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)