History

Fact Explanation
The onset of symptoms is within 3 months (DSM-IV) or 1 month (ICD-10) of exposure to the stressor Symptoms of low mood, sadness, worry, anxiety, insomnia, poor concentration, having their onset following a recent stressful. Above mentioned symptoms occurs following a event happened 1-3 months back. The event must be external and occur in close time proximity to the onset of symptoms. The longer the time period between the triggering event and the onset of symptoms, the less likely is the diagnosis to be adjustment disorder.[1],[2],[3]
Symptoms must be clinically significant Above mentioned symptoms are distressing and in excess of what would be expected by exposure to the stressor and/or there is significant impairment in social or occupational functioning. [1],[2],[3]
The symptoms are not due to another disorder such as depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa or schizophrenia. Symptoms must not meet the criteria for another disorder as depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia and must not be merely an exacerbation of a pre-existing depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia or personality disorders. [1],[2],[3]
Symptoms resolve within 6 months once the stressor or its consequences are removed. The symptoms must resolve within 6 months of the termination of the stressor but may persist for a prolonged period (longer than 6 months) if they occur in response to a chronic stressor or to a stressor that has enduring consequences. [1],[2],[3]
References
  1. CASEY P, BAILEY S. Adjustment disorders: the state of the art World Psychiatry [online] 2011 Feb, 10(1):11-18 [viewed 14 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048515
  2. CARTA MAURO, BALESTRIERI MATTEO, MURRU ANDREA, HARDOY MARIA. Adjustment Disorder: epidemiology, diagnosis and treatment. Array [online] 2009 December [viewed 16 July 2014] Available from: doi:10.1186/1745-0179-5-15
  3. Semprini, F., Fava, G. A., & Sonino, N. (2010). The spectrum of adjustment disorders: too broad to be clinically helpful. CNS Spectr, 15(6), 382-388. [viewed 16 July 2014] Available from: http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=2661

Examination

Fact Explanation
Mental state examination: Appearance and behaviour Patient may neglect self care and may appear unshaved, with out dressing properly. [1],[2],[3]
Mental state examination: Speech Most of time speech is normal. But some patients may have soft volume of speech and decrease rate of speech. [1],[2],[3]
Mental state examination: Mood Patient is usually in low mood. [1],[2],[3]
Mental state examination: Thoughts Normal [1],[2],[3]
Mental state examination: Perception Normal [1],[2],[3]
Mental state examination: Cognitive function Attention span may reduced. [1],[2],[3]
Mental state examination: Insight Normal [1],[2],[3]
References
  1. CASEY P, BAILEY S. Adjustment disorders: the state of the art World Psychiatry [online] 2011 Feb, 10(1):11-18 [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048515
  2. GRADUS JL, QIN P, LINCOLN AK, MILLER M, LAWLER E, LASH TL. The association between adjustment disorder diagnosed at psychiatric treatment facilities and completed suicide Clin Epidemiol [online] :23-28 [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943177
  3. SANSONE RA, SANSONE LA. Demoralization in Patients with Medical Illness Psychiatry (Edgmont) [online] , 7(8):42-45 [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945856

Differential Diagnoses

Fact Explanation
Depression Depression has to be excluded to make the diagnosis of an Adjustment disorder. Low mood, loss of interest and enjoyment, reduced energy are important criteria for diagnosing depression. [1]
Post traumatic Stress Disorder (PTSD) Post Traumatic Stress Disorder (PTSD) has to be excluded to make the diagnosis of Adjustment disorder. Following characteristics should be there for diagnosing Post traumatic Stress Disorder: exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone ; persistent remembering or "reliving" the stressor by intrusive flashbacks, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor; actual or preferred avoidance of circumstances resembling or associated with the stressor (not present before exposure to the stressor); inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor. [2],[3]
Acute Stress Disorder Acute Stress Disorder have to be exclude to make the diagnosis of Adjustment disorder. A transient disorder (lasting hours to days) that may occur as an immediate response to stress. [4]
References
  1. KESSLER RONALD C., BERGLUND PATRICIA, DEMLER OLGA, JIN ROBERT, KORETZ DOREEN, MERIKANGAS KATHLEEN R., RUSH A. JOHN, WALTERS ELLEN E., WANG PHILIP S.. The Epidemiology of Major Depressive Disorder. JAMA [online] 2003 June [viewed 16 July 2014] Available from: doi:10.1001/jama.289.23.3095
  2. STEIN, M. B., WALKER, J. R., HAZEN, A. L., & FORDE, D. R. (1997). Full and partial posttraumatic stress disorder: findings from a community survey. American Journal of Psychiatry, 154(8), 1114-1119. [online] 2003 June [viewed 16 July 2014] Available from: http://journals.psychiatryonline.org/data/Journals/AJP/3679/1114.pdf
  3. Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care. NICE Clinical Guidelines, No. 26. National Collaborating Centre for Mental Health (UK). Leicester (UK): Gaskell; 2005. [online] 2003 June [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0015848/pdf/TOC.pdf
  4. BRYANT RA, SACKVILLE T, DANG ST, MOULDS M, GUTHRIE R. Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques. Am J Psychiatry [online] 1999 Nov, 156(11):1780-6 [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10553743

Management - General Measures

Fact Explanation
Ventilating emotions This can be achieved by talking to a relative, friend or to the doctor/ psychologist. This will help to identify the causative stressor and develop a coping mechanism.[1],[2]
Prevent retraumatisation Some patients do not like to talk about the experience, they should not be pressurized to talk about it as it can cause much distress to the patient. [1],[2]
Enhancing coping stratergies This will encourage the patient to take care of themselves and take part in daily activity. Patients are encouraged to develop coping strategies as: seeking support - Asking for help, or finding emotional support from family members or friends, can be an effective way of maintaining emotional health during a stressful period. Problem-solving counselling is an instrumental coping mechanism that aims to locate the source of the problem and determine solutions. This coping mechanism is often helpful in work situations. Relaxation techniques such as engaging in relaxing activities, or practicing calming techniques, can help to manage stress and improve overall coping. Physical recreation activities such as regular exercise, such as running, or team sports, is a good way to handle the stress of given situation. This may involve yoga, meditation, progressive muscle relaxation, among other techniques of relaxation. Adjusting expectations and anticipating various outcomes to scenarios in life may assist in preparing for the stress associated with any given change or event.[1],[2]
References
  1. CASEY P, BAILEY S. Adjustment disorders: the state of the art World Psychiatry [online] 2011 Feb, 10(1):11-18 [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048515
  2. CARTA MAURO, BALESTRIERI MATTEO, MURRU ANDREA, HARDOY MARIA. Adjustment Disorder: epidemiology, diagnosis and treatment. Array [online] 2009 December [viewed 16 July 2014] Available from: doi:10.1186/1745-0179-5-15

Management - Specific Treatments

Fact Explanation
Cognitive Behavioral Therapy (CBT) Psychotherapy remains the treatment of choice for adjustment disorders. Goals of psychotherapy are: analysis of the stressors affecting and determine whether they can be eliminated or minimized. Clarification and interpretation of the meaning of the stressor for the patient,identification a means of reducing the stressor, and improvement of the patient’s coping skills. [1],[2],[4]
Pharmacological management: Antidepressants - Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin–Norepinephrine Reuptake Inhibitors (SNRIs), Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs) Used when depression is prolonged or psychotherapy is unsuccessful. They medications were effective because they enhanced serotonergic or noradrenergic mechanisms or both. Neither single antidepressant was found to be more effective than another agent in treating adjustment disorder, nor combining antidepressants improved symptom relief over monotherapy.[1],[2],[3],[6]
Pharmacological management: Anxiolytics (Benzodiazepines - Alprazolam, Lorazepam) Used when symptoms as anxiety or sleeping disturbances are prolonged or psychotherapy is unsuccessful. Action mechanisms include complex interaction with GABA-receptor.The binding sites are unevenly distributed in various brain areas and are associated with a GABA receptor and a chloride channel. Drug potentiate the increase in chloride ion conduction produced by GABA, thus enhancing this amino acid’s inhibitory effect. [1],[2],[5]
References
  1. CASEY P, BAILEY S. Adjustment disorders: the state of the art World Psychiatry [online] 2011 Feb, 10(1):11-18 [viewed 16 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048515
  2. CARTA MAURO, BALESTRIERI MATTEO, MURRU ANDREA, HARDOY MARIA. Adjustment Disorder: epidemiology, diagnosis and treatment. Array [online] 2009 December [viewed 16 July 2014] Available from: doi:10.1186/1745-0179-5-15
  3. GRAY A M, SPENCER P S J, SEWELL R D E. The involvement of the opioidergic system in the antinociceptive mechanism of action of antidepressant compounds. [online] 1998 June, 124(4):669-674 [viewed 16 July 2014] Available from: doi:10.1038/sj.bjp.0701882
  4. CASEY P.. Adjustment disorders: Fault line in the psychiatric glossary. [online] 2001 December, 179(6):479-481 [viewed 16 July 2014] Available from: doi:10.1192/bjp.179.6.479
  5. CRESTANI FLORENCE, MARTIN JAMES R, MöHLER HANNS, RUDOLPH UWE. Mechanism of action of the hypnotic zolpidem . [online] 2000 December, 131(7):1251-1254 [viewed 16 July 2014] Available from: doi:10.1038/sj.bjp.0703717
  6. CARTA MG, BALESTRIERI M, MURRU A, HARDOY MC. Adjustment Disorder: epidemiology, diagnosis and treatment Clin Pract Epidemiol Ment Health [online] :15 [viewed 17 July 2014] Available from: doi:10.1186/1745-0179-5-15