Adjustment Disorders


1. Describe adjustment disorders and define the diagnostic criteria for adjustment disorder with depression, with anxiety, with mixed emotional features, with disturbance of conduct and with mixed disturbance of emotion and conduct.

Adjustment disorder is a short term maladaptive response linked to a stressful incident. It can have emotional (i.e., anger, depression) and/or behavioral (i.e., acting out, self-neglect) manifestations. Adjustment disorder essentially presents in individuals of any age, without any pre-existing mental disorder, and in close temporal relationship with stressful events.

The diagnostic criteria for adjustment disorders are that there must be emotional and behavioral symptoms in response to an identifiable stressor within 3 months of stressor onset. Symptoms must be clinically significant, causing marked distress and/or impaired functioning, but not meet any criteria for another Axis I disorder. If criteria are met for another axis I disorder (i.e., mood or anxiety disorder), then do not use the adjustment disorder diagnosis.

Acute adjustment disorder has stressor and symptoms lasting less than 6 months with the symptoms lasting no longer than 6 months after stress is no longer present. Chronic adjustment disorder has stressor and symptoms lasting longer than 6 months.

Adjustment disorder has 6 subtypes. Depressed mood subtype presents with sadness, tearfulness, hopelessness, and helplessness. Anxiety subtype presents with tenseness, anxiousness, jitteriness, insomnia, and worrying. Disturbance of conduct subtype present with acting out of society norms or breaking of rules. Mixed anxiety and depressed mood subtypes present with both depressed mood and anxiety subtype symptoms. Mixed disturbance of emotions and conduct subtype contains a combination of symptoms of depressed mood, anxiety, and disturbance of conduct disorders. Unspecified subtype can present with non-compliance such as not following diet, exercise or medication regimen.

2. Explain the etiology of adjustment disorder.

Stressor in adjustment disorder is identifiable but usually not catastrophic. The severity, duration, and reversibility of the stressor as well as the developmental stage of the person affect the severity of the adjustment disorder symptoms. For example, the coping with the death of an adult is different for a child, than for an adolescent or an adult. The stressful event can happen to an individual, family, or group. For example, an individual, family, or neighborhood can be affected by an apartment fire, house fire, or neighborhood fire.

3. Discuss the relevance of the type, meaning of stress, and the person's vulnerability to stress on the development of adjustment disorders.

They stress experienced by an individual is modified by many psychodynamic factors that may exacerbate or protect a person from developing adjustment disorder. A person with past experience with the stress or similar stress may be better able to cope by drawing on their prior experiences. The perception of the stress can vary with one individual perceiving the same stress as less threatening than another individual. A person’s vulnerability to the particular stress is dependent on the person’s coping abilities as well as his or her age, gender, severity of illness, and availability of social support.

4. Summarize the major treatments for adjustment disorder and the prognosis for recovery.

Treatment is primarily prevention of adjustment disorder through the use of crisis intervention for acute stress disorder to stop the development of adjustment disorder.

After development of adjustment disorder, an assessment must be made to evaluate for suicidal thoughts, intent, and plans. Psychotherapy is employed to include stress management (i.e., relaxation, problem-solving). For acute symptoms, drug therapy may be useful.

Prognosis for adjustment disorder is usually good but declines if the stressor persists, there is little social support, individual has poor coping skills, and the individual is emotionally ill.

5. Contrast adjustment disorder with post traumatic stress disorder and with acute stress disorder.


Acute Distress Disorder
Adjustment Disorder
Post Traumatic Stress Disorder
Type of Stressor
Severe
Mild/Moderate
Severe
Time Between Stress and Symptoms
2-4 days
3 mos
Sometimes Years
Duration of Symptoms
Maximum of 4 weeks
6 months
  • 1 month

Adjustment disorder is also different from general anxiety disorder in that a specific identifiable stressor is present in adjustment disorder while there is no identifiable stressor present in general anxiety disorder.

6. Compare adjustment disorder with depressed mood and bereavement.

Bereavement is a depressive reaction to the loss of a loved one; it is a universal reaction that is ritualized and socially acknowledged. The source of bereavement can also be from the loss of health, function, employment, home, or friends.

Adjustment disorder with depressed mood is a maladaptive response to stress, which can be bereavement, but in excess of what is expected. Such a response can lead to pathological or complicated bereavement which is not ritualized and lacks social acknowledgement despite its devastating affects on the suffering individual.

7. Explain the risk factors for development of complicated bereavement.

Risk factors for development of complicated bereavement include:
(1) Multiple recent or past losses
(2) Perception that the loss was preventable
(3) Absence of social support
(4) Deficient coping skills
(5) Relationship with the deceased was ambivalent, guilty, or overly dependent
(6) Inhibited expression of grief

Physicians should encourage and normalize grieving, refer patient to support groups, and anticipate anniversary events. Physicians should also follow up to assess resolution of grieving process, and increase intervention if grieving becomes pathological.

8. List the criteria for the diagnosis of psychological factors affecting medical condition. Describe the links between affective disturbances, physical disorders, and illness behavior.

Psychological factors affecting medical conditions must have the following criteria for diagnosis:
(1) The person must have a medical condition
(2) Some psychological factor must be adversely affecting the medical condition (i.e., psychosomatic)

Psychological factors adversely affecting the medical condition does not necessarily mean a cause-and-effect link. However, there should be a close relationship in time between the psychological factors and the medical condition. Psychological factors affecting medical conditions also apply to worsening illness, delayed recovery, and additional health risks.

Affective disturbances such as mental disorder, emotional symptoms, personality traits, maladaptive health behaviors, and stress-related physiological responses are linked by pathways leading to physical disorders and illness behavior. These pathways may be biological, behavioral, cognitive, or social.

Mental disorders may be like major depressive disorder, which can increase mortality in post-heart attack patients. Emotional symptoms may be excessive anxiety, which can lead to shortness of breath in asthma or anger at physician increasing blood pressure in hypertension. Personality traits such as type A personality is associated with increasing risk and worsening heart disease. Maladaptive responses to stress can be like unhealthy eating habits increasing blood glucose in type II diabetes. Stress-related physiological responses can include stress hormones suppressing the immune system.

Biological pathways and stress-related physiological response can refer to the immune system and its interaction with the stress response. Behavioral pathways can refer to poor self care or self-neglect which can manifest in type II diabetes and unhealthy eating habits. Cognitive pathways can refer to tendency to think negatively which can lead to pessimism and non-compliance. Social pathways include isolation or poor social contacts, which can affect patient compliance.

9. Provide examples of three stress related disorders; discuss the role of personality in each disorder.

Essential Hypertension
Essential hypertension refers to blood pressure sensitivity to stress in certain individuals. Stress increases sympathetic activity and raises plasma cortisol. Personalities that are outwardly congenial with inhibited rage can exacerbate essential hypertension, particularly the “rage” characteristic. Treatment can include antihypertensive drugs depending on fluctuations in blood pressure, exercise if deconditioned, weight loss if overweight, salt reduction if salt sensitive, smocking cessation if smoking, and relaxation and biofeedback if stress-sensitive.

Migraine Headaches
Migraine headaches are characterized by severe, unilateral pains due to hyper-excitability of the brain. Food, alcohol, stress, disruptions in sleep schedule, and weather changes are also factors. Personalities that are perfectionistic, compulsive, and excessively self-demanding can exacerbate factors. Treatment includes preventive and “rescue” medications, avoidance of food triggers (nuts, alcohol, chocolate, MSG), relaxation, biofeedback, and cognitive behavioral therapy.

Tension-Type Headaches
Tension-type headaches are characterized by dull aching pain across the forehead, back of neck, or all over the head. Pain may last hours or days and is not associated with nausea or vomiting. Competitive, tense, or anxious personalities tend to exacerbate symptoms. Treatment can include drug therapy, anti-anxiety agents, muscle relaxants, antidepressants, psychotherapy, biofeedback, and relaxation therapy.

10. Contrast psychological factors affecting medical conditions with somatization disorder.

Psychological factors affecting medical conditions require that a physical medical condition be present. Somatoform disorders basically have symptoms that don’t match the data. These symptoms without empirical basis can manifest as hypochondriasis and excessive worrying, symptoms produced by strong psychological conflicts, and consciously produced symptoms.

11. Apply the biopsychosocial model to the design and treatment plan for three stress related disorders: migraine headache, tension-type headache, and essential hypertension.

See Objective 9.