Adjustment Disorder - DSM-5

Diagnostic Criteria

A) development of emotional / behavioural symptoms in response to an identifiable stressor within 3 months of stressor onset

B) symptoms + behaviours cause clinically significant distress (disproportionate to stressory severity / intensity + other contexts / cultural factors) and/or significantly impair functioning 

C) disturbance does not meet criteria for another mental disorder + isn’t an exacerbation of a preexisting mental disorder

D) symptoms don’t represent normal bereavement + aren’t better explained by prolonged grief disorder

E) once stressor / consequences of stressor is over, symptoms resolve within 6 months

Specifiers

• w/ depressed mood: predominantly low mood, tearfulness, or hopelessness

• w/ anxiety: predominantly nervous, worried, jittery, or separation anxiety

• w/ mixed anxiety + depressed mood

• w/ disturbance of conduct

• w mixed disturbance of emotions + conduct: emotions can be depressed or anxious

• unspecified: maladaptive reactions that don’t fit one of the other subtypes

Prevalence

• 12-month prevalence: 15.5%

  • higher in W (17.2%) than M (13.8%)

• 5 - 20% prevalence in outpatient MH treatment

• high prevalence in highly stressed populations (eg: 19% in cancer patients; 6 - 40% in refugees)

Development + Course

• starts within 3mo of stressor onset

• resolves within 6mos after stressor ends or adaptation occurs

• in ppl with chronic / ongoing stressors, symptoms can persist longer than 6mo

• generally has better prognosis than other disorders — most patients improve within months of removal / adaptation to stressor

Risk Factors

• being female, younger age, unemployed status, physical illness / injury, stress, low social support, history of mental health disorders

Controversies

• perceived as wastebacket diagnosis

• could be seen as pathologising normal stress

Treatments

• Psychotherapies:

  • CBT: identifies negative thought patterns related to stressor, develops adaptive coping + problem solving skills, behavioural activation

  • Solution-Focused Therapy + Interpersonal Therapy: focus on practical problem solving, improving interpersonal relationships affected by stressor

• Psychopharmacology

  • SSRIS + SNRIs

  • Benzos

Differential Diagnoses

• major depressive disorder

• general anxiety disorder

• posttraumatic stress disorder

• acute stress disorder

• bereavement 

• personality disorders

• normative stress response

Differential Diagnosis: Major Depressive Disorder

potential overlap w/ depressed mood subtype — but MDD has more severe symptoms and will meet full criteria for major depressive episode, without necessarily being linked to an identifiable stressor. if there is a stressor, symptoms will typically persist beyond its resolution in MDD

Differential Diagnosis: Generalised Anxiety Disorder

potential overlap w/ anxious subtype — but in GAD, symptoms must last at least 6 mos, won’t be tied to a specific stressor, + will be excessive in multiple areas

Differential Diagnosis: PTSD

in adjustment disorder, stressor can be of any severity / type — not bound to criterion A of PTSD. adjustment disorder is diagnosed when response to a criterion A event doesn’t meet all other PTSD criteria, or when the symptom pattern of PTSD happens in response to a non-criterion A event

Differential Diagnosis: Acute Stress Disorder

in adjustment disorders, stressors can be of any severity rather than having to meet criterion A of ASD. diagnosed when response to a criterion A event doesn’t meet the criteria for ASD (or another disorder), or when ASD symptom pattern happens in response to a non-criterion A event

Differential Diagnosis: Bereavement

potential overlap in sadness, concentration problems, social withdrawal. bereavement is normative response to loss, will typically come in waves, w/ preserved self-esteem

Differential Diagnosis: Personality Disorders

potential overlap in interpersonal difficulties + emotional disregulation. PDs will have long-standing maladaptive patterns of thinking, feeling, + behaving, present since adolescence or early adulthood. pervasive across situations and won’t resolve within 6mo

Differential Diagnosis: Normative Stress Response

will resolve quickly with stressor resolution or adaptation; will not cause significant impairment and will have mild symptoms