Psychiatry III EXIMIUS

ADJUSTMENT DISORDERS 2021

DR. ETHEL PAGADDU
SEPTEMBER 2019
OVERVIEW FAMILY AND GENETIC FACTORS
• characterized by an emotional response to a stressful event • life events and stressors are modestly correlated in twin pairs,
• the stressor involves financial issues, a medical illness, or a with monozygotic twins showing greater concordance than
relationship problem dizygotic twins
• may involve anxious or depressive affect or may present with a • concluded that the likelihood of developing symptoms in
disturbance of conduct response to traumatic life events is partially under genetic
• the symptoms must begin within 3 months of the stressor and control
must remit within 6 months of removal of the stressor
DIAGNOSIS and CLINICAL FEATURES
EPIDEMIOLOGY • the symptoms do not necessarily begin immediately after the
• Prevalence is estimated to be from 2-8% of the general stressor
population • up to 3 months may elapse between a stressor and the
• W > M, 2x development of symptoms
• single women are most at risk • symptoms do not always subside as soon as the stressor ceases;
• in children and adolescents, boys and girls are equally diagnosed if the stressor continues, the disorder may be chronic
with adjustment disorders
• occur at any age, but are most frequently diagnosed in DSM-5 DIAGNOSTIC CRITERIA FOR ADJUSTMENT DISORDERS
adolescents. A. The development of emotional or behavioral symptoms in
• among adolescents of either sex, common precipitating stresses response to an identifiable stressor(s) occurring within 3 months
are school problems, parental rejection and divorce, and of the onset of the stressor(s).
substance abuse. B. These symptoms or behaviors are clinically significant as
• among adults, common precipitating stresses are marital evidenced by either of the following:
problems, divorce, moving to a new environment, and financial a. marked distress that is in excess of what would be expected
problems from exposure to the stressor, taking into account the
external context and the cultural factors that might
ETIOLOGY influence symptom severity and presentation.
• the severity of the stressor or stressors does not always predict b. significant impairment in social or occupational (academic)
the severity of the disorder; the stressor severity is a complex functioning
function of degree, quantity, duration, reversibility, C. The stress-related disturbance does not meet the criteria for
environment, and personal context another specific Axis I disorder and is not merely an exacerbation
• stressors may be single or multiple; may be recurrent or of a preexisting mental disorder.
continuous D. The symptoms do not represent bereavement.
• it can occur in a group or community setting E. Once the stressor (or its consequences) has terminated, the
symptoms do not persist for more than an additional 6 months.
• specific developmental stages, such as beginning school, leaving

home, getting married, becoming a parent, failing to achieve
ADJUSTMENT DISORDER WITH DEPRESSED MOOD
occupational goals, having the last child leave home, and
retiring, are often associated with adjustment disorders • predominant manifestations are depressed mood,
tearfulness, and hopelessness
PSYCHODYNAMIC FACTORS • must be distinguished from MDD and uncomplicated
• understanding of three factors: (1) the nature of the stressor, bereavement.
(2) the conscious and unconscious meanings of the stressor, • Adolescents with this type of adjustment disorder are at
and (3) the patient's preexisting vulnerability increased risk for major depressive disorder in young
• has emphasized the role of the mother and the rearing adulthood.
environment in a person's later capacity to respond to stress
ADJUSTMENT DISORDER WITH ANXIETY
• Donald Winnicott's concept of the good-enough mother: a
person who adapts to the infant's needs and provides sufficient • symptoms of anxiety, such as palpitations, jitteriness, and
support to enable the growing child to tolerate the frustrations agitation, are present in adjustment disorder with anxiety,
in life which must be differentiated from anxiety disorders

• current events may reawaken past traumas or disappointments
ADJUSTMENT DISORDER WITH MIXED ANXIETY & DEPRESSED
from childhood, so patients should be encouraged to think about
MOOD
how the current situation relates to similar past events
• patients exhibit features of both anxiety and depression
• Throughout early development, each child develops a unique set
that do not meet the criteria for an already established
of defense mechanisms to deal with stressful events
anxiety disorder or depressive disorder
• Because of greater amounts of trauma or greater constitutional

vulnerability, some children have less mature defensive
ADJUSTMENT DISORDER WITH DISTURBANCE OF CONDUCT
constellations than other children
• the predominant manifestation involves conduct in which
• Resilience is also crucially determined by the nature of children's
the rights of others are violated or age-appropriate societal
early relationships with their parents
norms and rules are disregarded
• Studies of trauma repeatedly indicate that supportive, nurturant
• Ex.: truancy, vandalism, reckless driving, and fighting
relationships prevent traumatic incidents from causing
• be differentiated from conduct disorder and antisocial
permanent psychological damage.
personality disorder.

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 Psychiatry III EXIMIUS
ADJUSTMENT DISORDERS 2021
DR. ETHEL PAGADDU
SEPTEMBER 2019
ADJUSTMENT DISORDER WITH MIXED DISTURBANCE OF EMOTIONS
& CONDUCT
• a combination of disturbances of emotions and of conduct
sometimes occurs

ADJUSTMENT DISORDER UNSPECIFIED
§ a residual category for atypical maladaptive reactions to
stress
§ Ex.: inappropriate responses to the diagnosis of physical
illness, such as massive denial, severe noncompliance with
treatment, and social withdrawal, without significant
depressed or anxious mood

DIFFERENTIAL DIAGNOSIS
• Bereavement • MDD
• Brief psychotic disorder • GAD
• Somatization disorder • Substance-related disorder
• Conduct disorder • Academic problem
• Occupational problem • Identity problem
• PTSD

ACUTE AND POST TRAUMATIC STRESS DISORDERS
• presence of a stressor is a requirement in the diagnosis of
adjustment disorder, PTSD, and acute stress disorder
• PTSD and acute stress disorder have the nature of the
stressor better characterized and are accompanied by a
defined constellation of affective and autonomic symptoms
• the stressor in adjustment disorder can be of any severity,
with a wide range of possible symptoms
• when the response to an extreme stressor does not meet
the acute stress or PTSD threshold, the adjustment disorder
diagnosis would be appropriate

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
• Adolescents usually require a longer time to recover than
adults

TREATMENT
• Psychotherapy
o remains the treatment of choice for adjustment
disorders.
o Group therapy
o Individual psychotherapy
• Crisis Intervention
o short-term treatments by supportive techniques,
suggestion, reassurance, environmental modification,
and even hospitalization, if necessary
• Pharmacotherapy
o judicious use of medications can help patients with
adjustment disorders, but they should be prescribed
for brief periods
o Anti-anxiety, antidepressant, psychostimulant, or
antipsychotic drugs

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