The document discusses adjustment disorder, including its definition as a stress-related symptom complex occurring within 3 months of a stressor. It outlines the evolution of the diagnosis from the 11th century to DSM-5 and reviews epidemiology, diagnostic guidelines, clinical presentation, course/prognosis, management, and challenges regarding the diagnosis. While criticized as vague, adjustment disorder remains one of the most commonly diagnosed disorders, especially in consultation-liaison settings. Improving operationalization of the diagnosis is needed to address its shortcomings.

1. PRESENTER:Dr CIJU BENJAMIN
CHAIR:Dr THANGADURAI

2. Introduction
Defnition
history
Etiology
Epidemiology
Diagnostic guidelines
Reliability
Validity
Cultural perspective
Clinical presentation
Co-morbidities
Course and prognosis
Differential diagnosis
Management
Challenges/Issues
Future prospect

3.  SYNDROME IN WHICH A STRESSFUL EVENT LEADS
TO A SYMPTOM COMPLEX
 DSM-5 MUST BE WITHIN 3 MONTHS OF A STRESSOR
AND LASTS NO LONGER THAN 6 MONTHS AFTER
STRESSOR OR CONSEQUENCE HAS CEASED.

4.  11 century-Avicenna,islamic physician
 Severe war stress-evolution of crisis intervention
theory
 DSM-1:Transient situational personality disorder
 DSM-2:Transient situational disorder
 DSM III : “Adjustment disorder”
III R : specified that symptoms of an
adjustment disorder could not exceed
6 months.

5.  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

6. In DSM-5,
 Now included in the Trauma- and
Stressor-Related Disorders section of the
DSM-5.
 No change in the diagnostic guidelines

7.  Epidemiology
 Principal diagnosis in OPD : 5% - 20%
 According to DSM-5, estimates approach 50%
in hospital psychiatric consultation settings.
 Women are more likely to be diagnosed with
AD compared to men.
 Outcome of Depression International Network
(ODIN) study (18), which found a prevalence
of only 1% for adjustment disorder in five
European countries

9.  Studies have also found a higher rate of
adjustment disorder among persons
exhibiting suicidal behavior, particularly
adolescents and young adults.
 Studies of soldiers psychiatrically evacuated
from Iraq and Afghanistan over a 3-year
period found that adjustment disorder was
the most common diagnosis made in 37
percent of evacuees.
 Adjustment disorder has been reported to be
almost three times as common as major
depression (13.7 vs. 5.1%) in acutely ill
medical in-patients

10.  Many authors criticize the idea of linking a
single stressor to a symptom complex.
 The stressor

interaction
individual

11. • A person’s “ego strength” determines his or her
vulnerability to stressors.
• Studies of children have revealed a consistent
pattern of individual characteristics associated
with successful adaptation.
• Early experience with diminished control may
foster a cognitive style characterized by an
increased probability of interpreting or
processing subsequent events as out of one’s
control

12. Theory of associative network
formation following a significant
stressful experience.
Stimulus information about the
stressor
Information about cognitive,
behavioral, and physiological
reactions to the stressor
Meaning elements representing
basic assumptions and their
violation

13. • Focuses on the context in which an event occurs
and how this leads to symptom formation.
• A stressor leads to the generation of an affective
experience.
• Which in turn leads to the desire for
understanding of this affect.
• If others criticize, reject, or neglect the
individual, then he or she is left to cope on his
or her own, leading to symptom formation

14. 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
informationi

15. “Allostatic load” of neurochemical networks may relate
to individual resilience
 Lowest quartile
 HPA axis
 DHEA
 CRH
 Neuropeptide Y
 Locus ceruleus: norepinephrine and dopamine
 5-HT1A receptor and BZD receptor function
 Estrogen activity
 Testosterone
 Galanin
Highest measure LOWEST QUARTILE
HPA AXIS DHEA
CRH NEUROPEPTIDE Y
LOCUS
CERULEUS:EPINEPHRINE AND
NOREPINEPHRINE
5HT1RECEPTOR AND bzd
RECEPTOR DYSFUNCTION
ESTROGEN ACTIVITY TESTOSTERONE AND
GALANIN

16.  DSM-5
 ICD -10

19.  Stressor:
 significant life change or to the consequences of a
stressful life event (including the presence or
possibility of serious physical illness)
 may have affected the integrity of an individual's
social network or wider system of social supports
 may involve only the individual or also his or her
group or community.
 Individual predisposition or vulnerability plays a
role.
 The manifestations vary.

20.  The onset is usually within 1 month, duration
of symptoms does not exceed 6 months,
except IN prolonged depressive reaction.
 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.
 Normal bereavement reactions by code As
Z63.4 (disappearance or death of family
member) or Z73.3 (stress not elsewhere
classified)

21.  ICD-10 points to "usually interfering with
social functioning and performance" and
"some degree of disability in the
performance of daily routines" whereas
 DSM-IV/5 points to "marked distress that is in
excess of what would be expected given the
nature of the stressor by significant
impairment in social or occupational
functioning“
 Difference of onset duration

22.  One study showed an interrater agreement
for adjustment disorders to be 0.05 (p = not
significant) in a survey using 27 child and
adolescent case histories.
 The results of the (UK-WHO) study of
reliability of the ICD-9 categories in children
and adolescents were consistent with this.

23.  European Outcome of Depression International
Network (ODIN) research failed to demonstrate
content validity.
 A study to assess the predictive validity of the
diagnosis reveal that 79% percent of adults in the
study were well at 5-year follow-up. While
adolescents with 57 percent well at 5 years
 As per the findings of a recent study, patients
with adjustment disorders had higher mental
quality-of-life scores than patients with major
depressive disorder but lower than patients
without mental disorder.

24.  Those with adjustment disorder had shorter
duration of hospitalizations, more presented
suicidality, fewer psychiatric readmissions,
and re-hospitalization days 2 years after
discharge
 Diagnostic stability of Adjustment disorder –
A retrospective two year follow up, done in
our setup, highlighted the importance of the
need of adjustment disorder to remain a
separate entity

25.  It is important to consider diverse idioms of
distress
 This parallels the lay concept of a “nervous
breakdown” within a particular cultural
setting. In this sense, the adjustment
disorders share features with other culture-
bound syndromes such as susto, koro, and
Arctic hysteria.

26.  Common symptoms of adjustment disorders
identified in a large study of adjustment
disorder included
 depressed mood,
 low self esteem,
 suicidal behavior,
 increased motor activity,
 hypervigilance, impulsivity, and substance use.
 There is no impairment of emotional
modulation, and patients may find joy in
thoughts of revenge.

27.  Additional symptoms may include
 feelings of helplessness, self-blame,
rejection of help, suicidal ideation,
dysphoria, aggression,
 downheartedness, seeming melancholic
depression, unspecific somatic complaints,
loss of appetite, sleep disturbance,
 pain, phobic symptoms in respect to the
place or to persons related to the event, and
reduced drive.
 Anxious subtype>depressed subtype

28.  Few research studies have examined the
disorders that are comorbid with AD.
 About 70 percent of patients with adjustment
disorders had at least one additional Axis I
diagnosis.
 Personality disorder was commonly co-morbid
(15%) with adjustment disorder (Strain et al.,
1998).
 Distinguishing between adjustment disorder and
depressive episode in clinical practice: The role
of personality disorder

29.  Suicidality:
 Several studies have reported a significant
association of adjustment disorders with suicidal
ideation.
 . Thirty percent of AD patients have suicidal
thoughts, 58% of suicide attempters have AD, and
9–19% of those completing suicide have this
disorder
 In another study in an urban hospital setting, 56
percent of all admissions for suicidal behavior
were classified as having transient situational
disorders using the DSM-II criteria.

30.  Depressive disorders:
 “disorder not otherwise specified” only in the
absence of a preceding stressor. The presence of
a stressor warrants the diagnosis of AD. Change
to the appropriate NOS category after 6 months
 MDD.

31.  PTSD and Acute Stress Reaction
 There are both timing and symptom profile
considerations.
 With regard to symptom profiles, an adjustment
disorder may be diagnosed following a traumatic
event when an individual exhibits symptoms of
either acute stress disorder or PTSD that do not
meet or exceed the diagnostic threshold for
either disorder.

32.  Personality disorders:
 Lifetime history of personality functioning
 In the presence of a personality disorder, if the
symptom criteria for an adjustment disorder are
met, and the stress-related disturbance exceeds
what may be attributable to maladaptive
personality disorder symptoms (i.e.. Criterion C
is met), then the diagnosis of an adjustment
disorder should be made.

34.  The symptoms therefore have two prognostic
courses: Either they resolve or progress to a
more serious illness.
 A 5-year follow-up study at the University of
Iowa showed a recovery rate of 71 percent in
adults versus 44 percent in adolescents.
 While most of the adults major depressive
disorder and alcohol abuse,
 the adolescents developed schizophrenia,
bipolar disorder, antisocial personality disorder,
drug abuse, and major depressive disorder

35.  In 1978, Looney said that AD was found to be
less severe and disabling than other major
psychiatric disorders in terms of chronicity,
length of hospitalization, and disposition.

36.  A 16-year-old high school senior experienced
rejection in his first serious relationship.
 Dysphoric mood accompanied by anxiety and
psychomotor agitation.
 He had received counseling in junior-high school
when his parents divorced and he began using
alcohol and marijuana.
 A month after the breakup, he began to tell his
parents that life was no longer worth living
without his former girlfriend.
 Two months later his parents came home from
work and found him hanging in the garage with a
note stating he could not go on alone.

37.  Important to collect clinically relevant
information through interview and collateral
informant reports.
 Adjustment Disorder module of the Mini-
International Neuropsychiatric Interview
(Sheehan et al., 1998)
 Schedules for Clinical Assessment in
Neuropsychiatry (Wing et al., 1990)
 Adjustment Disorder module of the Structured
Clinical Interview for DSM-IV-TR (First et al.,
1994

38. Development and validation of the Diagnostic
Interview Adjustment Disorder (DIAD) L. R.
Cornelius, S. Brouwer, M. R. De Boer, J. W.
Groothoff & J. J. L. Vanderklink

39.  Because it is conceptualized as a transitory
diagnosis, brief therapies may be most
appropriate.
 The primary goals of treatment are to relieve
symptoms and the achievement of a level of
adaptive functioning that is better than, the
level of premorbid functioning.

40.  Supportive psychological approaches and
cognitive-behavioral and psychodynamic
interventions.
 Relaxation techniques training can reduce
symptoms of anxiety.
 In persons who engage in deliberate self-
harm, dialectical behavior therapy (DBT) has
the best evidence base.
 Practical measures may be useful to assist
the person in managing the stressful
situation.

41.  Ego enhancing therapy was found to be
useful during periods of transition in older
patients. This approach promotes the coping
strategy and helps the patient acknowledge
the stressors. [Frankel]
 “Mirror therapy”, a therapy including
psychocorporeal, cognitive, and
neurolinguistics components, was effective in
patients with adjustment disorder secondary
to myocardial infarction
 Other studies have demonstrated efficacy for
Kava-Kava and Ginkgo Biloba.

42.  The basic pharmacological management of
adjustment disorder consists of symptomatic
treatment of insomnia, anxiety and panic
attacks.
 Agents commonly used : benzodiazepines and
antidepressants.
 Nguyen [80] in 2006 explored the differences in
treating Adjustment Disorder with Anxiety with
etifoxine (a nonbenzodiazepine anxiolytic drug)
and lorazepam.
 A pilot study of cancer patients with anxious and
depressed mood found trazodone superior to a
benzodiazepine

43.  It is a shared opinion that currently,
psychotherapy remains the treatment of
choice for adjustment disorders.
 Maina et al. [68] in 1999 effectiveness of
brief dynamic psychotherapy and brief
supportive psychotherapy in the treatment of
minor depressive episodes.
 Interpersonal psychotherapy :

44.  Cochrane review for Interventions to facilitate
return to work in adults with adjustment
disorders revealed
 Moderate-quality evidence that CBT did not
significantly reduce time until partial RTW and low-
quality evidence that it did not significantly reduce
time to full RTW compared with no treatment.
 Moderate-quality evidence showed that PST
significantly enhanced partial RTW at one-year
follow-up compared to non-guideline based care but
did not significantly enhance time to full RTW at one-
year follow-up.
 Limitation of small number of studies included in the
meta-analyses and the small number of participants,
which lowered the power of the analyses

45.  The only Randomized Controlled Trial found
in literature about efficacy of Psychotherapy
in AD was the study of Van der Klink ad coll.
 They concluded that the experimental
intervention for adjustment disorders was
successful in shortening sick leave duration,
mainly by decreasing long term problems.
Based on Dutch guidelines

48.  Criticized as “wastebasket” or
“afterthought” diagnosis.
 increased medicalization of life problems as well
as the bias of biological models in psychiatry
 Symptoms lack specificity
 Use of AD for presentations that fail to meet the
criteria of other Axis I diagnoses, particularly
major or minor depression.

49. Stressor criteria :
 The DSM-IV-TR states only that the
stressor is identifiable but makes no
mention as to what would qualify as a
stressor.
Duration criteria:
It is extremely difficult for a clinician to
gauge when a stressor is no longer a
stressor

50.  Definition: Cluster of symptoms which are in
excess of the normal reaction to a stressor.
Types or stressors and subtypes of AD.
 Evolution from DSM I to DSM 5, starting off
with WW II.
 A common diagnosis in consultation liaison
setting and OPD as well. Although no large
epidemiological study supporting the figures
due to poor assessment tools.

51.  Various etiological models
 Diagnostic guidelines – DSM 5 and ICD 10 and the
differences.
 Doubts regarding validity and reliability of the
diagnosis with insufficient and varying data to
support either claims.
 Cultural perspectives
 Clinical presentation/Differential diagnoses to
be considered
 Association with suicidality, personality disorders
and substance use.
 Variable course, but mainly seen as a self
limiting disorder.
 Management – Psychotherapy, pharmacotherapy
and practical changes. Dutch guidelines for GPs
and occupational therapists.
 Challenges and issues with the diagnosis

52.  Creating an interactive model that takes into
account both stress and resiliency factors that
are responsive to individual and cultural
differences remains challenging.
 Obstacles are linked to the inadequate
operationalization of adjustment disorders, we
need to adjust the adjustment disorder category
to overcome the present shortcomings.
 Although has been widely criticized diagnosis
with vague criteria and questionable
reliability/validity, it remains as one of the most
commonly diagnosed disorder.