¶ Understanding Adjustment Disorder and Symptoms
Welcome to our Licensure Exams podcast . I'm Dr Linton Hutchinson and I'm joined by my co-host , stacey Frost . Today , as part of our Demystifying Disorders series , we'll be taking a closer look at adjustment disorder and all the different ways this disorder can manifest .
Now , before we jump into the diagnostic criteria , which I just know you're itching to hear , I thought I'd share a fun little tidbit first . Linton , did you know that adjustment disorder was first described as transient situational personality disorder , back in your day in the 50s , when the DSM-1 was first published ? I thought this might jingle some bells for you .
She says how old do you think I am ? Stacey .
Oh , Linton , you're ageless and timeless .
Oh , good recovery , Good recovery , Nice try , but for sure . Back in the day when dinosaurs roamed the earth and we had to walk miles through the snow to get to school , adjustment disorder was considered a personality disorder , if you can believe it .
But let's just fast forward to the present and start by reviewing the diagnostic criteria for adjustment disorder in the Gen Z generation according to the DSM-5-TR Stacey . Can you give us an overview ?
Sure Adjustment disorder is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor .
And what kind of stressors are we talking about , Stacey ?
Well , a stressor is any kind of event or change in your life that overwhelms your ability to cope , and this can be anything from a job loss , end of a relationship , moving to a new place , or a significant change in your roles and responsibilities , like becoming a caretaker for a family member .
And the stressor can be a single event like getting laid off from your job or losing power when playing Call of Duty on your PlayStation , or a series of events like trying to find a job , finally move out of your parents' home , or experiencing marital problems or chronic illness .
That's right , and the symptoms can manifest in a variety of ways , and this is where specifiers come in handy .
Oh God , stacey , you and your myopic specifiers .
Hey , the devil is in the details , Dr Generalist .
I suppose you also have a Roomba and have Alexa turn your lights on and off . Read me your list of specifiers . Anyways , One moment Alexa turn off the lights Go ahead .
Did she turn the lights ?
on . Yeah , she did . When we said that yeah .
Oh , linton , okay , All right . So here's the specifiers With a depressed mood , with anxiety , with mixed anxiety and depressed mood with disturbance of conduct , with mixed disturbance of emotions and conduct , and this is if it's both emotional symptoms like depression , anxiety , and behavioral issues .
And , of course , the catch-all , unspecified and the client's age makes a difference in how those symptoms manifest . Typically , children and adolescents' symptoms are more behavioral in nature .
For example , a child who is struggling to adjust to their parents' divorce may not directly express feelings of sadness or anxiety , but instead might become irritable , get into fights with peers and start skipping school skipping school .
That's right , and these behavioral shifts are their way of signaling distress when they may not yet have the language or self-awareness to fully understand or communicate what they're feeling . So now let's talk about the duration criteria for adjustment disorder , which can be a little bit tricky .
In order to make this diagnosis , the symptoms must appear within three months of the stressor and they should not continue for more than six months after the stressor or the consequences of the stressor have ended . So there's a caveat to the timeframe . It's not a simple three to six months , and this is where specifiers come in handy again .
Naturally .
I see you rolling your eyes , Lyndon . Well , in addition to the specifiers that describe the predominant manifestation of the client's symptoms , there are specifiers indicating the acute or chronic nature of the adjustment disorder . If the client's symptoms last less than six months , you'd specify acute .
If the stressor itself is chronic or the consequences of the stressor are still very much a part of the client's life and they're having difficulty adapting , then you would specify persistent .
You know what that reminds me of Stacey ?
I'm afraid to guess .
The muddy , mucky waters probably with some sewage in your basement you've been telling me about . With some sewage in your basement you've been telling me about . You know how the water keeps seeping in , no matter what you do , and it wasn't because of one big flood , but a slow , relentless trickle that just wouldn't stop .
Right , no matter how many times we thought we got it under control and no linten . There wasn't any sewage in it , Not this time . Anyway , that water kept finding a way back in the beauty of the Michigan basement . You're always , always dealing with it .
Exactly , the slow , persistent seepage is a lot like a chronic stressor it doesn't hit all at once , but gradually wears you down over time .
That's a great , very visual analogy . Lynch , it sounds like you like the word seepage . I do .
Now can you give an example of what that persistent form of adjustment disorder might look like for a client ?
Okay , imagine you're working with a client and let's call her Lacey , and she's been struggling for the past year since her marriage ended in a contentious divorce . The legal proceedings were stressful , but what's been even more difficult is the ongoing shared custody arrangement for Lacey's two young children .
Every time she interacts with her ex-husband about visitation , financial support or parenting decisions , she's reminded of the pain and conflict from the divorce . Her ability to cope and move on has been impaired by the ongoing nature of a custody arrangement which keeps the stressor active and prevalent in her life .
Now , linton , what if the stressor or the consequences of the stressor go away but the client is still on that struggle bus ?
Well , when you see that you should consider the possibility of another mental disorder , such as depression or an anxiety disorder . Here's an example Clinton experienced an acute psychosocial stressor in the form of unexpected termination of employment .
Within several weeks after he was fired , he manifested symptomology consistent with a diagnosis of adjustment disorder with depressed mood . His presenting symptoms included depressed mood and affect , sleep disturbance and feelings of hopelessness . These symptoms were linked to the identified psychosocial stressor , which was him losing his job .
Upon reevaluation six months after he lost his job , the clinical picture had evolved . Clinton's depression mood had worsened significantly .
All right . Well , it worsened . How so ?
Well , it's pretty grim . He no longer was interested in activities that he once enjoyed . He hasn't had public sushi with his friends Lacey in months and his juicer , once alive with the sound of pulverizing celery , now sit on his kitchen table gathering a layer of dust . He's lost a lot of weight due to a lack of appetite .
He expressed feelings of worthlessness and excessive guilt . What's the point of me looking for a job ? I'm not good at anything and my family is struggling financially because of me and I've let them down .
His self-esteem is taking a major blow and he no longer believes in his ability to find a new job or turn things around , and he has reoccurring thoughts of death . I've been thinking about how maybe things would be better for everyone if I just wasn't here anymore .
Well yeah , based on what you said there , it certainly does sound like Clinton's symptomology has evolved .
So doesn't he still have adjustment disorder ? It sounds like his job's loss . The initial stressor is still a problem for him .
Well , part of the criteria for adjustment disorder is that the stress-related symptoms do not meet the criteria for another mental disorder . And in Clinton's case his symptomology has evolved . It's no longer adjustment disorder depressed mood . Now he meets the criteria for a full-blown major depressive disorder .
Ah , very sneaky . Now let's move on to the differentials of adjustment disorder Other disorders that may present with similar symptoms .
Sure thing . So one important differential to consider is major depressive disorder , and this can look a lot like adjustment disorder with depressed mood . But , as we've talked about with Clinton , if the client has symptoms that meet full criteria for major depressive disorder , even if it's in response to a stressor , then adjustment disorder is off the table .
So he doesn't have both of them , just the one now . Is that right , correct ? Okay , then . Another differential to keep in mind is post-traumatic stress disorder . In PTSD , the stressor must be of an extreme nature , such as an exposure to actual or threatened death , serious injury or sexual violence . With adjustment disorder , the stressor can be of any severity .
An adjustment disorder can be diagnosed following exposure to a traumatic event , when the client exhibits signs of acute stress disorder or PTSD , but the client doesn't meet the full criteria for either of those disorders . It's also important to look at the timing of the symptoms when differentiating between adjustment disorder from acute stress disorder and PTSD .
That's right . So adjustment disorder can be diagnosed right away , whereas the time frame for acute stress disorder is three days to one month , and PTSD can't be diagnosed until at least one month has passed since the traumatic stressor occurred .
It's also important to distinguish adjustment disorder from normal stress reaction . While it's common for individuals to express distress in response to stressors , in adjustment disorder the symptoms must cause significant impairment in functioning .
All right , thanks , linton . So now let's talk about the development and course of adjustment disorder . So we all experience stress at various times in our lives . Some would argue , actually , that it's a part of the human experience . But why aren't we all diagnosed with adjustment disorder all the time ?
Well , it all comes down to these factors the nature of the stressor , our coping resources or how we respond . Stress and the presence of support systems .
Right . The nature of the stressor definitely matters . For example , a mild stressor , like missing a deadline at work , might cause temporary frustration or anxiety , but it doesn't usually lead to adjustment disorder .
On the other hand , a more severe or unexpected stressor , like losing your job without warning or being diagnosed with a chronic illness , might trigger more intense emotional or behavioral reactions .
Good point . Next , let's consider the individual's coping resources . Imagine you've got two people who are going through a divorce .
One person might have developed strong coping mechanisms over time , such as staying socially active with friends and family and utilizing stress relief hobbies like painting or gardening or having lemonade breaks with their chickens in the garden .
How about taking a short drive to Publix to pick up some sushi from Kai ?
Well , that would work too , Lyndon . The point is that one person might experience significant stress from a divorce , but managed to cope effectively , and the other person who's going through a divorce might not have developed healthy coping mechanisms .
Instead , they might isolate themselves , stop taking care of themselves and rely on unhealthy coping strategies , like excessive drinking or binge watching TV , to escape their feelings . Without effective coping strategies , this person might go on to develop adjustment disorder .
Absolutely . The last factor we'll talk about is the support systems . Let's take the example of a college student moving to a new city for school . If the student has a strong support system , including family , friends and a network of fellow students , they might adjust more smoothly .
However , if they lack this support system and feel isolated , the same situation could lead to a significant stress and difficulty in adjusting , increasing the risk of adjustment disorder .
So while stress is a universal part of life , the way that we experience and handle it varies greatly . When someone's coping resources are overwhelmed and they lack support , that's typically the precursor to adjustment disorder .
Let's move on to the associated features of adjustment disorder . These are characteristics that are commonly observed in individuals with the condition , but are not part of the diagnostic criteria .
One common associated feature is a sense of helplessness or hopelessness . Individuals with adjustment disorder may feel overwhelmed by their current circumstances and struggle to see a way forward . Adjustment disorders are linked to an increased risk of suicide-related behavior .
Another associated feature is a preoccupation with the stressor . The individual may find it difficult to focus on other aspects of their life and may constantly ruminate on the stressful event or situation . If the client is in school or has a job , their academic or occupational performance may suffer .
Individuals with adjustment disorder may also experience somatic symptoms , physical symptoms like headaches , stomach aches or trouble sleeping , and these physical symptoms can further contribute to their distress and impairment in functioning , as you can imagine , it's also not uncommon for adjustment disorder to co-occur with other mental health conditions .
Adjustment disorder frequently co-occurs with anxiety disorders such as generalized anxiety disorder and panic disorder . The stressful event or situation that triggered the adjustment disorder may also exacerbate pre-existing anxiety symptoms .
Substance use disorders are another commonly comorbidity . Individuals with adjustment disorder may turn to alcohol or drugs as a way of coping with their distress , which can lead to development of a substance use disorder .
And personality disorders , particularly borderline personality disorder , can also co-occur with adjustment disorder . The emotional instability and interpersonal difficulties associated with borderline may make it more challenging for these individuals to cope with stressors and adapt to new circumstances .
Great . Now let's review some of the evidence-based treatment interventions for adjustment disorder Stacey . What are some of the most effective approaches ?
Well , the nature of the symptoms often dictates which specific interventions will be most effective . So , for example , if your client's predominant symptoms are anxiety , then relaxation , training , mindfulness-based stress reduction and mindfulness-based cognitive therapy tend to be the most helpful . Or if a stressor has triggered excessive rumination .
Say , maybe your client is going through a divorce and they spend hours every day obsessing over what went wrong in their marriage , replaying arguments in their mind , constantly thinking about what they could have done differently . Well , this relentless focus on negative thoughts and past events not only exacerbates their stress , but also prevents them from moving forward .
And with this type of presentation , rational emotive behavior therapy and acceptance-based therapies like acceptance and commitment therapy and dialectical behavior therapy would be appropriate .
Regardless of the specific intervention she used , the primary goals are to help the client develop problem-solving skills , to minimize or eliminate the stressor when possible , to enhance their coping mechanisms and to modify their response if the stressor cannot be removed .
All right , as we wrap up our podcast , let's summarize the key takeaways for our listeners
¶ Understanding and Treating Adjustment Disorder
.
First adjustment disorder is a condition characterized by the development of emotional or behavioral symptoms in response to an identified stressor . These symptoms must emerge within three months of the onset of the stressor and cause significant impairment in functioning . Adjustment disorder can be acute or chronic , depending on how long the symptoms persist .
Symptoms can also manifest in a variety of ways , including depression , anxiety and behavioral issues .
Second , you need to consider differentials when diagnosing adjustment disorder , including , but not limited to , major depressive disorder , post-traumatic stress disorder and normal stress reactions .
Third treatment interventions for adjustment disorder depend on the nature of the client's symptom . For example , if the client presents with anxiety , consider using interventions like relaxation training and mindfulness-based cognitive therapy .
And , finally , the client's existing resources and coping mechanisms will form the basis of treatment . As a therapist , you should utilize a strengths-based approach and focus on enhancing the client's current strengths and assisting them in developing new coping skills , if needed client's current strengths and assisting them in developing new coping skills if needed .
Well , we hope this podcast has provided you with some valuable insights into the diagnosis and treatment of adjustment disorder . Until next time , keep learning , keep growing and keep making a difference in your life and the lives of your clients . As you continue on this journey towards licensure , remember it's in there .