adjustment disorders

**Definition (DSM-5-TR):** Emotional or behavioral symptoms in response to an identifiable stressor, with onset within 3 months of the stressor. Must show at least one of the following: - Marked distress out of proportion to the severity or intensity of the stressor (considering context and cultural factors) - Significant impairment in social, occupational, or other functioning

**Exclusions:** - Does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting one - Not normal bereavement - Symptoms resolve within 6 months after the stressor or its consequences end. If the stressor is chronic (e.g., a chronic illness), the disorder can persist. - Acute (<6 months) vs. persistent/chronic (≥6 months) specifiers

**Subtypes (specifiers):** - With depressed mood (tearfulness, hopelessness) - With anxiety (nervousness, worry, separation anxiety) - With mixed anxiety and depressed mood - With disturbance of conduct (violating rules or the rights of others, e.g., truancy, reckless driving, fighting) - With mixed disturbance of emotions and conduct - Unspecified

**Classic stressors:** Divorce or relationship breakup, job loss, moving, a new medical diagnosis, financial problems, school problems, retirement, birth of a sibling.

**Epidemiology and associations:** - Very common, especially in the general hospital and consultation-liaison setting - Occurs at any age; adolescents often have conduct symptoms and adults more often have depressed or anxious mood - Increased risk of suicide attempts and ideation, so always assess for suicidality

**Key differentiators (high-yield for boards):** - **vs. MDD:** MDD requires full criteria (≥5 symptoms for ≥2 weeks). Adjustment disorder is subthreshold and tied to a stressor. - **vs. PTSD/acute stress disorder:** These require an extreme traumatic stressor (actual or threatened death, serious injury, or sexual violence) with specific symptom clusters: intrusion, avoidance, negative cognition/mood, and hyperarousal. Acute stress disorder lasts 3 days to 1 month. PTSD lasts more than 1 month. In adjustment disorder, the stressor can be of any severity. - **vs. Normal bereavement:** Grief that is culturally expected is not adjustment disorder. Prolonged grief disorder has its own criteria. - **vs. Generalized anxiety disorder:** GAD involves excessive worry for ≥6 months, not tied to a specific stressor.

**Management:** - **First-line: psychotherapy.** Supportive therapy, CBT, and problem-solving or crisis intervention to build coping skills and social support. - **Pharmacotherapy:** Not first-line and is adjunctive for symptoms only, for example short-term anxiolytics or hypnotics, or SSRIs if symptoms are prominent. Avoid long-term benzodiazepine use. - **Prognosis:** Generally good, especially in adults. Adolescents have a higher risk of later psychiatric disorders (e.g., mood disorders, substance use).

**Exam pearl:** Typical vignette: a patient with low mood, anxiety, and impaired work performance for weeks after a layoff or breakup who does not meet MDD criteria. The answer is adjustment disorder, and the next step is psychotherapy with suicide risk assessment.