Adjustment disorder with anxiety and depression treatment plan

Adjustment disorder is a psychological response to stress involving marked distress and significant impairment in functioning, where the onset is linked to an identifiable stressor and will remit once the stress has abated. The responses can be delayed, and do not need to occur immediately after the stressor commences, although DSM-5 specifies a latency of no more than three months. The usual course is no longer than six months after the stressor is finished. The presentation can be varied and can include depressed mood, anxiety and behavioural disturbance.

Adjustment disorders can be associated with all varieties of stressors and life changes (e.g., relationship break-up, loss of a job, financial stress, car accident, family tension, becoming a parent, physical illness) and can therefore affect social, interpersonal and occupational functioning, including educational achievement. In adults the disorder tends to be self-limiting once the stressor has been removed, although this does not imply that intervention to relieve suffering is not important. In adolescents the diagnosis is more likely to be associated with long-term psychiatric disorder and is a known risk factor for suicide.

The prevalence rates for adjustment disorder vary depending on the setting. In medical settings where it is associated with health conditions it has been reported as being 14 per cent. In general populations the prevalence is approximately 2 to 4 per cent, with the higher rates being found for adolescents and children.

General principles of psychological assessment

Assessment for treatment formulation requires understanding the nature of the stressor, exploration of the meaning of the stressor in the context of the individual’s life, and consideration of any predisposing factors. The dimensions of psychological distress associated with adjustment disorder need to be understood, as well as the impact on functioning at work or school and on relationships. The level of actual or perceived support from important relationships needs to be examined, as this may affect an individual’s emotional and behavioural response to a stressor. Adjustment disorders associated with the stress of physical illness may complicate existing health conditions or compliance with medical treatment, and these issues should be carefully investigated. Consideration should be given to variations in cultural responses to stressful events when assessing stress reactions.

Recommended self-report assessment tools include the Depression Anxiety Stress Scales (DASS), the Hospital Anxiety and Depression Scale (HADS), which measures emotional distress amongst patients being treated for various disorders, and the Beck Depression Inventory (BDI).

Evidence-based psychological treatment guidance

Given that adjustment disorder is functionally linked to stress, treatment interventions should focus on managing the individual’s capacity for coping with the stress, as well as relieving the symptoms of psychological distress and their impact on the individual’s functioning. Treatment is aimed at returning the individual to some stability or more manageable level of adaptation to a continuing stressor, with consideration of the individual’s attribution of the stressor’s meaning and any predisposing factors. Assisting individuals to access support from their social networks at a time when they may feel to withdraw, can also be very helpful.

A variety of evidence-based cognitive behavioural interventions may be appropriate depending on the individual presentation. These include cognitive therapy (to address maladaptive thoughts or misattributions in relation to the stressor), activity scheduling (to increase the sense of mastery and control), skills training for problem solving, anger management and stress management, and relaxation strategies (to reduce tension and stress-related emotions).

In the area of adjustment disorder and physical illness the evidence indicates cognitive therapy may be effective, with the target being the individual’s interpretation of the stressor of the illness and their perceived capacity for coping. For adjustment disorders associated with workplace stressors, a stress inoculation training approach which includes a focus on self-efficacy (to enhance sense of personal control in the face of the stressor) and behavioural activation (to promote a more active versus passive role) has received good supportive evidence.

An important consideration in interventions for adjustment disorder is where it is present in children and adolescents, since the long-term outcomes of adjustment disorder may be worse than for adults.

Emerging treatment directions for the future

Since adjustment disorders are, by definition, self-limiting, conduct of intervention research is particularly problematic. Brief solution-focussed treatments such as mindfulness-based therapy and solution-focussed psychotherapy have been suggested as a possible focus of future research.

Key reading and information sources

• Stress management: A comprehensive handbook of techniques and strategies (Smith, 2002)
• Adjustment disorder: epidemiology, diagnosis and treatment (Carta et al., 2009)
• Adjustment disorders: the state of the art (Casey & Bailey, 2011)
• Dutch practice guidelines for managing adjustment disorders in occupational and primary care (Klink & van Dijk, 2003)

Disclaimer: Published in InPsych on October 2014. The APS aims to ensure that information published in InPsych is current and accurate at the time of publication. Changes after publication may affect the accuracy of this information. Readers are responsible for ascertaining the currency and completeness of information they rely on, which is particularly important for government initiatives, legislation or best-practice principles which are open to amendment. The information provided in InPsych does not replace obtaining appropriate professional and/or legal advice.