Adjustment disorder

Essential (Required) Features:

• A maladaptive reaction to an identifiable psychosocial stressor or multiple stressors (e.g., single stressful event, ongoing psychosocial difficulty or a combination of stressful life situations) that usually emerges within a month of the stressor. Examples include divorce or loss of a relationship, loss of a job, diagnosis of an illness, recent onset of a disability, and conflicts at home or work.
• The reaction to the stressor is characterized by preoccupation with the stressor or its consequences, including excessive worry, recurrent and distressing thoughts about the stressor, or constant rumination about its implications.
• The symptoms are not better accounted for by another mental disorder (e.g., a Mood Disorder, another Disorder Specifically Associated with Stress).
• Once the stressor and its consequences have ended, the symptoms resolve within 6 months.
• Failure to adapt to the stressor results in significant impairment in personal, family, social, educational, occupational or other importantareas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• Symptoms of preoccupation may worsen with reminders of the stressor(s), resulting in avoidance of stimuli, thoughts, feelings or discussions associated with the stressor(s) to prevent preoccupation or distress.
• Additional psychological symptoms of Adjustment Disorder may include depressive or anxiety symptoms as well as impulsive ‘externalizing’ symptoms, particularly increased tobacco, alcohol, or other substance use.
• Symptoms of Adjustment Disorders usually abate when the stressor is removed, when sufficient support is provided, or when the affected person develops additional coping mechanisms or strategy.

Boundary with Normality (Threshold):

• Adjustment Disorder represents a maladaptive reaction and failure to adapt to a stressor that is associated with significant preoccupation and results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning. Emotional reactions to negative life events that do not meet these requirements should not be diagnosed as Adjustment Disorder.
• Symptoms that occur as transient responses and resolve within a few days do not typically warrant a diagnosis of Adjustment Disorder.
• In cases in which responses to traumatic events are considered normal given the severity of the stressor, Acute Stress Reaction may be assigned.

Course Features:

• Onset of Adjustment Disorder usually occurs within a month afterexposure to a stressful life event (i.e., illness, marital distress). However, onset can occur after a longer delay (e.g., 3 months after exposure).
• Acute and intense stressful life events (e.g., sudden job loss) typically result in a correspondingly precipitous onset of symptoms thattend to have a shorter duration, whereas more persistent stressful life events (e.g., ongoing marital distress) typically result in delayed onset of symptoms and a longer duration.
• The intensity and duration of Adjustment Disorder varies widely.

Developmental Presentations:

• In children, the characteristic symptoms of preoccupation with a stressor or its consequences or constant rumination about the stressor areoften not expressed directly but rather are manifested in somatic symptoms (e.g., stomach aches or headaches), disruptive or oppositional behaviour, hyperactivity, tantrums, concentration problems, irritability, and increased clinginess. Other reactions to stressors including regression,bedwetting, and sleep disturbances may be a manifestation of Adjustment Disorder if they are persistent (e.g., have been present for approximately 1 month).
• In adolescents, behavioural manifestations of Adjustment Disorder can include substance use and various forms of acting out or risk-taking.
• Because children and adolescents may not explicitly verbalize a connection between stressful events and their own symptoms and behaviours, in making the diagnosis it is important to consider the temporal relationship between the stressor and the onset of symptoms and the extentto which they constitute a change from prior functioning.
• Among older adults, preoccupation with somatic complaints is a commonsign of distress related to stressors. Older adults who suffer from Adjustment Disorder tend to express greater anxiety about their health, report significant demoralization, and often display persistent somatization of psychological symptoms.

Culture-Related Features:

• Adjustment Disorder may be exacerbated in the context of limited family or community support, particularly in collectivistic or sociocentric cultures. In these societies, the focus of the preoccupation may extend to stressors affecting close relatives or friends.
• Symptoms of Adjustment Disorder may be influenced by local idioms (e.g., susto or espanto [fright] in Central America) that are associated with fear or subsequent preoccupation with a stressor with strong cultural connotations (e.g., experiencing intense fear when crossing an unpopulated area alone at night).

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Post-Traumatic Stress Disorder: In Adjustment Disorder, the stressor can be of any severity or any type, and is not necessarily of an extremely threatening or horrific nature. A response to a less serious event or situation that otherwise meets the symptom requirements for Post-Traumatic Stress Disorder should be diagnosed as Adjustment Disorder. Moreover, many people who have experienced an extremely threatening orhorrific event develop Adjustment Disorder and not Post-Traumatic Stress Disorder in its aftermath. The distinction should be made based on whether the full diagnostic requirements for either disorder are met, not solely based on the type of stressor.
• Boundary with other mental disorders: It is common for mental disorders to be triggered or exacerbated by stressful life experiences. Moreover, many mental disorders can involve symptoms including maladaptive reactions to stressors, preoccupation with stressors and excessive worry or rumination, and failure to adapt. In the presence of another mental disorder that can account for these symptoms (e.g., a Primary PsychoticDisorder, a Mood Disorder, another Disorder Specifically Associated with Stress, a Personality Disorder, an Obsessive-Compulsive or Related Disorder, Generalized Anxiety Disorder, Separation Anxiety Disorder, Autism Spectrum Disorder), a separate diagnosis of Adjustment Disorder should generally not be assigned, even if stressful life events or changing circumstances have led to an exacerbation of the symptoms. However, a diagnosis of Adjustment Disorder may be assigned in the presence of other mental disorders with substantially non-overlapping symptomatology (e.g., Specific Phobia, Panic Disorder, Bodily Distress Disorder) that do not fully account for the Adjustment Disorder symptoms, provided that the course of the two disorders is distinguishable and the full diagnostic requirements are met for each. If symptoms persist for longer than 6 months after a stressor has ended, it is generally appropriate to change the diagnosis to another relevant mental disorder.