| In an adjustment disorder, a psychological response occurs to an identifiable stressor or life event. This response includes significant emotional or behavioral symptoms that are usually manifested as decreased performance at work and temporary changes in social relationships. The life stressor may be a single event such as termination of a relationship; a recurrent situation, such as seasonal business crises; a continuous stressor, such as living in a crime-ridden neighborhood; a prolonged circumstance, such as a chronic, debilitating medical condition; or multiple events, such as business difficulties plus marital problems. In adjustment disorder with anxiety, the predominant symptoms include nervousness, worry, or jitteriness. The disorder does not meet the criteria for another psychiatric disorder such as major depression. Risk: As many as 50% of individuals who experience a specific stressor, such as cardiac surgery, will experience an adjustment disorder. Incidence and Prevalence: Adjustment disorders are fairly common, depending upon the population studied. They occur in up to 12% of general hospital patients who are referred for a mental health consultation and in 10% to 30% of those in mental health outpatient settings. |
Source: Medical Disability Advisor
| History: Diagnosis is based on criteria listed in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision). The symptoms should occur within 3 months of the recognizable stressful condition and not persist longer than 6 months after resolution of the stressful event or its consequences, unless the symptoms are in response to a chronic stressor. The symptoms or behaviors are identified as either a marked distress that is in excess of what would be expected, or a significant impairment in social or occupational functioning. The stress-related disturbance cannot be diagnosed as another specific psychiatric disorder or be merely an exacerbation of a pre-existing psychiatric disorder, and the symptoms cannot be related to bereavement. However, adjustment disorder may be diagnosed in the presence of another psychiatric disorder if the latter does not account for the pattern of symptoms that have occurred in response to the stressor. Physical exam: The physical exam is important in ruling out anxiety caused by the physiological effects of a medical condition such as hypothyroidism or chronic obstructive pulmonary disease. Observation of the individual's orientation, dress, mannerisms, behavior, and content of speech provide essential signs to help diagnose adjustment disorder with anxiety. For example, there may be poor attention to grooming, or verbalizations inconsistent with emotional state (affect), such as saying "I feel fine" while clenching the jaw and frowning. Physical manifestations of anxiety may include sweaty palms, rapid pulse, pale or flushed skin, frequent sighing, and restless behavior such as pacing or fidgeting. Tests: Psychological testing, such as the Minnesota Multiphasic Personality Inventory - 2 (MMPI-2) or the State-Trait Anxiety Inventory, can be a useful adjunct to diagnosing Adjustment Disorders. It is better to utilize objective psychological tests, such as the MMPI - 2 or the Millon Clinical Multi-axial Inventory-III (MCMI-III), instead of subjective inventories, such as the State-Trait Anxiety Inventory. Inventories and other subjective tests may allow outcomes of the testing to be easily influenced by the test taker, resulting in exaggeration of psychological distress. |
Source: Medical Disability Advisor
| Psychotherapy is the treatment of choice for adjustment disorders. Ending the stressful situation or removing the individual from the stressful situation is desirable. Group therapy has been effective, especially when individuals in the group have experienced similar stressors. Short-term, problem-focused, individual psychotherapy may be helpful to explore the meaning of the stressful situation to the individual so that the reactive anxiety may be resolved. Brief psychotherapy, when utilized in a crisis intervention, can help resolve the situation quickly through supportive techniques, suggestion, reassurance, environmental modification, and even hospitalization, if necessary. Cognitive behavioral therapy has a strong empirical base and helps correct disordered thinking and maladaptive behavior. Pharmacotherapy utilizes antidepressants, anti-anxiety agents, and anxiety-relieving antidepressants to reduce symptoms of anxiety. These should be used judiciously and for brief periods. |
Source: Medical Disability Advisor
| The overall prognosis for adjustment disorder is favorable with appropriate treatment. Adjustment disorders generally occur within a short period of time following the stressor and, by definition, should last no longer than 6 months after the stressor or its consequences have ended. Individuals generally return to normal functioning within a few months. |
Source: Medical Disability Advisor
| Adjustment disorders may be associated with alcohol or substance abuse, and physical (somatic) complaints. If an individual with a pre-existing mental or medical illness is also diagnosed with an adjustment disorder, the course of that illness may be complicated or prolonged, such as by decreased compliance with recommended treatment or increased hospital length of stay. In the presence of serious symptoms, other psychiatric disorders must be considered and ruled out.
Adjustment disorders are typically not associated with suicidal ideation or suicidal attempts. Anxiety adjustment disorder is a low-level diagnosis, in which the distress is quite short-lived and the individual can typically function on most levels. If the suicidal ideation diagnosis component is added, using clinical evaluation standards such as those of the American Psychiatric Association (APA), this moves the individual into a different diagnosis category altogether. |
Source: Medical Disability Advisor
| Work restrictions or accommodations are necessary only infrequently, for the most serious cases. In these instances, time-limited restrictions and work accommodations should be individually determined based on the characteristics of the individual's response to the disorder, the functional requirements of the job and work environment, and the flexibility of the job and work site. The purpose of the restrictions/accommodations is to help maintain the worker's capacity to remain at the workplace without a work disruption, or to promote timely and safe transition back to full work productivity. Often, the sense of fulfillment and distraction from one's concerns that work can provide may improve symptoms and speed recovery. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Was diagnosis confirmed?
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Was an underlying medical disorder overlooked?
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Did symptoms and behaviors match the criteria needed for diagnosis?
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Was stressor identified?
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What was individual's previous level of functioning?
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Was there a significant reduction in functioning?
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In what ways was individual's level of functioning impaired?
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Did individual have symptoms of other psychiatric disorders, such as major depression, dysthymic disorder, bipolar disorder, personality disorders, post-traumatic stress disorder, acute stress disorder, psychological factors affecting medical condition, attention-deficit/hyperactivity disorder, or bereavement?
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Does the adjustment disorder represent the early stages of a more severe psychiatric disorder that has not yet been diagnosed?
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Was there a history of depression or other psychological problem that may be contributing to the current condition?
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If there is concurrent drug or alcohol abuse, to what extent are these conditions causing additional problems?
Regarding treatment:
- Has stressor been identified?
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Has stressor been resolved?
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Does individual need more frequent therapeutic encounters or the addition of another type of therapy or therapist?
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If group psychotherapy is being used, have individuals in the group experienced similar stressors? If not, is a more appropriate group environment available?
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Have anti-anxiety agents and antidepressants been considered to reduce symptoms of anxiety or depression?
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Are side effects preventing optimal treatment response?
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Has psychotherapy been added to the pharmacotherapy regimen for the most effective results?
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Is individual motivated to participate in treatment, and does individual possess the capacity to engage in psychological exploration?
Regarding prognosis:
- If symptoms persist despite treatment, is environmental modification or hospitalization being considered?
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Does diagnosis need to be revisited?
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How are current stresses being dealt with?
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How were major stresses dealt with in the past?
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If healthy and adaptive methods were used in the past, are they being used currently?
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If maladaptive, such as drug or alcohol abuse, to what extent are these conditions causing additional problems?
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Does individual have a functional support system? Family? Friends? Church or other community affiliations? Are these being utilized effectively?
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Did individual enjoy previous work?
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What is happening outside of work that may be contributing to or worsening the problems experienced at work?
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Is individual motivated to recover, or do symptoms fulfill psychological, personal, or economic factors?
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Source: Medical Disability Advisor
| Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000. |
Source: Medical Disability Advisor
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