Adjustment disorders

An Adjustment Disorder is a stressor-related disorder, described in both the Diagnostic and Statistical Manual of Mental Disorders-5 psychiatric manual^[1] and the ICD-10 manual. An adjustment disorder is a stress response syndrome which normally occurs within a month of a distressing (traumatic or nontraumatic) event, usually causing both depression and anxiety. Examples of nontraumatic stressors include returning to work after life-stressors like paternal leave, bankruptcy, divorce or job loss.^[2]

DSM-5 diagnostic criteria

Minor updates to the specifiers were made in October 2013, which as included here.^[3]

DSM-5 309.0 (F43.21), 309.24 (F43.22), 309.26 (F43.23), 309.3 (F43.24), 309.4 (F43.25), 309.9 (F43.20) codes depend on specifiers

Categorized under Trauma and Stressor-Related Disorders

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
2. Significant impairment in social, occupational, or other important area of functioning.

C.The stress-related disturbance does not meet the criteria for another mental disorderThe DSM-5 psychiatric manual defines this as "a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."{{Rp|20}} and is not merely an exacerbation of a preexisting mental disorder:

D. The symptoms do not represent normal bereavement.

E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months. ^[4]:151-152

Specifiers for duration:

• Acute: less than 6 months
• Persistent (chronic): 6 months or more^:1-2

Specify whether it occurs: With depressed mood"Pervasive and sustained emotion" which affects a person's perception of the world.{{Rp|6}} (depression): Low mood, tearfulness, or feelings of hopelessness are predominant. With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant. With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant. With disturbance of conduct with mixed disturbance of emotions and conduct Unspecified.

^[3]:2[4]:xx

ICD-10 description

F43.2 is the code used for adjustment disorders. The ICD-10 gives this description

"States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event. The stressor may have affected the integrity of an individual's social network (bereavement, separation experiences) or the wider system of social supports and values (migration, refugee status), or represented a major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement).

Individual predisposition or vulnerability plays an important role in the risk of occurrence and the shaping of the manifestations of adjustment disorders, but it is nevertheless assumed that the condition would not have arisen without the stressor. The manifestations vary and include depressed mood, anxiety or worry (or mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, as well as some degree of disability in 9the performance of daily routine. Conduct disorders may be an associated feature, particularly in adolescents. The predominant feature may be a brief or prolonged depressive reaction, or a disturbance of other emotions and conduct."

Examples include:

• Culture shock
• Grief reaction
• Hospitalism in children^[5]

Posttraumatic Stress Disorder compared with Adjustment Disorder

PTSD can only be caused by traumatic experiences, such as fearing your life is in danger, very serious injury or sexual abuse/rape. Adjustment Disorder can be caused by non-traumatic events such as life changes, or less severe traumatic events.

Symptoms which may occur as part of PTSD but are not part of Adjustment Disorder include:

• flashbacks
• nightmares
• persistent feelings of horror, anger, fear, shame, distorted sense of blame or self-blame
• reminders of the traumatic event trigger (cause) overwhelming emotions and occur regularly
• the person intentionally avoids reminders of the event - people, places, things
• amnesia for part of the traumatic event
• in PTSD the trauma would feel traumatic to almost everyone, in Adjustment Disorder the trauma may be less severe or not traumatic to some people
• PTSD can last for any length of time - sometimes with Acute stress disorder occurring first, Adjustment Disorder can last up to 6 months
• Adjustment Disorder begins within one month of the event, PTSD begins within 6 months (on rare occasions it may begin later than that)
• PTSD can occur to witnesses of the traumaThe most fundamental effect of trauma is dissociation, so we define trauma as the event(s) that cause dissociation. {{Rp|75}} The original trauma in those with dissociative identity disorder was failure of secure attachment with a primary attachment figure in early childhood. {{Rp|83}}, or those close to a person who suffers life-changing trauma
• in Adjustment Disorder the stressor or trauma must happen to the person who has symptoms

Similarities between PTSD and Adjustment Disorder:

• both cause clinically significant distress
• depression and anxiety can occur in PTSD and almost always occur in Adjustment disorder
• physical (somatic) symptoms often occur in both, e.g. problems sleeping

References

1. ^ Diagnostic and Statistical Manual of Mental Disorders-5.
2. ^ Friedman, Matthew J.; Strain, James J. (2011). Considering adjustment_disorders_as_stress response syndromes for DSM-5. Depression and Anxiety, volume 28, issue 9, page 818-23. (doi:10.1002/da.20782)
3. ^ a b American Psychiatric Association CRITERIA CORRECTIONS for ADJUSTMENT DISORDERS IN DSM-5 and DSM-5 DESK REFERENCE. retrieved on 13 January 2014
4. ^ a b American Psychiatric Association, . Desk Reference to the Diagnostic Criteria from DSM-5. APA.
5. ^ World Health Organisation, (2010). ICD-10 Classification of Mental and Behavioural Disorders.