Adjustment Disorder

Adjustment Disorder is a maladaptive reaction to an identifiable stressor. The symptoms are time limited and last until the stressor is removed or a new level of adaptation has occurred. The severity of the stressor is not necessarily related to the level intensity of the stressor but to the coping mechanisms of the individual. To meet criteria for the DSM-IV, an individual must develop the symptoms within 3 months of the onset of the stressor. Once the stressor has terminated, the symptoms do not persist for more than 6 months. There are six subtypes of the disorder, including: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of conduct and emotions, and unspecified. Children are more likely to manifest symptoms in the realm of conduct problems. Sometimes, adjustment disorders can look like a variety of other types of conduct disorders, because children generally tend to externalize problems in behavior rather than internalize them with anxiety of depression. This is more common in boys than in girls.

You will need to conduct an assessment and address any safety issues with your patient (e.g., suicide potential, self care issues). Establishing a good therapeutic rapport and relieving immediate symptoms is imperative. If the patient has a depressed mood or major depression, one must rule out depression as a primary diagnosis. Identifying a specific stressor is important here. Do not overlook what may appear to you to be “low level” stressors. What is important is the meaning to the patient. If the patient is depressed, you might use the BDI-II to measure the severity of the patient’s depression. The assessment should include suicide and homicide risks. If suicidality is present, you should discuss the plan or means of suicide and take necessary action. A referral to a physician is a good idea to rule out any possible general medical condition that may pre-exist (obtain a release). A referral to a physician will be necessary also to obtain an antidepressant medication evaluation. If the patient is very anxious, anxiolytics may be useful in the short term to help the patient sleep and function better. Be sure that the patient understands that the medication is short term only, that they must learn to deal with the situation rather than the symptom alone.

Some theoretical approaches that seem to be helpful are supportive, cognitive-behavioral and interpersonal psychodynamic. When patients exhibit mild or moderate symptoms psychotherapy is the number one treatment. However, it has been shown that both medication and psychotherapy together may be most effective in some cases. Supportive psychotherapy will allow space for the client to express their concerns and to ventilate. The primary reason for using a cognitive behavioral approach is to help patients change their thinking and behavior. The interpersonal therapy helps to refine social functioning and improve the level of social support.

Treatment may focus on several goals. This depends on a good assessment to evaluate where the deficits lie. For example, if the person exhibits deficits in coping, focus on improving coping mechanisms (e.g. teach relaxation techniques, improve self care skills such as exercise, nutrition, etc.), and educate in positive self talk techniques. Other areas of focus may include improved self-esteem, developing social supports, and alleviating the stressor itself (e.g. leaving an abusive husband), and problems solving.

Often stressors are minimized or avoided. Sometimes the individual overreacts to stress and a discussion about the worst possible scenario is useful. Help the patient to gain perspective and look at the situation in a new way. Always help the individual to put their feelings of anger or sadness into words. This can be a good starting point for determining what course of action the patient can take to eliminate or cope with the issue at hand.