In a multiaxial assessment (see Appendix L), the nature of the stressor is indicated by listing it on Axis IV (e.g., marital, divorce, work, or academic problem). Box 5-2 contrasts adjustment disorder responses and bereavement responses.

BOX 5-2

Responses of Adjustment Disorder and Bereavement

Adjustment disorder: Responses to stress are generally unexpected.

Bereavement (grief): Responses to stress are generally expected, such as death of a loved one. ^*

^*A diagnosis of adjustment disorder may be made if the response in bereavement is in excess of or more prolonged than what is typically expected.

ETIOLOGY

Specific etiologic factors are associated with adjustment disorders (Box 5-3). The etiology of adjustment disorders varies widely. The stressor may be internal, such as development of a medical condition, or external, such as loss of a job because of downsizing of employer agency (see Box 5-1).

BOX 5-3

Etiologic Factors Related to Adjustment Disorders ^*

BIOLOGIC/GENETIC

▪ Physiologic response to crisis and stress, such as acute or chronic illness/injury, that requires a biologic adjustment.

BIOCHEMICAL

▪ Activation of adrenaline and other neurotransmitters, as noted in stress adaptation and crisis models.

PSYCHODYNAMIC

▪ Maladaptive ego defenses or lack of ego strength at critical life stages.

▪ Inability of the ego to adapt/adjust to crises.

PSYCHOSOCIAL

▪ Psychologic/emotional responses to crisis/stressor events or inability to use existing coping methods or create new ones; may be influenced by timing, intensity, or repetition of the stressor event.

▪ A chronic, debilitating illness may require both physical and psychologic adjustments to the ongoing stressors.

DEVELOPMENTAL

▪ Stressors experienced at critical developmental stages of adolescence, adulthood, middle adulthood, and older adulthood.

CULTURAL

▪ Sociocultural adjustment, response to illness, and meaning of illness vary among individuals from different cultures.

▪ An individual’s culture may determine whether the reaction to the stressor is expected or exceeds the usual response.

*Etiology is attributed to a combination of biologic, psychologic, psychosocial, and environmental factors.

EPIDEMIOLOGY

Adjustment disorders are common and may occur in any age group, including children. Men and women are equally affected. Epidemiologic features vary widely because of the types of populations studied and the assessment methods used. A higher incidence of adjustment disorders, however, seems to occur in individuals from disadvantaged life circumstances than in the general population in that they often experience a high rate of stressors, including the results of poverty, unemployment, crime, unwanted pregnancies, malnutrition, single parenthood, drug abuse, and other physical and psychologic abuses.

The percentage of people in outpatient mental health treatment with a diagnosis of adjustment disorder ranges from approximately 10% to 30%.

The onset of symptoms occurs within 3 months of an identified stressor and may occur within days if the event is acute. Duration is usually brief, lasting months, but symptoms may persist if the stressor is prolonged (e.g., threatening neighborhood, persisting marital strife).

ASSESSMENT AND DIAGNOSTIC CRITERIA

The defining characteristic for adjustment disorders is development of emotional or behavioral symptom disturbance in direct response to a psychosocial or environmental stressor. The symptom picture is accompanied by disturbance in social relationships and occupational functioning (school or work) or by marked distress in the individual that exceeds an expected normal response.

Although adjustment disorders do occur alone, they are also associated with preexisting mental disorders, medical conditions, or surgical procedures. Individuals with adjustment disorders often have problems with substance use and abuse; suicide ideation, gestures, threats, attempts, and completions; and somatic complaints. Symptoms vary widely depending on the type of disorder.

DSM-IV-TR Criteria

Various categories of adjustment disorder have been identified based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision ( DSM-IV-TR) criteria (see the DSM-IV-TR box; see also Appendix L).

The response of the client with an adjustment disorder is considered maladaptive because of noted impairment in social, academic, or occupational functioning or because the resultant symptoms or behaviors exceed normal, usual, or expected responses. Each type of disorder will additionally be specified as acute or chronic (lasting under or more than 6 months).

DSM-IV-TR

American Psychiatric Association
Adjustment Disorders^*

*Adjustment disorders are coded according to the subtype that best characterizes the predominant symptoms.

Adjustment disorder with depressed mood

Adjustment disorder with anxiety

Adjustment disorder with mixed anxiety and depressed mood

Adjustment disorder with disturbance of conduct

Adjustment disorder with mixed disturbance of emotions and conduct

Adjustment disorder, unspecified

Adjustment Disorder with Depressed Mood

The defining characteristics of adjustment disorder with depressed mood are depressed mood, tearfulness, sadness, and feelings of hopelessness/helplessness. More serious responses are melancholia, regression, psychophysiologic decompensation, and depersonalization.

Adjustment Disorder with Anxiety

The defining characteristics of adjustment disorder with anxiety are worry, nervousness, jitteriness, and in children, fears of separation from major attachment figures, resulting in myriad symptoms.

Adjustment Disorder with Mixed Anxiety and Depressed Mood

The defining characteristics of adjustment disorder with mixed anxiety and depressed mood are symptoms of both anxiety and depression, as described in the previous two categories.

Adjustment Disorder with Disturbance of Conduct

The defining characteristics of adjustment disorder with disturbance of conduct is a violation of others’ rights or of major age-appropriate societal norms and rules, such as truancy, vandalism, reckless driving, substance abuse, fighting and other inappropriate forms of anger/aggression/impulsivity, and defaulting on legal responsibilities.

Adjustment Disorder with Mixed Disturbance of Emotions and Conduct

The defining characteristics of adjustment disorder with mixed disturbance of emotions and conduct combine emotional symptoms such as depression and anxiety with a disturbance in conduct, as described previously.

Adjustment Disorder, Unspecified

The defining characteristics of adjustment disorder, unspecified, are not classifiable in any of the other subtypes, such as physical complaints, social withdrawal, school or work problems, or other psychosocial stressors.

INTERVENTIONS

Treatment Settings

Clients with adjustment disorders are typically treated on an outpatient basis. Exceptions occur when the stressor or its consequences are greater than the individual’s ability to cope and short-term acute care in a treatment facility is necessary. Clients will be admitted to a facility if suicidal. A variety of therapeutic techniques may be employed by an interdisciplinary team, depending on the professional preference, assessment of problem, and desired outcome.

Medications

Medications are used sparingly for clients with adjustment disorders because symptoms of these disorders are expected to resolve after the immediate cause is identified and treated. Also, practitioners prefer to observe the client without the effects of medication because symptoms of adjustment disorder may include symptoms of anxiety and may even progress to include symptoms of a major mental disorder such as depression.

In general, both benzodiazepines and antidepressants are used to treat adjustment disorders, depending on the symptoms (see Appendix H).

Psychosocial Therapies

Therapeutic Nurse-Client Relationship

A facilitative therapeutic alliance can be beneficial for the client who experiences an adjustment disorder. Being able to express feelings, thoughts, and behaviors with an empathic and nonjudgmental nurse often brings emotional catharsis, initial organization of thoughts and problem solving, and modification of problematic behaviors that have occurred or worsened as a result of responses to the stressors. With use of therapeutic techniques the nurse can affect or assist client change and provide a necessary affiliation needed by the client during stressful times (see Chapter 1).

Adjunctive Therapies

Recreational therapies may be useful for clients diagnosed with adjustment disorder, whether they are in an outpatient or inpatient setting. Leisure activities promote socialization and help clients become more comfortable with others who may have similar problems, even if they do not all share the same diagnosis. Recreational therapies also inspire clients to engage in more self-directed pursuits that may build confidence and increase self-esteem. Exercise can be a constructive anxiety-reducing outlet for some clients; others may prefer relaxation strategies.

Occupational therapy may help clients whose crises are related to role changes or who may have some residual dysfunction as a result of a concomitant physical disability. The client’s developmental stage, capabilities, presented problems, and preferences should be assessed before adjunctive therapeutic activities are initiated.

Supportive Therapies

Clinical nurse specialists, social workers, physicians, and psychologists are prepared and trained to manage the care of clients with adjustment disorders through a therapeutic interdisciplinary team approach. A variety of treatment options are available for outpatients, depending on professional preference, assessment of problems, and desired outcomes. Cognitive therapy, brief strategic therapy, and other types of behavioral interventions may be used effectively in combination with psychodynamic, psychotherapeutic, or interpersonal approaches. Family therapy may be selected when the identified stressor is a crisis within the family system. Group therapy may also be used (see Appendix G).

Other Therapies

Biofeedback, psychodrama, hypnosis, meditation, visual imagery, and journal writing are other therapeutic modalities that may be helpful for clients with adjustment disorders, depending on individual problems and client/practitioner preference. Pastoral counseling is made available when clients request it (see Appendixes F and G).

PROGNOSIS AND DISCHARGE CRITERIA

Unless a client is suicidal, out of control, or abusing drugs in addition to having an adjustment disorder, treatment is usually at home or in other outpatient settings. Discharge may mean suspension of outpatient treatment when symptoms have abated. The prognosis for the client with adjustment disorder is usually good based on the symptom duration of 6 months or less. Chronic disorders may occur when symptoms persist in response to a chronic stressor (e.g., HIV/AIDS). The following criteria demonstrate the client’s readiness for discharge: