LIFE IS A CONTINOUS PROCESS

OF ADJUSTMENT
IF YOU CAN ADJUST BETTER,
YOU HAVE TO SUFFER LESS
ADJUSTMENT
DISORDERS
 Specific objectives
INTRODUCTION
EPIDEMIOLOGY
ETIOLOGY
ICD 10 CLASSIFICATION
ICD 11 CLASSIFICATION
DSM 5 DIAGNOSTIC CRITERIA
 Specific objectives
ASSESSMENT
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
ROLE OF NURSES
ADDITIONAL INFORMATION
RESEARCH EVIDENCE
 Adjustment disorders
Adjustment disorders are characterized by maladaptive emotional
and behavioral symptoms in response to a stressful event.
The symptom complex that develops may involve anxious or
depressive affect or may present with a disturbance of conduct
It is one of the few diagnostic entities in which an external stressful
event is linked to the development of symptoms.
 Adjustment disorders…
 The greatest contribution to the diagnosis of this disorder was given
by ICD 11
 For the first time, adjustment disorder acquires the status of a full
syndrome with its own set of specific diagnostic criteria in ICD 11
 EPIDEMIOLOGY

Women two times

Prevalence – more risk than men In children and
2 to 8 percent of the Single women adolescents, boys and
general population. significantly more girls equal risk
risk.
 EPIDEMIOLOGY…

The disorders can occur at

any age , but are most
frequently diagnosed in One of the most common
adolescents. psychiatric diagnoses of
patients hospitalized for
medical and surgical problems.

10 to 30 percent of mental health outpatients and up to 50 percent of

general hospital inpatients referred for mental health consultations
have been diagnosed with adjustment disorders
 ETIOLOGY

STRESS

 One or more stressor

Chronic stressor
 Recurrent stressors
 Multiple stressors acting together
 ETIOLOGY…
STRESS

Divorce

Loss of a job

Death of a person important to a patient

Physical illness

Seasonal business difficulties

 ETIOLOGY…
STRESS

Chronic illness

Poverty

Natural disaster

Having the child leave home

Specific developmental stages

 Etiology, Stress…
Specific developmental stages

Getting Failing to
Beginning Leaving Becoming achieve Retirin
marrie
school home
d
a parent occupati- g
onal goals
 Etiology…
Psychodynamic Factors

 A concurrent personality disorder

 Loss of a parent during infancy or being reared in a dysfunctional
family.
 Fixation in early psychosexual stages.
 The role of the mother and the rearing
environment especially in the early infancy
 Etiology…
Psychodynamic Factors

 The meaning of the current situation to similar past events.

 Defense mechanisms developed by the person
 Relation between the stressor and the human developmental life
cycle.
 Actual or perceived support from key relationships
 Etiology…
Family and Genetic Factors
 

 Several studies in twins have stressed on the family and genetics role
in adjustment disorders.
 Monozygotic twins showing greater concordance than dizygotic twins
 ICD 10
F43 Reaction to severe stress, and adjustment disorders

These disorders can

Cause- thus be regarded as
An exceptionally stressful life maladaptive
event or a significant life responses to severe
change or continued stress
 ICD 10
F43 Reaction to severe stress, and adjustment disorders…

The condition
would not have
arisen without the
stressor.
 ICD 10
F43 Reaction to severe stress, and adjustment disorders…

Reactions to severe
stress and adjustment
disorders in all age
groups, including
children and
adolescents, are
included.
 ICD10 Classification
F43 Reaction to severe stress, and adjustment
disorders

F43.1 Post-traumatic stress disorder

F43.2 Adjustment disorders

 ICD10 Classification

F43.20 Brief depressive reaction

F43.21 Prolonged depressive reaction

F43.22 Mixed anxiety and depressive reaction

 ICD10 Classification…

F43.23 With predominant disturbance of other emotions

F43.24 With predominant disturbance of conduct

F43.25 With mixed disturbance of emotions and conduct

F43.28 With other specified predominant symptoms

 F43.2 Adjustment disorders…
Arising in the period
of adaptation to a Individual
significant life change predisposition or
or to the vulnerability plays a
consequences of a greater role
stressful life event

The stressor may have

Usually interfering with affected the individual's
social functioning and social network/ the
performance wider system of social
supports and values
F43.2 Adjustment disorders, Clinical
manifestations
The manifestations vary

Depressed mood, Anxiety, Worry (or a

mixture of these)

Feeling of inability to cope, plan ahead

Feeling of inability to continue in the

present situation
some degree of disability in the
performance of daily routine
 F43.2 Adjustment disorders, Clinical
manifestations…
✽None of the symptoms is of sufficient severity to justify a more
specific diagnosis.
✽Dramatic behaviour or outbursts of violence, rarely occur
✽Conduct disorders (e.g. aggressive or dissocial behaviour) may be an
associated feature, particularly in adolescents.
✽In children, regressive phenomena such as return to bed-wetting,
babyish speech, or thumb-sucking are frequently seen
F43.2 Adjustment disorders, Duration of
symptoms…

Duration of If the symptoms

The onset is usually symptoms does not persist beyond this
within 1 month of the usually exceed 6 period, the diagnosis
occurrence of the months, except in the should be changed
stressful event or life case of prolonged according to the
change depressive reaction clinical picture
(F43.21). present
 ICD 10, Diagnostic criteria…

Form, content, and

severity of symptoms
Diagnosis
depends on a
careful evaluation Previous history and
of the personality
relationship
between Stressful event,
situation, or life
crisis.
ICD 10, Diagnostic criteria…

If the stressor is
relatively minor, or if a
temporal cannot be
demonstrated, the
disorder should be
classified elsewhere,
according to its
presenting features.
F43.20 Brief depressive reaction

A transient, mild depressive state

of duration not exceeding 1
month.
F43.21 Prolonged depressive reaction

A mild depressive state

occurring in response to
a prolonged exposure to
a stressful situation but
of
duration not exceeding
2 years.
F43.22 Mixed anxiety and depressive
reaction

Both anxiety and depressive

symptoms are prominent, but at
levels no greater than specified in
mixed anxiety and depressive
disorder (F41.2) or other mixed
anxiety disorder (F41.3).
 F43.23 With predominant disturbance of
other emotions
• The symptoms are usually of several types of emotion, such as anxiety,
depression, worry, tensions, and anger.
• Symptoms of anxiety and depression may fulfil the criteria for mixed
anxiety and depressive disorder or other mixed anxiety disorder
• But they are not so predominant that other more specific depressive or
anxiety disorders can be diagnosed.
• This category can also be used for reactions in children in which regressive
behaviour such as bed-wetting or thumb-sucking are also present.
 F43.24 With predominant disturbance of
conduct
o The main disturbance is one involving conduct
o Eg: An adolescent grief reaction resulting in aggressive or dissocial
behaviour.
 ICD 10 CLASSIFICATION….
F43.25 With mixed disturbance of emotions and conduct
Both emotional symptoms and disturbance of conduct are prominent
features.
F43.28 ,With other specified predominant symptoms
 DSM 5, Diagnostic criteria

The development of Marked

Significant
emotional or distress that impairment in
behavioral
symptoms in
is out of social,
response to an proportion occupational,
identifiable to the or other
stressor(s) occurring important
within 3 months of
severity or
the onset of the intensity of areas of
stressor(s). the stressor functioning.
 DSM 5, Diagnostic criteria…

The stress-related Once the

disturbance does stressor or its
not meet the The consequences
criteria for symptoms do have
another mental not represent terminated, the
disorder and is normal symptoms do
not merely an bereavement. not persist for
exacerbation of a more than an
pre-existing additional 6
mental disorder. months.
DSM 5 Adjustment disorder- subcategories
With depressed mood:
Low mood, tearfulness, or feelings of hopelessness are predominant.
With anxiety:
Nervousness, worry, jitteriness, or separation anxiety is predominant.
With mixed anxiety and depressed mood:
A combination of depression and anxiety is predominant.
 DSM 5 Adjustment disorder-
subcategories…
With disturbance of conduct:
Disturbance of conduct is predominant.
With mixed disturbance of emotions and conduct:
Both emotional symptoms (e.g., depression, anxiety) and a disturbance
of conduct are predominant.
Unspecified:
For maladaptive reactions that are not classifiable as one of the specific
subtypes of adjustment disorder
ICD 11,6B43- Adjustment disorder
Characterized by
preoccupation with the
Adjustment disorder stressor or its consequences,
is a maladaptive including
reaction to an  Excessive worry
identifiable  Recurrent and distressing
psychosocial stressor thoughts about the stressor
or multiple stressors  Constant rumination about
that usually emerges its implications
within a month of  Constant rumination about
the stressor. failure to adapt to the
stressor
 ICD 11,6B43- Adjustment disorder…
It causes significant impairment in personal, family, social,
educational, occupational or other important areas of functioning.
The symptoms are not of sufficient specificity or severity to justify
the diagnosis of another Mental and Behavioural Disorder
Typically resolve within 6 months, unless the stressor persists for a
longer duration.
 ASSESSMENT

• ADNM (Adjustment Disorder—New Module)

• DIAD (Diagnostic Interview for Adjustment Disorder)
ADNM 20 (Adjustment Disorder—New Module)

Core symptoms:
 Preoccupations with the stressor
 Failure to adapt
Accessory symptoms:
• Avoidance
Cut off
• Depressed mood score=
• Anxiety 47.5
• Impulsivity
 DIFFERENTIAL DIAGNOSIS

 Uncomplicated bereavement
 Major depressive disorder
 Generalized anxiety disorder
 Somatic symptom disorder
 Substance-related disorder
 PTSD
Management of adjustment disorders
Psychotherapy
 Management of adjustment disorders
Psychotherapy…

 Treatment of choice for adjustment disorders.

 Group therapy can be particularly useful for patients who have had
similar stresses
 Individual psychotherapy offers the opportunity to explore the
meaning of the stressor to the patient so that earlier traumas can be
worked through.
 After successful therapy, patients sometimes emerge from an
adjustment disorder stronger than in the premorbid period,
 Management of adjustment disorders
Psychotherapy…

 Help persons adapt to stressors

 Preventive intervention if the stressor does remit.
 Therapist should identify any secondary gain if present
 If Patients with an adjustment disorder includes a conduct disturbance,
therapist should not attempt to rescue such patients from the
consequences of their actions.
 Family therapy can help in such occasions.
 Management of adjustment disorders
Pharmacotherapy…

 Only limited research evidence

 Should be prescribed for brief periods.
 The patient may respond to an antianxiety agent or to an antidepressant.

 Patients with severe anxiety bordering on panic can benefit from anxiolytics
such as lorazepam (2 mg per day) and diazepam

 Those patients in withdrawn or inhibited states may be helped by a short course

of psychostimulant medication like methylphenidate
 Management of adjustment disorders
Pharmacotherapy…

 Benzodiazepines can be given only for a brief period

 Antipsychotic drugs may be used if there are signs of decompensation or
impending psychosis.
 Selective serotonin reuptake inhibitors have been found useful in treating
symptoms of traumatic grief.
 Recently, there has been an increase in antidepressant use to augment
psychotherapy.
 Management of adjustment disorders
Pharmacotherapy…

 Placebo-controlled trials provide some support for the herbal agent euphytose
 Studies report that etifoxine is superior to buspirone and benzodiazepines for
adjustment disorder with anxiety.
 Buspirone-
 Etifoxine –
 It is important to note that the diagnosis "adjustment disorder" is most likely a
working diagnosis in inpatients
 Overall, pharmacotherapy for inpatients with this diagnosis is mostly symptom-
oriented and focuses on depressive moods, agitation and anxiety.
 Nursing diagnosis
RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE
COMPLICATED GRIEVING
ANXIETY
INEFFECTIVE COPING
RISK-PRONE HEALTH BEHAVIOR
RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE

Assess suicidal ideation thoroughly

Observe client’s behavior frequently

Observe for warning signs of suicide

Obtain non suicidal contract from

client
Encourage appropriate expression of angry
feelings
RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE…

Remove all dangerous objects from client’s

environment
Try to redirect violent behavior by means of physical
outlets for the client’s anxiety

Have sufficient staff available

Administer tranquilizing medications as ordered
by physician if necessary
Restrain if necessary
 COMPLICATED GRIEVING

 Assess stage of grief in which the client is fixed. Discuss normalcy of

feelings and behaviors related to stages of grief.
 Acknowledge feelings of guilt or self-blame that client may express
 Assess for maladaptive coping strategies
 Identify available resources from which the individual may seek
assistance if problems with complicated grieving persist.
 COMPLICATED GRIEVING…

 Help client solve problems as he or she attempts to determine

methods for more adaptive coping with the experienced loss.
 Provide positive feedback for strategies identified and decisions
made.
 Encourage the client to reach out for spiritual support during this time
in whatever form is desirable to him or her.
 ANXIETY
¨Provide a quiet environment
¨Be available to stay with client especially during anxiety episodes
¨Help client identify situation that precipitated onset of anxiety
symptoms
¨Relaxation exercises
¨Discuss with client signs of increasing anxiety
¨Discuss ways of intervening to maintain the anxiety at a manageable
level
 INEFFECTIVE COPING
• Encourage client to express fears and feelings associated with the stressor
• Identify the maladaptive coping response
• Review client’s methods of coping with similar situations in the past.
• Assist client through the adaptive coping like problem-solving
• Provide positive reinforcement for adaptive coping
• Take care not to reinforce dependent and manipulative behaviors.
 RISK-PRONE HEALTH BEHAVIOR

Encourage client to talk about lifestyle prior to the change in health

status.
Encourage client to discuss the change or loss and particularly to
express fear and anger associated with it
Provide assistance with activities of daily living (ADLs) as required,
but encourage independence as possible
Help client with decision making regarding incorporation of change
or loss into lifestyle
 RISK-PRONE HEALTH BEHAVIOR…

Identify problems that the altered health is likely to create. Discuss

alternative solutions
Use role-playing of potential stressful situations and how to deal it in
relation to the health status change
Ensure that client & family are fully knowledgeable about the
condition and the necessary steps to take for optimal wellbeing
 Relapse prevention
¤ Medication adherence
¤ Stress management
¤ Positive coping
¤ Strengthen social support
¤ Follow up visits
 Course and prognosis

✽ Overall prognosis of an adjustment disorder is generally favourable

with appropriate treatment.
✽ Most patients return to their previous level of functioning within 3
months.
✽ Some persons (particularly adolescents) who receive a diagnosis of an
adjustment disorder later have mood disorders or substance related
disorders.
 Course and prognosis…
✽ Adolescents usually require a longer time to recover than adults.
✽ Adjustment disorders possess a very risk for suicide, especially in
adolescents
✽ Comorbid diagnoses of substance abuse and personality disorder
contributed to the suicide risk profile.
 Additional information

 Studies suggest increased risk of parkinsonism disease in adjustment

disorder clients
 Prevalence of adjustment disorder in Cancer patients varying between
6 and 19%
 COVID Stress Syndrome
¨ Fear of SARSCoV2 infection and fear of coming into contact with objects or
surfaces contaminated with the coronavirus

¨ Fear of socio-economic impacts of the pandemic

¨ Fear of foreigners for fear that they are infected

¨ Pandemic-related compulsive checking and reassurance-seeking

¨ Pandemic-related traumatic stress symptoms.

 COVID Stress Disorder…
• A severe form of the syndrome, characterized by clinically significant
distress and impairment in functioning, is the COVID Stress Disorder,
which is regarded as a pandemic-related adjustment disorder
 Research evidence

• An internet-based intervention for adjustment disorder (TAO): study

protocol for a randomized controlled trial
• Iryna Rachyla, Marian Pérez-Ara, Mar Molés, Daniel Campos, Adriana Mira,
Cristina Botella & Soledad Quero
• BMC Psychiatry volume 18, Article number: 161 (2018)
 An internet-based intervention for adjustment disorder (TAO)…

• Background

Adjustment Disorder (AjD) is a common and disabling mental health problem. The
lack of research on this disorder has led to the absence of evidence-based
interventions for its treatment. Moreover, because the available data indicate that a
high percentage of people with mental illness are not treated, it is necessary to
develop new ways to provide psychological assistance. The present study describes
a Randomized Controlled Trial (RCT) aimed at assessing the effectiveness and
acceptance of a linear internet-delivered cognitive-behavioral therapy (ICBT)
intervention for AjD.
An internet-based intervention for adjustment disorder (TAO)…

• Methods

A two-armed RCT was designed to compare an intervention group to a waiting list

control group. Participants from the intervention group will receive TAO, an internet-
based program for AjD composed of seven modules. TAO combines CBT and Positive
Psychology strategies in order to provide patients with complete support, reducing their
clinical symptoms and enhancing their capacity to overcome everyday adversity.
Participants will also receive short weekly telephone support. Participants in the control
group will be assessed before and after a seven-week waiting period, and then they will
be offered the same intervention. Participants will be randomly assigned to one of the 2
groups. Measurements will be taken at five different moments: baseline, post-
intervention, and three follow-up periods (3-, 6- and 12-month). BDI-II and BAI will be
used as primary outcome measures. Secondary outcomes will be symptoms of AjD,
posttraumatic growth, positive and negative affect, and quality of life.
 An internet-based intervention for
adjustment disorder (TAO)…
• Discussion
The development of ICBT programs like TAO responds to a need for
evidence-based interventions that can reach most of the people who
need them, reducing the burden and cost of mental disorders. More
specifically, TAO targets AjD and will entail a step forward in the
treatment of this prevalent but under-researched disorder. Finally, it
should be noted that this is the first RCT focusing on an internet-based
intervention for AjD in the Spanish population
Adjustment disorder and the course of the
suicidal process in adolescents
Gwendolyn Portzky 1, Kurt Audenaert, Kees van Heeringen

• Background:
Adjustment disorders are often associated with suicidal behaviour but
there is little information regarding the nature of the relationship and the
effect of adjustment disorders on the suicidal process. The authors' goal
was to investigate the association of adjustment disorders (with
depressed mood) and suicide in adolescents by means of a
psychological autopsy study.
Adjustment disorder and the course of the
suicidal process in adolescents…
• Method:
Relatives and other informants of 19 suicide victims were interviewed
by means of a semi-structured interview schedule. Differences in
duration of the suicidal process between suicide victims diagnosed with
adjustment disorder and suicide cases diagnosed with other psychiatric
disorders were examined.
Adjustment disorder and the course of the
suicidal process in adolescents…
• Results:
The suicidal process was significantly shorter in suicide victims
diagnosed with adjustment disorder compared with suicide cases
diagnosed with other disorders. No indications of a history of emotional
or behavioural problems during early adolescence were found in suicide
cases diagnosed with adjustment disorder.
• Limitations:
The study sample consists of a small sample size and retrospective
interviews of relatives were used.
Adjustment disorder and the course of the
suicidal process in adolescents…
• Conclusions:
The suicidal process in suicide victims diagnosed with adjustment
disorder appears to be short and rapidly evolving without any prior
indications of emotional or behavioural problems. The importance of
assessing the suicidal risk in patients diagnosed with adjustment
disorder is underlined
 Conclusion
 Despite of its high prevalence, adjustment disorders are under looked
 Consultation liaison psychiatry should be strengthened to promote a good
prognosis of adjustment disorders.
 It is interesting to note that adjustment disorder trajectories accumulate
symptoms over time, again suggesting that adjustment disorder is an early
marker for a more severe disorder like PTSD.
 The treatment options regarding adjustment disorders should be explored
and findings regarding psychotherapy should be brought more
extensively to clinical settings.
 Reference

 Benjamin James Sadock, Virginia Alcott Sadock, Kaplan and Sadock’s synopsis of psychiatry,
Tenth edition, Wolters Kluwer
 C.Marry Townsend, Psychiatric Mental health nursing, Eighth edition, Jaypee publications
 ICD 10
 ICD 11
 Gwendolyn Portzky , Kurt Audenaert, Kees van Heeringen Adjustment disorder and the course of
the suicidal process in adolescents
 Iryna Rachyla, Marian Pérez-Ara An internet-based intervention for adjustment disorder (TAO):
study protocol for a randomized controlled trial
 Meaghan L. O’Donnell , James A. Agathos etal Adjustment Disorder: Current developments and
future Directions