Adjustment disorder (including acute
stress reaction)
Adjustment disorder - F43.2 (including acute stress reaction) (Clinical term: Adjustment
disorders Eu43.2)
Presenting complaints
• Patients feel overwhelmed or unable to cope.
• There may be stress-related physical symptoms such as insomnia, headache, abdominal
pain, chest pain and palpitations.
• Patients may report symptoms of acute anxiety or depression.
• Use of alcohol or other substances may increase.
Diagnostic features
• Acute reaction to a recent stressful or traumatic event.
• Extreme distress resulting from a recent event, or preoccupation with the event.
• Symptoms may be primarily somatic.
• Other symptoms may include:
- low or sad mood
- anxiety
- worry
- feeling unable to cope.
Acute reaction usually lasts from a few days to several weeks.
Differential diagnosis and co-existing conditions
Acute symptoms may persist or evolve over time. Patients should be followed up after 1-2 weeks.
If significant symptoms persist, consider an alternative diagnosis.
• If significant symptoms of depression persist, see Depression - F32#
• If significant symptoms of anxiety persist, see Generalized anxiety - F41.1 or Panic
disorder - F41.0
• If significant symptoms of both depression and anxiety persist, see Chronic mixed anxiety
and depression - F41.2
• If stress-related somatic symptoms persist, see Unexplained somatic complaints - F45
• If symptoms are due to a loss, see Bereavement and loss - Z63
• If anxiety is long-lasting and focused on memories of a previous traumatic event, see
Post-traumatic stress disorder - F43.1
• If dissociative symptoms (sudden onset of unusual or dramatic somatic symptoms) are
present, see Dissociative (conversion) disorder - F44
Essential information for patient and family
• Stressful events often have mental and physical effects. The acute state is a natural
reaction to events. (see Psychological responses to traumatic stress)
• Stress-related symptoms usually last only a few days or weeks.
General management and advice to patient and family
(ref 12)
• Elicit and explain patient’s concerns (this is important for preventing somatic symptoms
from continuing).
• Review and reinforce positive steps the patient has taken to deal with the stress.
• Identify steps the patient can take to modify the situation that produced the stress. If the
situation cannot be changed, discuss coping strategies. (See Solving problems and
achieving goals)
• Identify relatives, friends and community resources able to offer support.
• Encourage a return to usual activities within a few weeks.
• Short-term rest and relief from stress may help the patient. Consider short-term sickness
certification.
• Encourage the patient to acknowledge the personal significance of the stressful event.
• Offering a further consultation with a member of the primary-care team, to see how the
situation develops, can be valuable in helping the patient through the episode.
References
12 Consensus (BV). As people reacting to stresses such as unemployment or divorce are at high
risk of developing a mental disorder, studies on prevention in high-risk groups may be relevant.
These support the offering of social support and problem-solving. [NHS Centre for Reviews and
Dissemination. Mental health promotion in high-risk groups. Effect Health Care Bull 1997, 3(3): 1-
10.]
Medication
Most acute stress reactions will resolve without the use of medication. Skilled GP advice and
reassurance is as effective as benzodiazepines (ref 13). However, if severe anxiety symptoms
occur, consider using anti-anxiety drugs for up to 3 days. If the patient has severe insomnia, use
hypnotic drugs for up to 3 days. Doses should be as low as possible. (BNF sections 4.1.1 and
4.1.2.)
References
13 Catalan J, Gath D, Edmonds G, Ennis J. The effects of not prescribing anxiolytics in general
practice. Br J Psychiatry 1984, 144: 593-602. (BII) GP advice and reassurance is as effective as
administration of benzodiazepines. The mean time spent by the GP for giving advice and
reassurance was 12 minutes, compared with 10.5 minutes for giving a prescription.
Referral
See General referral criteria. Usually self-limiting.
Routine referral to secondary mental health services is advised if:
• symptoms persist and general referral criteria are met.
• unsure of the diagnosis.
Consider recommending a practice counsellor or voluntary/non-statutory counselling (ref 14)
services in all other cases where symptoms persist.
References
14a Roth AD, Fonagy P. What Works For Whom? A Critical Review of Psychotherapy Research.
New York: Guilford Press, 1996. (CII) The efficacy of counselling in primary-care settings is
difficult to assess because of the methodological problems of available research. It seems more
appropriate for milder presentations of disorders, however, than for more severe presentations,
and evidence is better for counselling focused on a particular client group (eg relationship or
bereavement counselling).
14b Bower P, Rowland N, Mellor Clark J et al. Effectiveness and cost-effectiveness of counselling
in primary care (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update
Software. (B1) Seven studies were analysed. Results showed that counselling is significantly
more effective than 'usual care' in the short - but not the long-term. Satisfaction with counselling
was high. Patients had a mix of 'emotional disorders'.
Resources for patients and families
Solving problems and achieving goals Psychological responses
to traumatic stress: what to expect
BACP (British Association for Counselling and Psychotherapy) 0870 443 5252.
Website: http://www.counselling.co.uk
Provides advice on sources of individual counselling and family therapy in the UK.
The Samaritans National phone number 08457 909 090 (helpline 24-hours a day)
Email: jo@samaritans.org; website: http://www.samaritans.org.uk
Offers confidential emotional support to any person who is despairing or suicidal.
Victim Support 0845 30 30 900 (Support line 9am–9pm, Monday–Friday; 9am–7pm,
Saturday/Sunday; 9am–5pm, bank holidays)
Email: contact@victimsupport.org.uk; website: http://www.victimsupport.com
Provides emotional support and practical information for anyone who has suffered the effects of
crime, regardless of whether the crime has been reported.
Citizens Advice Bureau (see local telephone directory)
Main website: http://www.citizensadvice.org.uk (gives directory of all offices and advice by email);
Advice Guide website: http://www.adviceguide.org.uk
Provides a wide range of free and confidential advice and help. Subjects include social security
benefits, housing, family and personal matters, money advice and consumer complaints.
Relate 01788 573 241/0845 456 1310
Email: enquiries@relate.org.uk; website: http://www.relate.org.uk
Counselling for adults with relationship difficulties, whether married or not.
International Stress Management Association (ISMA) UK 0700 780 430 (helpline)
Email: stress@isma.org.uk; website: http://www.isma.org.uk
Promotes knowledge and best practice in the prevention and reduction of acute stress.
Coping with stress at work. Talking Life, 1A Grosvenor Road, Hoylake, Wirral CH47 3BS, UK.
Tel: 0151 632 0662; website: http://www.talkinglife.co.uk
This is a tape teaching you to recognize stress symptoms. It includes a relaxation exercise.
