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
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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 dev elopment 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.
Read more: Adjustment disorder - children, define, causes, DSM, effects, therapy,
adults, person, people, medication, brain, personality, skills, women, health, traits,
mood, Definition http://www.minddisorders.com/A-Br/Adjustment-
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