Acute Stress Disorder and Adjustment Disorders

Acute Stress Disorder

Acute stress disorder is similar to post-traumatic stress disorder (PTSD) but describes a disorder that lasts between three days and one month after a traumatic event. After one month, a diagnosis of acute stress disorder would be considered PTSD. The diagnostic symptoms are similar to that of PTSD, although diagnosis requires at least nine of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the traumatic event(s) occurred.

Intrusion symptoms

• recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) (Note: in children, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.)
• recurrent distressing dreams in which the content and/or affect of the dream are related to the events(s) (Note: In children older than six, there may be frightening dreams without recognizable content.)
• dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring; such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings (Note: in children, trauma-specific reenactment may occur in play.)
• intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic events

Negative Mood

• persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings)

Dissociative Symptoms

• an altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing)
• inability to remember an important aspect of the traumatic events(s), typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs

Avoidance symptoms

• efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
• efforts to avoid external reminders (people, places, conversations, activities, objects, or situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

Arousal symptoms

• sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep)
• irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
• hypervigilance
• problems with concentration
• exaggerated startle response

Adjustment Disorder

Adjustment disorder (AD) represents an abnormal stress response that is different from normal adaptive reactions (Casey, 2014) that occurs within three months of the onset of a stressor. Adjustment disorder (AD) usually follows a stressful event such as losing a job, ending a relationship, financial conflict, changing environments, feeling overwhelming school or job stress, living in a dangerous situation, death of friends or family, illness, etc. According to DSM-5, adjustment disorder (AD) is characterized by:

• (A) emotional or behavioral symptoms in response to an identifiable stressor that
• (B) are of clinical significance and
• (C) do not meet the criteria for another mental disorder, and
• (D) do not represent normal bereavement.

Typically, AD remits within six months if the stressor is terminated; however, a persistent form of AD has been described if the stressor persists (First, 2013; Maercker and Lorenz, 2018). Furthermore, untreated AD poses the risk of persistent AD, and may pave the way for psychiatric disorders other than AD, particularly major depressive disorder and anxiety disorders (O’Donnell et al., 2016).^[1]

Some emotional signs of adjustment disorder are sadness, hopelessness, lack of enjoyment, crying spells, nervousness, anxiety, desperation, feeling overwhelmed, thoughts of suicide, performing poorly in school/work, etc. Common characteristics of AD include mild depressive symptoms, anxiety symptoms, and traumatic stress symptoms or a combination of the three. According to the DSM-5, there are six types of AD, which are characterized by the following predominant symptoms: depressed mood, anxiety, mixed depression and anxiety, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified. However, the criteria for these symptoms are not specified in greater detail.

Unlike major depression, adjustment disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation. The condition is different from an anxiety disorder, which lacks the presence of a stressor, or post-traumatic stress disorder and acute stress disorder, which usually are associated with a more intense stressor and involve different experiences, such as flashbacks. AD is a result of subjective and emotional distress triggered as a consequence of a meaningful change in life.^[2]

Treatment for Adjustment Disorders

There has been little systematic research regarding the best way to manage individuals with an adjustment disorder. Because natural recovery is the norm, it has been argued that there is no need to intervene unless levels of risk or distress are high. However, for some individuals treatment may be beneficial. AD sufferers with depressive or anxiety symptoms may benefit from treatments usually used for depressive or anxiety disorders. One study found that AD sufferers received similar interventions to those with other psychiatric diagnoses, including psychological therapy and medication.

Like many of the items in the DSM, adjustment disorder receives criticism from a minority of the professional community as well as those in semi-related professions outside the healthcare field. First, there has been criticism of its classification. The DSM has been criticized for its lack of specificity of symptoms, behavioral parameters, and close links with environmental factors. Relatively little research has been done on this condition.^[3]

An editorial in the British Journal of Psychiatry described adjustment disorder as being so “vague and all-encompassing . . . as to be useless,”^[4] but it has been retained in the DSM-5 because of the belief that it serves a useful clinical purpose for clinicians seeking a temporary, mild, non-stigmatizing label, particularly for patients who need a diagnosis for insurance coverage of therapy.

Prolonged Grief Disorder

In March 2022, prolonged grief disorder (PGD) was added as a mental disorder in the DSM-5-TR. It is characterized by a distinct set of symptoms following the death of a family member or close friend (ie. bereavement). People with PGD are preoccupied with grief and feelings of loss to the point of clinically significant distress and impairment, which can manifest in a variety of symptoms including depression, emotional pain, emotional numbness, loneliness, identity disturbance, and difficulty in managing interpersonal relationships. Difficulty accepting the loss is also common, which can present as rumination about the death, a strong desire for reunion with the departed, or disbelief that the death occurred. PGD is estimated to be experienced by about 10 percent of bereaved survivors, although rates vary substantially depending on populations sampled and definitions used.^[5]

Along with bereavement of the individual occurring at least one year ago (or six months in children and adolescents), there must be evidence of one of two “grief responses” occurring at least daily for the past month:

• Intense yearning/longing for the deceased person.
• Preoccupation with thoughts or memories of the deceased person (in children and adolescents, preoccupation may focus on the circumstances of the death).

Additionally, the individual must have at least three of the following symptoms occurring at least daily for the past month:

• Identity disruption (e.g., feeling as though part of oneself has died) since the death
• A marked sense of disbelief about the death
• Avoidance of reminders that the person is dead (in children and adolescents, may be characterized by efforts to avoid reminders)
• Intense emotional pain (e.g., anger, bitterness, sorrow) related to the death
• Difficulty reintegrating into one’s relationships and activities after the death (e.g., problems engaging with friends, pursuing interests, or planning for the future)
• Emotional numbness (absence or marked reduction of emotional experience) as a result of the death
• Feeling that life is meaningless as a result of the death
• Intense loneliness as a result of the death

The duration and severity of the distress and impairment in PGD must be clinically significant, and not better explainable by social, cultural, or religious norms, or another mental disorder. PGD can be distinguished from depressive disorders with distress appearing specifically about the bereaved as opposed to a generally low mood. According to Holly Prigerson, an editor on the trauma and stressor-related disorder section of the DSM-5-TR, “intense, persistent yearning for the deceased person is specifically a characteristic symptom of PG [prolonged grief], but is not a symptom of MDD (or any other DSM disorder).”^[6]