1. Adjustment Disorders A Category of Compromise?

2. Some people react to a major stressor in their lives with extended and excessive feelings of anxiety, depressed mood, or antisocial behaviors.

3. The symptoms do not quite add up to acute stress disorder or posttraumatic stress disorder, nor do they reflect an anxiety or mood disorder… but they do cause considerable distress or interfere with the person’s job, schoolwork, or social life.

4. Should we consider such reactions normal?

5. No! says the DSM-IV-TR

6. Somewhere between effective coping strategies and stress disorders lie the Adjustment Disorders.

7. The essential feature of Adjustment Disorder is: The development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors.

8. DSM-IV-TR lists six types of Adjustment Disorders 1.309.0 With Depressed Mood: Depressed mood, tearfulness, feelings of hopelessness 2.309.24 With Anxiety: Nervousness, worry, jitteriness, or (in children) fears of separation from attachment figures.

9. DSM-IV-TR lists six types of Adjustment Disorders 3. 309.28 With Mixed Anxiety and Depressed Mood Combination of depressed mood, tearfulness, feelings of hopelessness and nervousness, worry, jitteriness, or (in children) fears of separation from attachment figures.

10. DSM-IV-TR lists six types of Adjustment Disorders 4. 309.3 With Disturbance of Conduct Violation of rights of others; e.g., truancy, vandalism, reckless driving, fighting.

11. DSM-IV-TR lists six types of Adjustment Disorders 5. 309.4 With Mixed Disturbance of Emotions and Conduct Both emotional symptoms (e.g., depression, anxiety) and disturbance of conduct

12. DSM-IV-TR lists six types of Adjustment Disorders 6.309.9 Unspecified Maladaptive reactions (e.g., physical complaints, social withdrawal) that is not one of the subtypes.

13. Adjustment Disorder (con’t.) Adjustment Disorder should not be diagnosed if the reaction to stress is: – What might be expected, given the situation and – Does not cause significant impairment in social or occupation functioning

14. Adjustment Disorder (con’t.) Characteristics a.Symptoms must develop within 3 months after the onset of the stressor b.Client must have marked distress in excess of what would be expected given the nature of the stressor c.Diagnosis is not used if disturbance meets the criteria for another specific Axis I disorder or is an exacerbation of a preexisting Axis I or Axis II disorder.

15. Adjustment Disorder (con’t.) d.Diagnosis may be used with an Axis I or Axis II disorder if they do not account for the pattern of symptoms that have occurred in response to the stressor. e.Diagnosis is not used when symptoms represent Bereavement. f.Adjustment Disorder must be resolved within 6 months of termination of the stressor (or its consequences). g.May persist longer than 6 months if it occurs in response to a chronic stressor

16. Adjustment Disorder (con’t.) Adjustment Disorders are coded based on subtype The subtype is selected according to the predominant symptom. The specific stressor(s) can be specified on Axis IV

17. Adjustment Disorder (con’t.) Subtypes 309.0 With Depressed Mood – Depressed mood, tearfulness, feelings of hopelessness 309.24 With Anxiety - Nervousness, worry, jitteriness, or (in children) fears of separation from attachment figures 309.28 With Mixed Anxiety and Depressed Mood - Combination of above) 309.3 With Disturbance of Conduct - Violation of right of others (e.g., truancy, vandalism, reckless driving, fighting) 309.4 With Mixed Disturbance of Emotions and Conduct - Both emotional symptoms (e.g., depression, anxiety) and disturbance of conduct 309.9 Unspecified - Maladaptive reactions (e.g., physical complaints or social withdrawal) that is not one of the subtypes.

18. Adjustment Disorder (con’t.) Specify if: Acute: If the disturbance lasted less than 6 months Chronic: If the disturbance lasts for 6 months or longer

19. Differential Diagnosis All of the following diagnoses are characterized by the presence of an extreme stressor:  Adjustment Disorder  Posttraumatic Stress Disorder (PTSD)  Acute Stress Disorder (AST)

20. Differential Diagnosis PTSD and Acute Stress Disorder require an extreme stressor. Adjustment Disorder Can be triggered by a stressor of any severity, and May involve a wide range of possible symptoms.

21. Differential Diagnosis With the death of a loved one: Bereavement is generally diagnosed instead of Adjustment Disorder. However, Adjustment Disorder may be used if the reaction is in excess of, or more prolonged than, what would be expected.