Adjustment Disorders
INTRODUCTION
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. The disorder is time-limited, and symptoms
lessen 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 (Strain, 1998). 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" (Strain, 1998). 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."
A problem with this diagnostic construct is apparent in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) description of AD as a "maladaptive reaction to an identifiable psychosocial stressor, or stressors, that occurs within 3 months after onset of that stressor." 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.
PATHOPHYSIOLOGYStudies 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.
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.
FREQUENCYComorbidity 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 (Strain, 1995).
MORTALITY AND MORBIDITY
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.
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.
DEMOGRAPHICSRace 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.
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.
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, DIAGNOSIS, AND
TREATMENT
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:
Diagnostic criteria
The DSM-IV diagnostic criteria for AD are as follows:
Specify whether the condition is acute or chronic, as follows:
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, 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.
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.
Treatment
Strain et al report that only one randomized controlled trial for AD
has been conducted to assess treatment effectiveness (Bourin, 1997). 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 AD has
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 AD. Clinical symptoms in children and adolescents differ from
those in adults and elderly persons. Andreasen and Hoenk reported that in
children and adolescents, more serious mental illnesses were present at 5
years of follow-up. 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
AD. 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" (Strain, 1995).
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:
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.
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. Schatzberg
suggests that clinicians consider both psychotherapy and pharmacotherapy
for patients with AD with anxious mood. 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."
History
VULNERABILITIES FOR ADULTS AND
CHILDREN
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 diagnosed with AD were consistent with the
conceptual framework of AD as a maladaptation to a psychosocial stressor.
Patients diagnosed with AD 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.
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 an 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 in order 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 AD are
largely dependent on the individual presentation of symptoms. The
impulsivity that can accompany 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. 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.
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. 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 an AD 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 an 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.
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Continuing Education Courses CEU for Nurses and Healthcare Professional
Factors that
contribute to AD 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.
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