Adjustment disorder

Adjustment disorder is a psychiatric condition that occurs in response to a specific life event, change or stressor, such as a relationship breakdown, life-changing medical diagnosis or job loss. Adjustment disorder is characterised by distress and emotional disturbance, which affects the patient’s levels of occupational, personal and social functioning. The symptoms are seen as disproportionate to the severity of the stressor and not in line with the person’s social or cultural norms (O’Donnell et al, 2019).

Adjustment disorder is the seventh most common psychiatric diagnosis and is more common among certain populations, but not in regard to ethnicity (Bachem and Casey, 2018). Some populations and settings in which adjustment disorder is more prevalent include:

• low socio-economic background
• history of physical or mental illness
• high-stress populations, such as refugees, unemployed people and military personnel
• health settings, such as primary care, psychiatric liaison, accident and emergency, oncology, haematology and cardiology departments

Despite

The International Classification of Diseases (ICD-10) (World Health Organization, 2019) describes the following symptoms of adjustment disorder, which can present as predominantly depressive, anxious or a mixture of both:

• distress
• emotional disturbance
• low mood
• anxiety
• perceived inability to cope
• impact on social and occupational functioning
• conduct disorders, described as rebelliousness, destructiveness and/or impulsiveness (particularly common in adolescents)

An identifiable stressor, or combination of stressors, is the primary cause of adjustment disorder (O’Donnell et al, 2019).

Not everyone who experiences a stressful life

A diagnosis of adjustment disorder is clinical and based on a thorough mental state examination. The criteria for diagnosis include:

• symptoms starting within 1 month of the onset of the stressor
• both distress and impairment in day-to-day functioning
• does not meet the criteria for any other psychiatric diagnosis
• not diagnosed in bereavement
• not diagnosed if the symptoms are an exacerbation of an existing mental illness
• symptoms will usually resolve within 6 months of the stressor coming to an end or new coping strategies being developed

There are several differential diagnoses to consider before diagnosing adjustment disorder. These include:

• no psychiatric illness, as the response is appropriate to the stressor
• depressive episode
• anxiety disorder
• post-traumatic stress disorder, which is distinguished by a more extreme and threatening stressor, with symptoms such as flashbacks and nightmares
• acute stress reaction, which presents with mixed, transient symptoms that resolve within 3 days (Strain, 2016)

Ascertaining

There are no current UK guidelines for the treatment and management of adjustment disorders. Whether to provide any treatment for the disorder has been subject to debate, given the transient symptoms and relation to normal life stressors. However, adjustment disorders can develop into a more severe and enduring mental illness, such as depression or anxiety disorder, and may significantly affect the patient’s quality of life (O’Donnell et al, 2019). Treatment can also reduce the likelihood of recurrence in the future (Zelviene and Kazlauskas, 2018).