Adjustment Disorder DSM 5 Criteria

What is adjustment disorder?

Adjustment Disorder, also known as situational depression or stress response syndrome, is a mental health condition characterized by emotional or behavioral symptoms that arise in response to a specific stressor or life event. The disorder typically develops within three months of the stressor's onset and can manifest in various forms, depending on the predominant symptoms.

The types of Adjustment Disorder include:

1. Adjustment disorder with depressed mood: Symptoms primarily involve feelings of sadness, hopelessness, and a lack of enjoyment in life.
2. Adjustment disorder with anxiety: Symptoms are primarily characterized by nervousness, worry, and jitteriness.
3. Adjustment disorder with mixed anxiety and depressed mood: This type includes both anxiety and depressive symptoms.
4. Adjustment disorder with disturbance of conduct: Symptoms mainly involve behavioral issues, such as impulsivity, recklessness, or defiance.
5. Adjustment disorder with mixed disturbance of emotions and conduct: This type includes both emotional symptoms (anxiety or depression) and disturbances in conduct.
6. Adjustment disorder unspecified: Used for reactions to stress that don't fit neatly into the other categories, often involving physical complaints or social withdrawal.

Symptoms for each type of adjustment disorder

Each type of adjustment disorder presents distinct symptoms:

• Depressed mood: Persistent feelings of sadness, tearfulness, and hopelessness.
• Anxiety: Excessive worry, nervousness, and fear about everyday situations.
• Mixed anxiety and depressed mood: A combination of depressive and anxious symptoms.
• Disturbance of conduct: Disruptive behaviors, such as vandalism, reckless driving, or fighting.
• Mixed disturbance of emotions and conduct: Emotional symptoms accompanied by behavioral issues.
• Unspecified: Various symptoms that don't align with the specific categories, such as physical complaints or social withdrawal.

Adjustment disorder causes

Adjustment disorder is triggered by significant life changes or stressors, which can be positive or negative. Here are some common triggers:

• Relationship issues: Divorce, breakups, or conflicts with family or friends.
• Job-related stress: Job loss, workplace conflicts, or starting a new job.
• Relocation: Moving to a new home, city, or country.
• Health problems: Chronic illnesses, injuries, or surgeries.
• Financial difficulties: Debt, bankruptcy, or changes in financial status.
• Major life events: Bereavement, becoming a parent, or retirement.

The disorder arises when an individual's ability to cope with these stressors is overwhelmed, leading to emotional or behavioral symptoms. Genetic, biological, and environmental factors can also contribute to the development of adjustment disorder, influencing an individual's resilience and coping mechanisms.

How do healthcare professionals diagnose adjustment disorder?

Diagnosing adjustment disorder involves a comprehensive assessment process to rule out other mental health conditions and confirm that the symptoms are directly related to a specific stressor. Here are the steps and assessments involved:

• Clinical interview: A detailed discussion with the patient about their symptoms, the stressors they've experienced, and their coping mechanisms.
• Medical history review: Examination of the patient's medical history to identify any physical health issues that could be contributing to their symptoms.
• Psychological evaluation: Standardized questionnaires or psychological tests may be used to assess the patient's emotional state and behavior.
• Observation of behavior: Healthcare professionals may observe the patient's behavior and interactions to gather more information about their condition.
• Application of DSM-5 criteria: The healthcare professional uses the DSM-5 criteria to determine if the patient's symptoms and the context of their occurrence meet the standards for Adjustment Disorder.

What is the DSM-5?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the standard classification system used by mental health professionals to diagnose mental disorders. Developed by the American Psychiatric Association, the DSM-5 provides a common language and standard criteria for the classification of mental disorders, ensuring consistency and reliability in diagnosis.

Without the DSM-5, diagnosis of adjustment disorder would be impossible.

DSM 5 criteria for adjustment disorder

The DSM-5 outlines specific criteria for diagnosing Adjustment Disorder:

• Criterion A: The development of emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
• Criterion B: These symptoms or behaviours are clinically significant, as evidenced by 1 or both of the following:some text
  • 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.
  • Significant impairment in social, occupational, or other important areas of functioning.
• Criterion C: The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.
• Criterion D: The symptoms do not represent normal bereavement.
• Criterion E: Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional six months.

Differences between the DSM 4 and DSM 5 criteria for adjustment disorder

The transition from DSM-IV to DSM-5 brought several changes to the criteria for Adjustment Disorder:

• Criterion B (Clinical significance): In DSM-5, the wording was changed to "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." This addition emphasizes the importance of considering the context and cultural factors when assessing the severity of distress.
• Criterion C (Exclusion of other disorders): The language was simplified in DSM-5 to "the stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder," removing the reference to specific Axis I and Axis II disorders.
• Criterion D (Bereavement): DSM-5 specifies "the symptoms do not represent normal bereavement," clarifying that the symptoms should be distinguished from the normal grieving process.
• Acute and Chronic Specifiers: DSM-IV included specifiers for acute (less than 6 months) and chronic (6 months or longer) adjustment disorders. DSM-5 does not specify these durations.
• Subtypes: Both DSM-IV and DSM-5 include subtypes based on predominant symptoms. However, DSM-5 provides updated codes and descriptions for these subtypes, aligning with the ICD-10 coding system:some text
  • 309.0 (F43.21) With depressed mood
  • 309.24 (F43.22) With anxiety
  • 309.28 (F43.23) With mixed anxiety and depressed mood
  • 309.3 (F43.24) With disturbance of conduct
  • 309.4 (F43.25) With mixed disturbance of emotions and conduct
  • 309.9 (F43.20) Unspecified

Research on adjustment disorder

Recent studies have significantly advanced our understanding of adjustment disorder and its prognosis. Key findings include the potential for symptoms to increase over time in some subpopulations and the risk of progression to more severe disorders like major depressive disorder or generalized anxiety disorder.

A systematic review by Morgan et al. (2022) highlighted the importance of comprehending the course and trajectory of adjustment disorder over time. This review suggested that many patients retain an AjD diagnosis or are diagnosed with another mental health disorder months to years after the initial diagnosis.

Additionally, patients with adjustment disorder tended to show higher rates of symptom improvement and utilized less treatment compared to patients with other disorders. However, there was a noted increase in the development of physical conditions such as infections, cancers, Parkinson's disease, and cardiovascular events in adjustment disorder-diagnosed groups compared to control groups.

Another significant contribution to adjustment disorder research is the development of the Adjustment Disorder–New Module 20 (ADNM-20) as a screening instrument. Lorenz, Bachem, and Maercker (2016) identified a threshold value for people at high risk for adjustment disorder using cluster analysis and Receiver Operating Characteristic (ROC) analysis. The recommended cut-off score of 47.5 on the ADNM-20 facilitates distinguishing between individuals at high and low risk for AjD, thereby aiding in research and clinical practice.

The ADNM-20's ability to differentiate between low, moderate, and high symptomatology levels provides a valuable tool for screening and assessing AjD. This advancement in screening instruments underscores the ongoing efforts to improve the diagnosis and understanding of AjD.

Overall, recent research on Adjustment Disorder emphasizes the need for continued investigation into its prognosis and the development of effective screening tools.

How is adjustment disorder treated?

Adjustment disorder is treated using various approaches, tailored to the individual's specific symptoms and needs. The primary goal of treatment is to alleviate symptoms and help the patient return to their normal level of functioning. Here are some common treatment methods:

1. Psychotherapy: Also known as talk therapy, psychotherapy is often the first line of treatment for adjustment disorder. Different types of psychotherapy can be effective, including:some text
   • Cognitive-behavioral therapy (CBT): Helps patients identify and change negative thought patterns and behaviors.
   • Interpersonal therapy: Focuses on improving communication skills and relationships.
   • Supportive therapy: Provides emotional support and helps patients cope with stress.
2. Group therapy: Provides a supportive environment where patients can share their experiences and learn coping strategies from others facing similar challenges.
3. Family therapy: Involves family members in the treatment process to improve communication and resolve conflicts within the family.
4. Medication: While there are no specific medications for adjustment disorder, antidepressants, anti-anxiety medications, or sleep aids may be prescribed to manage symptoms of depression, anxiety, or insomnia.
5. Stress management techniques: Patients are taught relaxation techniques, mindfulness, and stress-reduction strategies to help manage their stress levels.
6. Lifestyle changes: Encouraging healthy habits such as regular exercise, a balanced diet, and adequate sleep can improve overall well-being and resilience.
7. Psychoeducation: Educating patients about their condition, its causes, and treatment options can empower them to actively participate in their recovery.

It's important to note that the treatment plan should be tailored to the individual's needs and may involve a combination of these approaches. Regular follow-up with a mental health professional is crucial to monitor progress and make necessary adjustments to the treatment plan.

References

Adjustment disorder. (2021, May 17). PsychDB. https://www.psychdb.com/trauma-and-stressors/adjustment

John Hopkins Medicine. (2019). Adjustment disorders. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/adjustment-disorders

Lorenz, L., Bachem, R., & Maercker, A. (2016). The adjustment disorder–new module 20 as a screening instrument: Cluster analysis and cut-off values. The International Journal of Occupational and Environmental Medicine, 7(4), 215–220. https://doi.org/10.15171/ijoem.2016.775

Morgan, M. A., Kelber, M. S., Bellanti, D. M., Beech, E. H., Boyd, C., Galloway, L., Ojha, S., Garvey Wilson, A. L., Otto, J., & Belsher, B. E. (2022). Outcomes and prognosis of adjustment disorder in adults: A systematic review. Journal of Psychiatric Research, 156, 498–510. https://doi.org/10.1016/j.jpsychires.2022.10.052

Substance Abuse and Mental Health Services Administration. (2016, June). Table 3.19, DSM-IV to DSM-5 adjustment disorders comparison. National Library of Medicine; Substance Abuse and Mental Health Services Administration (US). https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t19/