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Adjustment Disorder

para>Excludes separation anxiety disorder of childhood

Can present with divorce or unstable family environment (5)[C]

More prevalent among adolescents than adult AD (5)[B]

Adolescents with AD show presence of suicidal thoughts and behaviors (6)[B].

Reports of symptoms of suicidal tendency in adolescents with AD was more prevalent among girls than boys (6)[A].

Geriatric Considerations

Physical Exam

Complete physical exam to identify evidence that may contribute to any medical or neurologic disorder. Focus on pulmonary, cardiac, neurologic, and psychiatric.

Differential Diagnosis

  • Posttraumatic stress disorder
  • Acute stress disorder
  • Major depressive disorder
  • Personality disorders
  • Normative stress reactions
  • Bereavement

Diagnostic Tests & Interpretation

  • Clinical diagnosis made by DSM V criteria
  • Rule out depression or other Axis I disorder.
  • No questionnaire type currently exists for AD diagnosis (1).

Treatment

General Measures

  • Treatment for AD is under investigation, although brief psychological interventions are preferred (3)[A].
  • Symptoms resolve after resolution of stressor(s) and its consequences.

Medication

  • The use of antidepressants in AD is not properly supported and should be avoided (1)[B]
  • Psychotherapy is more solidly supported by clinical evidence.
  • There are few trials specifically directed to the pharmacologic treatment of AD (3)[B].

First Line

Psychotherapy in groups or individually

  • Cognitive behavioral therapy
  • Dialectical behavioral therapy

Second Line

  • Antidepressants may be recommended for AD types with depressed mood.
  • Anxiolytics may be used for AD subtype with anxiety. Benzodiazepines may be used to treat symptoms of AD relating to insomnia, anxiety, and panic attacks (3)[B].

Inpatient Considerations

Admission Criteria/Initial Stabilization

  • AD alone, without associated types, is not an indication for admission.
  • Inpatient care is indicated for AD patients at risk for suicide/homicide and for comorbid conditions.

Discharge Criteria

  • Depressive symptoms resolve
  • Suicidal symptoms resolve
  • Appropriate outpatient follow-up

Ongoing Care

Patient Education

Coping skills for life stressors

Prognosis

Short term: improvement within 6 months of elimination of stressor and consequences

Complications

  • Increase risk of attempts and completed suicide
  • Low quality of life

References

1.Carta MG, Balestrieri M, Murru A, et al. Adjustment disorder: epidemiology, diagnosis and treatment. Clin Pract Epidemiol Ment Health. 2009;5:15.

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2.Casey P. Adjustment disorder: epidemiology, diagnosis and treatment. CNS Drugs. 2009;23(11):927-938.

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3.Casey P, Bailey S. Adjustment disorders: the state of the art. World Psychiatry. 2011;10 (1):11-18.

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4.Fern ¡ndez A, Mendive JM, Salvador-Carulla L, et al. Adjustment disorders in primary care: prevalence, recognition and use of services. Br J Psychiatry. 2012;201:137-142.

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5.Pelkonen M, Marttunen M, Henriksson M, et al. Adolescent adjustment disorder: precipitant stressors and distress symptoms of 89 outpatients. Eur Psychiatry. 2007;22(5):288-295.

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6.Ferrer L, Kirchner T. Suicidal tendency in a sample of adolescent outpatients with adjustment disorder: gender differences. Compr Psychiatry. 2014;55(6):1342-1349.

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Additional Reading

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-V). 5th ed. Washington, DC: American Psychiatric Publishing; 2013.

Codes

ICD09

  • 309.9 Unspecified adjustment reaction
  • 309.0 Adjustment disorder with depressed mood
  • 309.24 Adjustment disorder with anxiety
  • 309.3 Adjustment disorder with disturbance of conduct
  • 309.28 Adjustment disorder with mixed anxiety and depressed mood
  • 309.29 Other adjustment reactions with predominant disturbance of other emotions
  • 309.4 Adjustment disorder with mixed disturbance of emotions and conduct
  • 309.82 Adjustment reaction with physical symptoms
  • 309.89 Other specified adjustment reactions

ICD10

  • F43.20 Adjustment disorder, unspecified
  • F43.21 Adjustment disorder with depressed mood
  • F43.22 Adjustment disorder with anxiety
  • F43.24 Adjustment disorder with disturbance of conduct
  • F43.23 Adjustment disorder with mixed anxiety and depressed mood
  • F43.25 Adjustment disorder with mixed disturbance of emotions and conduct
  • F43.29 Adjustment disorder with other symptoms

SNOMED

  • 17226007 Adjustment disorder (disorder)
  • 57194009 Adjustment disorder with depressed mood (disorder)
  • 47372000 Adjustment disorder with anxious mood (disorder)
  • 84984002 Adjustment disorder with disturbance of conduct (disorder)
  • 192063005 Adjustment reaction with physical symptoms (disorder)
  • 55668003 Adjustment disorder with mixed emotional features (disorder)
  • 66381006 Adjustment disorder with mixed disturbance of emotions AND conduct (disorder)

Clinical Pearls

Short-term disorder: occurs within 3 months of a stressor(s) and should resolve within 6 additional months from termination of stressor(s) or consequences of stressor(s)