Adjustment disorder

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Adjustment disorder

Definition

An adjustment disorder is a type of mental disorder resulting from maladaptive, or unhealthy, responses to stressful or psychologically distressing life events. This low level of adaptation then leads to the development of emotional or behavioral symptoms.

Description

Often, a person experiences a stressful event as one that changes his or her world in some fundamental way. An adjustment disorder represents significant difficulty in adjusting to the new reality.

The stressful events that precipitate an adjustment disorder vary widely. They may include the loss of a job; the end of a romantic relationship; a life transition such as a career change or retirement; or a serious accident or sickness. Some are acute "one-time" stressors, such as relocating to a new area, while others are chronic, such as caring for a child with mental retardation .

Psychiatrists have disagreed about the validity of the diagnosis of adjustment disorder, largely because of its lack of specificity. What qualifies as a stressful event, and what is an abnormal response to it? While adjustment disorders are more difficult to quantify than other mental disorders, many researchers consider the category a useful one for two reasons: 1) an adjustment disorder may be an early sign of a major mental disorder and allow for early treatment and intervention ; 2) adjustment disorders are "situational" or "reactive"; they do not imply that the patient has an underlying brain disease.

Causes and symptoms

Causes

The Diagnostic and Statistical Manual of Mental Disorders , which is the basic reference work consulted by mental health professionals, included an important change in its most recent version, the DSM-IV-TR, with regard to the criteria for adjustment disorder. In the previous edition, the identifiable stressor was described as being "psychosocial," a category that excludes physical illnesses and natural disasters. In the DSM-IV-TR, the word "psychosocial" was deleted in order to make the point that any stressful event can lead to an adjustment disorder. It is important to recognize, however, that while adjustment disorders are triggered by external stressors, the symptoms result from the person's interpretation of and adaptation to the stressful event or circumstances. Beliefs, perceptions, fears, and expectations influence the development of an adjustment disorder.

People with chronic physical illnesses appear to have an increased risk of developing adjustment disorders, particularly one with depressed mood. This connection has been demonstrated among cancer patients. The relationship between chronic pain (as is commonly experienced by cancer patients) and depressive symptoms is still being studied.

Symptoms

DSM-IV-TR states that the symptoms of an adjustment disorder must appear within three months of a stressor; and that they must meet at least one of the following criteria: 1) the distress is greater than what would be expected in response to that particular stressor; 2) the patient experiences significant impairment in social relationships or in occupational or academic settings. Moreover, the symptoms cannot represent bereavement, as normally experienced after the death of a loved one.

DSM-IV-TR specifies six subtypes of adjustment disorder, each with its own predominant symptoms:

With depressed mood: The chief manifestations are feelings of sadness and depression, with a sense of accompanying hopelessness. The patient may be tearful and have uncontrollable bouts of crying.
With anxiety: The patient is troubled by feelings of apprehension, nervousness, and worry. He or she may also feel jittery and unable to control his or her thoughts of doom. Children with this subtype may express fears of separation from parents or other significant people, and refuse to go to sleep alone or attend school.
With mixed anxiety and depressed mood: The patient has a combination of symptoms from the previous two subtypes.
With disturbance of conduct: This subtype involves such noticeable behavioral changes as shoplifting, truancy, reckless driving, aggressive outbursts, or sexual promiscuity. The patient disregards the rights of others or previously followed rules of conduct with little concern, guilt or remorse.
With mixed disturbance of emotions and conduct: The patient exhibits sudden changes in behavior combined with feelings of depression or anxiety. He or she may feel or express guilt about the behavior, but then repeat it shortly thereafter.
Unspecified: This subtype covers patients who are adjusting poorly to stress but who do not fit into the other categories. These patients may complain of physical illness and pull away from social contact.

Adjustment disorders may lead to suicide or suicidal thinking. They may also complicate the treatment of other diseases when, for instance, a sufferer loses interest in taking medication as prescribed or adhering to diets or exercise regimens.

An adjustment disorder can occur at any stage of life.

Demographics

Adjustment disorder appears to be fairly common in the American population; recent figures estimate that 5%–20% of adults seeking outpatient psychological treatment suffer from one of the subtypes of this disorder. As many as 70% of children in psychiatric inpatient settings may be diagnosed with an adjustment disorder. In a 1991 questionnaire that was sent to child psychiatrists, 55% admitted to giving children the diagnosis of an adjustment disorder to avoid the stigma associated with other disorders.

Women are diagnosed with adjustment disorder twice as often as men, while in clinical samples of children and adolescents, boys and girls were equally likely to be diagnosed with an adjustment disorder. Nolen-Hoeksema, a researcher who has conducted numerous studies on gender differences in depression, has argued that women over the age of 15 exhibit a more depressive temperament than men. She theorizes that women are more likely to respond to depression in ways that make the disorder worse and prolong it. Her findings appear to have some applicability to adjustment disorder with depressed mood.

There are no current studies of differences in the frequency of adjustment disorder in different racial or ethnic groups. There is, however, some potential for bias in diagnosis, particularly when the diagnostic criteria concern abnormal responses to stressors. DSM-IV-TR specifies that clinicians must take a patient's cultural background into account when evaluating his or her responses to stressors.

Diagnosis

Adjustment disorders are almost always diagnosed as the result of an interview with a psychiatrist . The psychiatrist will take a history, including identification of the stressor that has triggered the adjustment disorder, and evaluate the patient's responses to the stressor. The patient's primary physician may give him or her a thorough physical examination to rule out a previously undiagnosed medical illness.

The American Psychiatric Association considers adjustment disorder to be a residual category, meaning that the diagnosis is given only when an individual does not meet the criteria for a major mental disorder. For example, if a person fits the more stringent criteria for major depressive disorder , the diagnosis of adjustment disorder is not given. If the patient is diagnosed with an adjustment disorder but continues to have symptoms for more than six months after the stressor and its consequences have ceased, the diagnosis is changed to another mental disorder. The one exception to this time limit is situations in which the stressor itself is chronic or has enduring consequences. In that case, the adjustment disorder would be considered chronic and the diagnosis could stand beyond six months.

The diagnosis of adjustment disorder represents a particular challenge to clinicians because it has no checklist of specific and observable symptoms. The diagnosis is instead based on a broad range of emotional and behavioral symptoms that can vary widely in appearance and severity. The lack of a diagnostic checklist does in fact distinguish adjustment disorders from either post-traumatic stress disorder or acute stress disorder . All three require the presence of a stressor, but the latter two define the extreme stressor and specific patterns of symptoms. With adjustment disorder, the stressor may be any event that is significant to the patient, and the disorder may take very different forms in different patients.

Adjustment disorders must also be distinguished from personality disorders , which are caused by enduring personality traits that are inflexible and cause impairment. A personality disorder that has not yet surfaced may be made worse by a stressor and may mimic an adjustment disorder. A clinician must separate relatively stable traits in a patient's personality from passing disturbances. In some cases, however, the patient may be given both diagnoses. Again, it is important for psychiatrists to be sensitive to the role of cultural factors in the presentation of the patient's symptoms.

If the stressor is a physical illness, diagnosis is further complicated. It is important to recognize the difference between an adjustment disorder and the direct physiological effects of a general medical condition (such as the usual temporary functional impairment associated with chemotherapy). This distinction can be clarified through communication with the patient's physician or by education about the medical condition and its treatment. For some individuals, however, both may occur and reinforce each other.

Treatments

There have been few research studies of significant scope to compare the efficacy of different treatments for adjustment disorder. The relative lack of outcome studies is partially due to the lack of specificity in the diagnosis itself. Because there is such variability in the types of stressors involved in adjustment disorders, it has proven difficult to design effective studies. As a result, there is no consensus regarding the most effective treatments for adjustment disorder.

Psychological and social interventions

There are, however, guidelines for effective treatment of people with adjustment disorders. Effective treatments include stress-reduction approaches; therapies that teach coping strategies for stressors that cannot be reduced or removed; and those that help patients build support networks of friends, family, and people in similar circumstances. Psychodynamic psychotherapy may be helpful in clarifying and interpreting the meaning of the stressor for a particular patient. For example, if the person is suffering from cancer, he or she may become more dependent on others, which may be threatening for people who place a high value on self-sufficiency. By exploring those feelings, the patient can then begin to recognize all that is not lost and regain a sense of self-worth.

Therapies that encourage the patient to express the fear, anxiety, rage, helplessness and hopelessness of dealing with the stressful situation may be helpful. These approaches include journaling, certain types of art therapy, and movement or dance therapy. Support groups and group therapy allow patients to gain perspective on the adversity and establish relationships with others who share their problem. Psychoeducation and medical crisis counseling can assist individuals and families facing stress caused by a medical illness.

Such types of brief therapy as family therapy , cognitive-behavioral therapy , solution-focused therapy, and interpersonal therapy have all met with some success in treating adjustment disorder.

Medications

Clinicians do not agree on the role of medications in treating adjustment disorder. Some argue that medication is not necessary for adjustment disorders because of their brief duration. In addition, they maintain that medications may be counterproductive by undercutting the patient's sense of responsibility and his or her motivation to find effective solutions. At the other end of the spectrum, other clinicians maintain that medication by itself is the best form of treatment, particularly for patients with medical conditions, those who are terminally ill, and those resistant to psychotherapy . Others advocate a middle ground of treatment that combines medication and psychotherapy.

Alternative therapies

Spiritual and religious counseling can be helpful, particularly for people coping with existential issues related to physical illness.

Some herbal remedies appear to be helpful to some patients with adjustment disorders. For adjustment disorder with anxiety, a randomized controlled trial found that patients receiving Euphytose (an herbal preparation containing a combination of plant extracts including Crataegus, Ballota, Passiflora, Valeriana, Cola, and Paullinia) showed significant improvement over patients taking a placebo.

Prognosis

Most adults who are diagnosed with adjustment disorder have a favorable prognosis. For most people, an adjustment disorder is temporary and will either resolve by itself or respond to treatment. For some, however, the stressor will remain chronic and the symptoms may worsen. Still other patients may develop a major depressive disorder even in the absence of an additional stressor.

Studies have been conducted to follow up on patients five years after their initial diagnosis. At that time, 71% of adults were completely well with no residual symptoms, while 21% had developed a major depressive disorder or alcoholism. For children aged 8–13, adjustment disorder did not predict future psychiatric disturbances. For adolescents, the prognosis is grimmer. After five years, 43% had developed a major psychiatric disorder, often of far greater severity. These disorders included schizophrenia , schizoaffective disorder , major depression, substance use disorders, or personality disorders. In contrast with adults, the adolescents' behavioral symptoms and the type of adjustment disorder predicted future mental disorders.

Researchers have noted that once an adjustment disorder is diagnosed, psychotherapy, medication or both can prevent the development of a more serious mental disorder. Effective treatment is critical, as adjustment disorder is associated with an increased risk of suicide attempts, completed suicide, substance abuse, and various unexplained physical complaints. Patients with chronic stressors may require ongoing treatment for continued symptom management. While patients may not become symptom-free, treatment can halt the progression toward a more serious mental disorder by enhancing the patient's ability to cope.

Prevention

In many cases, there is little possibility of preventing the stressors that trigger adjustment disorders. One preventive strategy that is helpful to many patients, however, is learning to be proactive in managing ordinary life stress, and maximizing their problem-solving abilities when they are not in crisis.

See also Anxiety-reduction techniques; Bodywork therapies; Cognitive retraining techniques; Generalized anxiety disorder; Cognitive problem-solving skills training

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Araoz, Daniel L., and Marie Carrese. Solution-Oriented Brief Therapy for Adjustment Disorders: A Guide for Providers Under Managed Care. New York: Brunner/Mazel, Inc, 1996.

Gabbard, Glen O., M.D. "Adjustment Disorders." In Treatment of Psychiatric Disorders, written by James. J. Strain, M.D., Anwarul Karim, M.D. and Angela Cartagena Rochas, M.A. 3rd ed, Volume 2. Washington, D.C.: American Psychiatric Press, 2001.

Nicholi, Armand, ed. The New Harvard Guide to Psychiatry. Cambridge, MA: Harvard University Press, 1988.

PERIODICALS

Angelino, Andrew F. and Glenn J. Treisman. "Major Depression and Demoralization in Cancer Patients: Diagnostic and Treatment Considerations." Supportive Cancer Care 9 (November 2000): 344-349.

Jones, Rick, and others. "Outcome for Adjustment Disorder with Depressed Mood: Comparison with Other Mood Disorders." Journal of Affective Disorders 1999, 55.

Strain, James J., and others. "Adjustment Disorder: A Multisite Study of its Utilization and Interventions in the Consultation-Liaison Psychiatry Setting." General Hospital Psychiatry 1998, 20.