ADJUSTMENT DISORDERS
DSM-IV
ADJUSTMENT DISORDERs (SPECIFY if ACUTE/CHRONIC)
309.24 With anxiety
309.0 With depressed mood
309.3 With disturbance of conduct
309.4 With mixed disturbance of emotions and conduct
309.28 With mixed anxiety and depressed mood
The essential feature of adjustment disorders is a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months of the onset of the stressor. (The reaction to the death of a loved one is not included here, as it is generally diagnosed as bereavement.) The stressor also does not meet the criteria for any specific Axis I disorder or represent an exacerbation of a preexisting Axis I or Axis II disorder.
The response is considered maladaptive because social or occupational functioning is impaired or because the behaviors are exaggerated beyond the usual expected response to such a stressor. Duration of the symptoms for more than 6 months indicates a chronic state. By definition, an adjustment disorder must resolve within 6 months of the termination of the stressor or its consequences. If the stressor/consequences persist (e.g., a chronic disabling medical condition, emotional difficulties following a divorce, financial reversals resulting from termination of employment, or a developmental event such as leaving one’s parental home, retirement), the adjustment disorder may also persist.
ETIOLOGICAL THEORIES
Psychodynamics
Factors implicated in the predisposition to this disorder include unmet dependency needs, fixation in an earlier level of development, and underdeveloped ego.
The client with predisposition to adjustment disorder is seen as having an inability to complete the grieving process in response to a painful life change. The presumed cause of this inability to adapt is believed to be psychic overload—a level of intrapsychic strain exceeding the individual’s ability to cope. Normal functioning is disrupted, and psychological or somatic symptoms occur.
Biological
The presence of chronic disorders is thought to limit an individual’s general adaptive capacity. The normal process of adaptation to stressful life experiences is impaired, causing increased vulnerability to adjustment disorders. A high family incidence suggests a possible hereditary influence.
The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.
Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes; acute myocardial infarction; pheochromocytomas; substance intoxication and withdrawal; hypoglycemia; caffeine intoxication; mitral valve prolapse; and complex partial seizures.
Family Dynamics
The individual’s ability to respond to stress is influenced by the role of the primary caregiver (her or his ability to adapt to the infant’s needs) and the child-rearing environment (allowing the child gradually to gain independence and control over own life). Difficulty allowing the child to become independent leads to the child having adjustment problems in later life.
Individuals with adjustment difficulties have experienced negative learning through
inadequate role-modeling in dysfunctional family systems. These dysfunctional patterns impede the development of self-esteem and adequate coping skills, which also contribute to maladaptive adjustment responses.
CLIENT ASSESSMENT DATA BASE
(Symptoms of affective, depressive, and anxiety disorders are manifested dependent on the individual’s specific response to a stressful situation.)
Activity/Rest
Fatigue
Insomnia
Ego Integrity
Reports occurrence of personal stressor/loss (e.g., job, financial, relationship) within past 3 months
May appear depressed and tearful and/or nervous and jittery
Feelings of hopelessness
Neurosensory
Mental Status: Depressed mood, tearful, anxious, nervous, jittery
Attention and memory span may be impaired (depends on presence of depression, level of anxiety, and/or substance use)
Communication and thought patterns may reveal negative ruminations of depressed mood or flight of ideas/loose associations of severely anxious condition
Pain/Discomfort
Various physical symptoms such as headache, backache, other aches and pains (maladaptive response to a stressful situation)
Safety
Anger expressed inappropriately
Involvement in high-risk behaviors (e.g., fighting, reckless driving)
Suicidal ideations may be present
Social Interactions
Difficulties with performance in work/social setting, when no difficulties had been experienced prior to the occurrence of the stressor
Socially withdrawn/refuses to interact with others (e.g., isolates self in own room)
Reports of vandalism, reckless driving, fighting, defaulting on legal responsibilities, violation of the rights of others or age-appropriate norms and rules
May display manipulative behavior (e.g., testing limits, playing individuals/family members against each other)
Teaching/Learning
Academic difficulties, failure to attend class/complete course work
Substance use/abuse possibly present
DIAGNOSTIC STUDIES
Diagnostic studies and psychological testing as indicated to rule out conditions that may mimic or coexist (e.g., endocrine imbalance, cardiac involvement, epilepsy, or a differential diagnosis with affective, anxiety, conduct, or antisocial personality disorders).
Drug Screen: Determine substance use.
NURSING PRIORITIES
1. Provide safe environment/protect client from self-harm.
2. Assist client to identify precipitating stressor.
3. Promote development of effective problem-solving techniques.
4. Provide information and support for necessary lifestyle changes.
5. Promote involvement of client/family in therapy process/planning for the future.
DISCHARGE GOALS
1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation reduced.
2. Anger expressed in an appropriate manner.
3. Maladaptive behaviors recognized and rechanneled into socially accepted actions.
4. Client involved in social situations/interacting with others.
5. Ability and willingness to manage life situations displayed.
6. Plan in place to meet needs after discharge.
DSM-IV
ADJUSTMENT DISORDERs (SPECIFY if ACUTE/CHRONIC)
309.24 With anxiety
309.0 With depressed mood
309.3 With disturbance of conduct
309.4 With mixed disturbance of emotions and conduct
309.28 With mixed anxiety and depressed mood
The essential feature of adjustment disorders is a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months of the onset of the stressor. (The reaction to the death of a loved one is not included here, as it is generally diagnosed as bereavement.) The stressor also does not meet the criteria for any specific Axis I disorder or represent an exacerbation of a preexisting Axis I or Axis II disorder.
The response is considered maladaptive because social or occupational functioning is impaired or because the behaviors are exaggerated beyond the usual expected response to such a stressor. Duration of the symptoms for more than 6 months indicates a chronic state. By definition, an adjustment disorder must resolve within 6 months of the termination of the stressor or its consequences. If the stressor/consequences persist (e.g., a chronic disabling medical condition, emotional difficulties following a divorce, financial reversals resulting from termination of employment, or a developmental event such as leaving one’s parental home, retirement), the adjustment disorder may also persist.
ETIOLOGICAL THEORIES
Psychodynamics
Factors implicated in the predisposition to this disorder include unmet dependency needs, fixation in an earlier level of development, and underdeveloped ego.
The client with predisposition to adjustment disorder is seen as having an inability to complete the grieving process in response to a painful life change. The presumed cause of this inability to adapt is believed to be psychic overload—a level of intrapsychic strain exceeding the individual’s ability to cope. Normal functioning is disrupted, and psychological or somatic symptoms occur.
Biological
The presence of chronic disorders is thought to limit an individual’s general adaptive capacity. The normal process of adaptation to stressful life experiences is impaired, causing increased vulnerability to adjustment disorders. A high family incidence suggests a possible hereditary influence.
The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.
Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes; acute myocardial infarction; pheochromocytomas; substance intoxication and withdrawal; hypoglycemia; caffeine intoxication; mitral valve prolapse; and complex partial seizures.
Family Dynamics
The individual’s ability to respond to stress is influenced by the role of the primary caregiver (her or his ability to adapt to the infant’s needs) and the child-rearing environment (allowing the child gradually to gain independence and control over own life). Difficulty allowing the child to become independent leads to the child having adjustment problems in later life.
Individuals with adjustment difficulties have experienced negative learning through
inadequate role-modeling in dysfunctional family systems. These dysfunctional patterns impede the development of self-esteem and adequate coping skills, which also contribute to maladaptive adjustment responses.
CLIENT ASSESSMENT DATA BASE
(Symptoms of affective, depressive, and anxiety disorders are manifested dependent on the individual’s specific response to a stressful situation.)
Activity/Rest
Fatigue
Insomnia
Ego Integrity
Reports occurrence of personal stressor/loss (e.g., job, financial, relationship) within past 3 months
May appear depressed and tearful and/or nervous and jittery
Feelings of hopelessness
Neurosensory
Mental Status: Depressed mood, tearful, anxious, nervous, jittery
Attention and memory span may be impaired (depends on presence of depression, level of anxiety, and/or substance use)
Communication and thought patterns may reveal negative ruminations of depressed mood or flight of ideas/loose associations of severely anxious condition
Pain/Discomfort
Various physical symptoms such as headache, backache, other aches and pains (maladaptive response to a stressful situation)
Safety
Anger expressed inappropriately
Involvement in high-risk behaviors (e.g., fighting, reckless driving)
Suicidal ideations may be present
Social Interactions
Difficulties with performance in work/social setting, when no difficulties had been experienced prior to the occurrence of the stressor
Socially withdrawn/refuses to interact with others (e.g., isolates self in own room)
Reports of vandalism, reckless driving, fighting, defaulting on legal responsibilities, violation of the rights of others or age-appropriate norms and rules
May display manipulative behavior (e.g., testing limits, playing individuals/family members against each other)
Teaching/Learning
Academic difficulties, failure to attend class/complete course work
Substance use/abuse possibly present
DIAGNOSTIC STUDIES
Diagnostic studies and psychological testing as indicated to rule out conditions that may mimic or coexist (e.g., endocrine imbalance, cardiac involvement, epilepsy, or a differential diagnosis with affective, anxiety, conduct, or antisocial personality disorders).
Drug Screen: Determine substance use.
NURSING PRIORITIES
1. Provide safe environment/protect client from self-harm.
2. Assist client to identify precipitating stressor.
3. Promote development of effective problem-solving techniques.
4. Provide information and support for necessary lifestyle changes.
5. Promote involvement of client/family in therapy process/planning for the future.
DISCHARGE GOALS
1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation reduced.
2. Anger expressed in an appropriate manner.
3. Maladaptive behaviors recognized and rechanneled into socially accepted actions.
4. Client involved in social situations/interacting with others.
5. Ability and willingness to manage life situations displayed.
6. Plan in place to meet needs after discharge.
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