Adjustment disorders

Adjustment disorders are a frequent working diagnosis and an even more frequent differential: the exam asks you to tie symptoms to an identifiable stressor and its timeline, and to step aside when another disorder's full criteria are met.

Criteria at exam depth. Emotional or behavioral symptoms develop within 3 months of the onset of an identifiable stressor (divorce, job loss, illness, relocation, a parent's separation). The symptoms are clinically significant, shown by marked distress out of proportion to the stressor (judged with cultural factors in mind) and/or significant impairment. The disturbance does not meet criteria for another mental disorder and is not just a flare of a preexisting one. It is not normal bereavement and is not better explained by prolonged grief disorder. Once the stressor or its consequences end, symptoms do not persist more than an additional 6 months; the condition can last longer when the stressor itself is ongoing. Subtypes: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, and unspecified.

Hinge differentials.

• Major depressive disorder: when full MDD criteria are met, diagnose MDD even if a stressor triggered it; adjustment disorder fits subthreshold, stressor-linked symptoms that fluctuate with the stressor.
• PTSD and acute stress disorder: require a qualifying trauma plus their full symptom sets; a trauma without full criteria can be an adjustment disorder.
• Generalized anxiety disorder: worry is broad and not tied to a single stressor.
• Normal bereavement and prolonged grief disorder: expected grief is not an adjustment disorder; persistent yearning at least 12 months after a death (6 months for youth) points to prolonged grief disorder.
• Normal stress response: expected distress without out-of-proportion reaction or impairment.
• Conduct disorder: a persistent pattern of rule violation not explained by a recent stressor.

On the NCMHCE. Establish the stressor, its onset, and symptom onset precisely, since the timeline is what the questions turn on. Screen for suicide risk; adjustment disorders are associated with increased suicide risk even when symptoms are subthreshold for other diagnoses. Rule out substance use and medical causes. First-line care is brief, focused psychotherapy: CBT for coping skills and maladaptive thoughts, problem-solving therapy, supportive counseling, and family work for youth. Bolster social supports and practical resources. Consider culture when judging whether distress is "out of proportion." Reassess if symptoms intensify into another disorder or persist beyond the expected window.

Clinical Pearl: Symptoms within 3 months of a stressor, out of proportion or impairing, that do not meet another disorder's criteria = adjustment disorder. If another disorder's criteria are met, diagnose that disorder instead.