_ RCGP Learning

Written by Dr Dirk Pilat

It is part of our lives to be exposed to stressful events, none of us will be spared these. It is nevertheless human nature to adapt and adjust to these stressors and slowly recover. In general practice we regularly see people who seek solace, support or need help after distressing events in their life. These can be traumatic events, such as exposure to actual or threatened death, as well as nontraumatic events such as interpersonal conflict, unemployment, financial difficulties, or personal ill health. The majority of people suffering from these events don’t come to see us at all (the so called ‘symptom iceberg’), and those who see us often improve with empathetic and non-judgmental support, or benefit from appropriate signposting. Nevertheless, sometimes the stressful event can trigger a temporary episode that is more than just the normal reaction to distress. In this case it might be appropriate to consider the diagnosis of adjustment disorder. 

The term ‘adjustment disorder’ has been around since 1980, and is usually associated with the following presentation, as suggested by DSM 5 – TR:

Emotional or behavioural symptoms within three months of a stressful event:

• exceeding what is acceptable within a cultural or societal context or

• associated with significant impairment within the social or occupational environment and

• does not meet the criteria for another significant mental health disorder and 

• once the stressor is over, the symptoms do not persist.

Its prevalence is variable from country to country (particularly prevalent in those with current or recent conflict), and some papers suggest it is the seventh most common diagnostic category used by psychiatrists worldwide with a lifetime prevalence of up to 21%. 

A meta-analysis from 2022 that aimed to determine those most at risk showed that female gender, unemployed status, low income, low social support, and a history of mental health disorders predicted adjustment disorders compared with no mental health condition. Those with adjustment disorder had 12 times the rate of suicide compared to those without this diagnosis.

Due to its presentation, adjustment disorder has a range of more severe differential diagnoses: for instance the diagnosis of PTSD and acute stress disorder require the stressful trigger to be of a magnitude that would be traumatic for almost everyone and also have a different group of symptoms. If the initial symptoms are worsening after a period of watchful waiting, the patient might be developing a severe mental disorder such as depression or general anxiety, particularly if the stressor vanishes.

The diagnosis is often criticised as the medicalisation of problems of modern life, as it may pathologise a normal stress response. We nevertheless know in primary care that different individuals will develop different responses to the same stressors (as the COVID-19 pandemic so powerfully demonstrated): some people will have no issues, some people will develop minor symptoms and handle them easily, while some people will develop an adjustment disorder. The decision whether the symptoms of our patient represents an adaptive or abnormal response is therefore a clinical one: some authors suggest assessing whether there is functional impairment present, whether the trajectory of the patient’s symptoms shows adaptation and whether the trajectory demonstrates the patient's resilience.

If the decision is made that support from primary care will not suffice, the next treatment of choice for people with adjustment disorders is psychological therapy, so signposting to your local talking therapies team (or a referral, if necessary) would be an appropriate next step. If significant distress and/or insomnia is present, short term pharmacological management with benzodiazepines might be appropriate in extreme cases. As the condition by definition is self-resolving, the use of medication is controversial, and has the potential to cause harm through side effects or dependence. Some papers suggest the use of a sedative anti-depressant such as trazodone may be helpful but there are no universal recommendations. There are randomised, placebo controlled trials that have shown the benefits of herbal remedies such as valerian or kava-kava (though there have been reports about hepatotoxicity). When recommending herbal supplements, always suggest that the patient checks the product for the THR Certification Mark: this indicates that the herbal medicine has been registered with the Medicines and Healthcare products Regulatory Agency and meets the required standards relating to its quality, safety, evidence of traditional use.

Placed in the middle of the community and with intricate knowledge of our patients, primary care is well placed to support patients with adjustment disorders, as we are able to assess the severity of their symptoms over time and are aware of their social circumstances, coping skills, beliefs and attitudes. This will help us determine whether the period of distress is settling or whether is causing a more severe mental health problem.

References

1. Bachem R, Casey P. Adjustment disorder: A diagnosis whose time has come. Journal of Affective Disorders. 2018 Feb; 227: 243–53.
2. Casey P, Bailey S. Adjustment disorders: the state of the art. World Psychiatry [Internet]. 2011 Feb; 10(1): 11–8.
3. Geer K. Adjustment Disorder. Primary Care: Clinics in Office Practice. 2023 Mar;50(1):83–8.
4. Gradus J. Prevalence and prognosis of stress disorders: a review of the epidemiologic literature. Clinical Epidemiology [Internet]. 2017 May; Volume 9: 251–60.
5. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Kava Kava. [Updated 2018 Apr 10].
6. McAteer A, Elliott AM, Hannaford PC. Ascertaining the size of the symptom iceberg in a UK-wide community-based survey. British Journal of General Practice. 2011 Jan 1; 61(582): e1–11.
7. Medicines and Healthcare products Regulatory Agency: The Traditional Herbal Registration (THR) Certification Mark: Guidance for Business.