Adjustment Disorders ?>

Adjustment Disorders

Adjustment Disorders


Background

Adjustment disorder (AD) is a stress-related, short-term, nonpsychotic disturbance. Persons with AD are often viewed as disproportionately overwhelmed or overly intense in their responses to given stimuli. These responses manifest as emotional or behavioral reactions to an identifiable stressful event or change in the person’s life; for instance, in the pediatric population, these events could be parental separation or divorce, a new birth in the family, or loss of an attachment figure or object (eg, pets). The disorder is time-limited, usually beginning within 3 months of the stressful event, and symptoms lessen within 6 months upon removal of the stressor or when new adaptation occurs.

AD is considered one of the subthreshold disorders, which are less well defined and share characteristics of other diagnostic groups. Subthreshold disorders fall between defined disorders and problem level (V Code) diagnoses.1 Subthreshold disorders allow for the “classification of early or temporary states when the clinical picture is vague and indiscreet and yet the morbid state is more than expected in a normal reaction.”1 Because of insufficient behavioral criteria for patients with AD, reliability and validity of this disorder remain problematic.

Diagnosis is constructed to allow for the classification of psychiatric conditions that are clinically significant but do not meet major criteria for major syndromes. In 1998, Strain et al asserted that the diagnostic construct for patients with AD is “clinically significant and deemed to be in excess of a normal reaction to the stressor in question, and not solely the result of a psychosocial problem (V Code) requiring medical attention.”1

A problem with this diagnostic construct is apparent in the Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) description of AD as a “maladaptive reaction to an identifiable psychosocial stressor, or stressors, that occurs within 3 months after onset of that stressor.”2 The definition of maladaptive reaction is potentially broad and systemically relative depending on the racial, ethnic, and cultural identifications of the patient and psychiatrist. No guidelines are provided to help identify a psychosocial stressor. Additionally, the delineation between AD, anxiety not otherwise specified (NOS), and depression NOS are unclear. Studies have examined the constructs of stress-related and non–stress-related diagnoses, but interpretations of the results have not been conclusive.

Despite the difficulty in defining this diagnosis, the discomfort, distress, turmoil, and anguish to the patient are significant and the consequences, such as the suicidal potential, are extremely important.

Pathophysiology

The pathology of adjustment disorder is not clear. ADs are caused by a disruption of the process of adaptation to stressful occurrences. Psychiatric symptoms result from the disruption of normal functioning caused by stress. Stress is thought to be the common antecedent to AD. Cohen suggests that acute and chronic stress differ in psychologic and physiologic terms and that the meaning of stress is influenced by ecologic modifiers (eg, support systems, resilience).

Studies by Tripodianakis et al examined the neurochemical variables of patients with AD who were suicidal and found that platelet monoamine oxidase (MAO) activity was significantly lower in both male and female patients compared to controls of the same sex. Plasma levels of cortisol were significantly higher in the patients compared to the controls. These results suggest that low platelet MAO activity may be a biologic characteristic of people who attempt suicide.3

Rao et al conducted another study that observed the relationship of blood serotonin concentrations to underlying psychiatric disorders. Patients with AD had a significantly higher maximal binding capacity of the platelet serotonin-2A receptor. These findings were consistent with other psychiatric patients who were suicidal and suggest that a reduction in the availability of serotonin and an up-regulation of the serotonin-2A receptors in psychiatric patients are associated with a loss of control over suicidal impulses.4
Frequency

Adjustment disorder is thought to be common, although few studies support this assertion. Some studies (eg, Strain, 19981) suggest rates as high as 22.6% in clinical patient populations. Depressed mood was the most common subtype of AD assigned (11.6%), followed by AD with anxious mood, mixed anxiety and depressed mood, and disturbance of conduct.

Comorbidity with other psychiatric diagnoses, such as the personality disorders, anxiety disorders, affective disorders, and psychoactive substance abuse disorder, is reported in up to 70% of patients with AD in adult medical settings of general hospitals.5

Mortality and Morbidity

No clear correlation exists between adjustment disorder (AD) and mortality; however, research findings suggest that patients with AD are at an increased risk for morbidity and mortality. Polyakova et al compared the characteristics of the suicide attempts of 69 patients experiencing major depression with those of 86 patients with AD. While no significant difference was found in the methods of suicide, several social and demographic differences were found between the 2 groups. The patients with AD had less education and lower social status, and they were more likely to be unmarried when compared with the group experiencing major depression. More than half the patients who attempted suicide in the group with AD reported unstable parental families, early orphanhood, and emotional deprivation during childhood. Less than 35% of the group with major depression reported such experiences.6

This study also found that the interval from the first symptoms to the suicide attempt is shorter in the group with AD than in the group with major depression. Furthermore, suicide attempts of people with AD frequently are not planned.

Runeson, Beskow, and Waern studied 58 consecutive suicides among individuals aged 15-29 years through psychologic autopsy and study of the suicidal process. They found that the median interval from the first suicidal communication to the suicide was less than 1 month for persons with AD.7

In a study by Pelkonen et al, of the 89 patients who received a diagnosis of AD, those who showed suicide attempts, suicidal threats, or ideation compared to those with the same diagnosis but no suicidal tendencies were characterized by previous psychiatric treatment, poor psychosocial functioning at treatment entry, suicide as a stressor, dysphoric mood, and psychomotor restlessness.8

As such, psychiatric assessment of patients with AD should include careful monitoring of both symptomatology and potential for suicide and harm to significant others.

Portzky et al in their study of adjustment disorder and the course of the suicidal process in adolescents also confirmed that the suicidal process in AD was significantly shorter and more rapidly evolving without any prior indications of emotional or behavioral problems.9 Underlying once more, the importance of assessing the suicidal risk for patients diagnosed with adjustment disorder.

Patients with AD engage in deliberate self-harm at a rate that surpasses most other disorders. They may also be at an increased risk for substance abuse disorders. In a study by Vlachos et al, self-poisoning comprised most of the deliberate self-harm behaviors. However, a study by Mitrev found that of cases of deliberate self-poisoning among persons with AD, suicidal thoughts persisted in only 11% of patients. Suicide risk was higher in patients with chronic AD and in individuals with previous suicide attempts. Patients aged 15-19 years demonstrated the highest suicide risk. Mitrev also found that the suicide risk for women increased with age.10
Demographics

Age

Although longitudinal data are limited, studies suggest that adults with adjustment disorder (AD) have a good long-term prognosis, while adolescents eventually may develop major psychiatric illnesses. Most studies report no significant differences in prevalence of AD among different age groups.

Race and sex

No findings suggest any racial or sexual predilection for AD. Jones et al found that AD is more equitably distributed between the sexes than major depression, dysthymia, or depression NOS. A study by Jones et al found that male patients were more likely than female patients to be diagnosed with an AD than with major depression or dysthymia.11

Social

In a multisite referred study of 686 patients with confirmed AD diagnoses, significant factors for having AD as a comorbid diagnosis with other axis I or II diagnoses included being married, having full-time employment, and not living alone. The most frequent confirmed diagnoses associated with AD were personality disorders, organic mental disorders, and psychoactive substance abuse disorders. AD was least frequently assigned as a diagnosis with schizophrenia and mood disorders. Additionally, Kienlen et al found that nonpsychotic “stalkers” tended to meet diagnostic criteria for either major depression or AD in addition to axis II personality disorders.12

Economic

Evidence indicates that patients with average to better-than-average incomes are more often diagnosed with AD than patients who lack socioeconomic stability.

Clinical

History

Adjustment disorder (AD) and other subthreshold syndromes can include substantial psychopathology, such as suicidal ideation and other behaviors that should be documented and treated.

The following 6 types of AD are listed in the DSM-IV-TR2 :
AD with depressed mood: Symptoms are that of a minor depression.
AD with anxious mood: Symptoms of anxiety dominate the clinical picture.
AD with mixed anxiety and depressed mood: Symptoms are a combination of depression and anxiety.
AD with disturbance of conduct: Symptoms are demonstrated in behaviors that break societal norms or violate the rights of others.
AD with mixed disturbance of emotions and conduct: Symptoms include combined affective and behavioral characteristics of AD with mixed emotional features and AD with disturbance of conduct.
AD NOS: This residual diagnosis is used when a maladaptive reaction that is not classified under other ADs occurs in response to stress.

Physical

No physical findings correlate with AD.

Although the lack of specificity of the AD category allows for the demarcation of early or temporary states when the clinical presentation is vague and the morbid state is more severe than expected in a normal reaction, most aspects of the diagnostic construct for AD are difficult to assess and measure, including the stressor, the maladaptive reaction, the accompanying mood and feature, and the time and relationship between the stressor and the psychological response to it. No diagnostic decision tree exists for AD, which renders the diagnosis lacking in validity and reliability.
Diagnosis

Diagnostic Criteria

The DSM-IV-TR diagnostic criteria for adjustment disorder are as follows2:
The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurs within 3 months of the onset of the stressor(s).
These symptoms or behaviors are clinically significant, as evidenced by either of the following:
Marked distress in excess of what is expected from exposure to the stressor
Significant impairment in social or occupational (academic) functioning
The stress-related disturbance does not meet criteria for another specific axis I disorder and is not merely an exacerbation of a preexisting axis I or axis II disorder.
The symptoms do not represent bereavement.
Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.

Specify whether the condition is acute or chronic, as follows:
Acute: If the disturbance lasts less than 6 months, it is considered acute.
Chronic: If the disturbance lasts 6 months or longer, it is considered chronic.

AD is coded according to subtype, which corresponds with the presenting symptoms. The subtypes of AD include depressed mood, anxiety, mixed anxiety and depressed mood, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified. Before the release of the DSM-IV-TR, AD was a time-limited diagnosis that could not exceed 6 months.

Differential Diagnosis

ADs are located on a continuum between normal stress reactions and specific psychiatric disorders. Symptoms are not likely a normal reaction if the symptoms are moderately severe or if daily social or occupational functioning is impaired. If a specific stressor is involved and/or the symptoms are not specific but are severe, alternate diagnoses (eg, posttraumatic stress disorder, conduct disorder, depressive disorders, anxiety disorders, depression or anxiety due to a general medical condition) are unlikely.

Mental Status
As in all psychiatric diagnoses, a complete mental status must be conducted. This includes paying special attention to the potential for suicide and homicide and the presence of hallucinations and delusions, which indicate a psychotic process, and disorientation and memory loss suggesting an organic etiology.

Sample mental status

Following is a sample Mental Status Examination of a young adult with adjustment disorder, depressed type.

A 19-year-old college freshman home for spring break was brought into the emergency department for evaluation by his mother. His mother states that his demeanor since coming home has been subdued, a marked departure from his usual personality. Initially, she had assumed he was going through the usual adjustments to college life, meeting course expectations, and establishing new relationships. However, that evening at dinner, he was observed to be absent-minded and withdrawn from the usual family after-dinner activities, leaving abruptly with his dinner untouched. His mother, alarmed at this behavior and fearing he might have become involved in the college drug culture, confronted him. He stormed out of the house, tearful and somewhat agitated. After several hours he returned and apologized to his mother and retired to his room. The next day his dad asked to speak with him and learned of his recent break-up with his high-school sweetheart and that college life has been extremely challenging for a rural Kentucky lad studying in California. He denied any use of substances and agreed to see some one to “talk things through.”

Further assessment by an attending psychiatrist revealed that the patient had become depressed for the first week after the break-up, with poor appetite and loss of interest in his usual activities, mostly the ones they both enjoyed. His concentration had been poor lately but was improving; he also had slept poorly the first couple of days but had started sleeping better. He denied any thoughts of suicide or of harming his girlfriend but did feel hopeless the first couple of days initially. He was aware his behavior had been strange, but he felt he had to deal with the break-up as a man without involving the family. Though he had lost some weight, he attributed it mostly to the stress of his college work and being in a new environment getting used to “eating junk food for the first time in my life.” His affect was reactive; he denied any suicidal thoughts or thoughts of self-harm. He also denied use of alcohol or substances, though he had been exposed to and offered many times by his college pals. He had insight into his problems and was willing to work with the physician to address his issues.

A diagnosis of adjustment disorder with depressed mood was made and explained to him and his family. At this stage, individual psychotherapy was the treatment of choice to explore all identified stressors, including the possibility of transferring to a college closer home.

Treatment

Strain et al report that only one randomized controlled trial for adjustment disorder has been conducted to assess treatment effectiveness.6 In this study, patients received either a plant extract preparation or placebo. Individuals who took the experimental plant extract improved significantly when compared with those who took the placebo. While ADs have been included in other randomized controlled trials among an array of mood and anxiety disorders, no studies have examined cohorts of ADs only.

Newcorn and Strain report that the age of the cohorts affects treatment outcome for ADs. Clinical symptoms in children and adolescents differ from those in adults and elderly persons.46 Andreasen and Hoenk reported that in children and adolescents, more serious mental illnesses were present at 5 years of follow-up.3 This is in contrast to adults, who remain generally free of mental disorder. Strain reports that as many as 70% of adult inpatients in a general hospital experience comorbidity with other psychiatric diagnoses, commonly personality, anxiety, or affective disorders.

Clinical treatments are important for the alleviation of symptoms of ADs. Because no randomized clinical trials have been conducted to help direct the choice of treatment modalities, Strain states that treatment choices “remain a clinical decision influenced by consensus.” That said, no official consensus has been reached on the optimal treatment for ADs.

Because AD originates from a psychological reaction to a stressor, the stressor must be identified and communicated by the patient. The nonadaptive response to the stressor may be diminished if the stress can be “eliminated, reduced or accommodated.”33

Therefore, treatment of ADs entails psychotherapeutic counseling aimed at reducing the stressor, improving coping ability with stressors that cannot be reduced or removed, and formatting an emotional state and support systems to enhance adaptation and coping.

Strain suggests that the goals of psychotherapy should include the following:
Analyze the stressors that are affecting the patient, and determine whether they can be eliminated or minimized.
Clarify and interpret the meaning of the stressor for the patient.
Reframe the meaning of the stressor.
Illuminate the concerns and conflicts the patient experiences.
Identify a means to reduce the stressor.
Maximize the patient’s coping skills.
Assist patients to gain perspective on the stressor, establish relationships, attend support groups, and manage themselves and the stressor.

Psychotherapy, crisis intervention, family and group therapies, cognitive behavioral therapy, and interpersonal psychotherapy are effective for eliciting the expressions of affects, anxiety, helplessness, and hopelessness in relation to the identified stressor(s). Sifneos stated that brief psychotherapy can be most beneficial to persons with AD.15

Stewart et al recommend trials of antidepressants in patients with minor or major depressive disorders who have not responded to psychotherapy or other supportive interventions for 3 months.31 Schatzberg suggests that clinicians consider both psychotherapy and pharmacotherapy for patients with AD with anxious mood.26 Strain reminds clinicians that the predominant mood that accompanies AD is a major consideration for both pharmacological and supportive treatments.

Treatments that are effective with other stress-related disorders may be constructive interventions for AD. According to Strain and colleagues, treatment relies on the specificity of the diagnosis, the construct of stressor-related disorders, and whether the stressors are involved as “etiological precipitants, concomitants, or essentially unrelated factors.”
Vulnerabilities for Adults and Children

Factors that contribute to adjustment disorder include the patient’s preexisting personality, psychologic makeup, and overall constitution. Form and presentation of the stressor also contribute to the individual’s reaction. What may be perceived as a minor irritant by one person could be the stressor that challenges both the resources and coping skills of another person. In a retrospective study of 72 adolescents with AD, al-Ansari and Matar found that disappointment in relationships with a family member or friend of the opposite sex was the primary stressor.43

A 1998 multisite study of AD by Strain et al in the medical consultation-liaison setting found that AD was diagnosed in 25% of patients seen by consultation-liaison services. The authors found that the attributes of patients with an AD diagnosis were consistent with the conceptual framework of AD as a maladaptation to a psychosocial stressor. Patients with an AD diagnosis were less likely than other patients seen by the consultation-liaison service to have had a psychiatric diagnosis in the 12 months prior to the consultation, were higher functioning, and were more often found to have a neoplasm. This study found that data collected indicated that more studies are needed that focus on the association between AD and the personality, organic, and substance abuse disorders.32

Diagnosis of adjustment disorder in children and adolescents

The diagnosis of AD in children and adolescents is shaped by a combination of factors similar to those found in adults. In 1996, Tomb identified 4 areas that may contribute to the development of AD. These included the nature of the stressor, the vulnerabilities of the child, intrinsic factors, and extrinsic factors.

Intrinsic factors included age; sex; intellectual, emotional, and ego development; coping skills; temperament; and past experiences. Extrinsic factors included the child’s parents and support systems, expectations, understanding, skills, maturity, and available support of the child’s larger environment.

The most important factor in the development of AD in a child is the vulnerability of the child. Vulnerability depends on the characteristics of both the child and the child’s environment. The development of a reliable and valid survey instrument is still needed. The ADs constitute a diagnostic category that lies between health and pathology. Prompt treatment of persons with AD is critical to prevent worsening of symptoms and social, relational, academic, and occupational impairment. While the AD diagnosis has not been studied extensively in controlled treatment trials and its diagnostic construct lacks rigor, the potential sequelae of this diagnosis remain serious and treatment, although without specificity, is very important.

Medicolegal Considerations

The legal considerations of clinicians who treat patients with adjustment disorders are largely dependent on the individual presentation of symptoms. The impulsivity that can accompany an AD should be assessed in order to address potential harm to self or others.

Beck reviewed published tort cases that arose after a patient impulsively hurt or killed someone. All cases involved either alleged breach of duty to protect (Tarasoff) or negligent release from hospitals. Beck found that as a matter of law, courts generally hold that impulsive acts of violence are not foreseeable.5 Furthermore, the ethical duty to perform careful clinical work was found to be essentially identical to the legal duty to use due care in cases that involve violence.

Tolman recommends that clinicians should develop and use conceptual models for violence risk assessment and management in order to improve clinical practice, reduce legal liability, and increase public safety.20 Walcott advocates that clinicians make thorough well-documented assessments of risk of violence as the optimal means by which to address concerns about potential legal liability.39 Additionally, all clinicians should keep informed about local laws and relevant court cases that pertain to violent behaviors of patients.
Patient and Family Education

Patients and their families should comprehend that adjustment disorder occurs when a psychological stressor challenges an individual’s capacity for coping. The stressor can be anything that is important to the patient. Everyone reacts differently to a situation depending on the importance and intensity of the event, the personality and temperament of the person, and the person’s age and well-being. Thus, only one event may cause AD, or, a string of events may wear down individual resources. Encourage the patient to acknowledge the personal significance of the stressful event.

Patients and families should be reassured that stressful events often have emotional and physical effects. The acute state experienced by a newly diagnosed patient is a natural reaction to events. Stress-related symptoms usually last only days or weeks. AD is time-limited, and patients can generally expect a return to prior levels of functioning. Encourage the patient to identify relatives, friends, and community resources that can provide support during the acute period.

For patient education visit the following Web sites:
WebMD, Mental Health: Adjustment Disorder
MayoClinic, Support groups
MayoClinic, Adjustment Disorders

For other patient education resources, visit eMedicine’s Depression Center. Also, see eMedicine’s patient education articles Depression, Post-traumatic Stress Disorder (PTSD), and Suicidal Thoughts.

Keywords

adjustment disorder, AD, mental illness, psychiatric disorder, nonpsychotic disturbance, subthreshold disorders, subthreshold syndromes, psychosocial stressor, maladaptive reaction, stress disorders, suicide, suicidal ideation, suicidal impulses, anxiety not otherwise specified, anxiety NOS, depression NOS, depression not otherwise specified, self-harm, self-poisoning, psychopathology, stress reactions

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