice, but wes till lack
data about its rightful clinical entity. This may be caused by a
difficulty in facing, with purely descriptive methods, a "pathogenic
label", based on a stressful event, to which a subjective impact has to
be considered.
The only advantage of using this diagnosis is that it permit the
classification of early or prodromal states when the clinical picture
is vague and indistinct, and yet the morbid state is in excess of that
expected in a normal reaction and this morbidity needs to be identified
and often treated.
Therefore, AD has an essential place in the psychiatric taxonomy.
CONCLUSION

35. REFERENCES
o Gelder, M., Andreasen, N., Lopez-Ibor, J., & Geddes, J. (2009). New Oxford
Textbook of Psychiatry (2 volume set) (2nd ed.). Oxford University Press.
o Sadock, B. J., Sadock, V. A., & Md, R. P. (2014). Kaplan and Sadock’s
Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (Eleventh ed.).
LWW.
o Sadock, B. J., Sadock, V. A., & Md, R. P. (2017). Kaplan and Sadock’s
Comprehensive Textbook of Psychiatry (2 Volume Set) (10th ed.). LWW.
o World Health Organization. (1992). The ICD-10 Classification of Mental and
Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines (1st
ed.). World Health Organization.

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