Adjustment disorder

Adjustment disorder (Situational Depression)
Classification and external resources
Specialty psychiatry
ICD-10 F43.2
ICD-9-CM 309
DiseasesDB 33765
MedlinePlus 000932
eMedicine med/3348
MeSH D000275

An adjustment disorder (AD) (sometimes called exogenous, reactive, or situational depression)[1] occurs when an individual is unable to adjust to or cope with a particular stress or a major life event. Since people with this disorder normally have symptoms that depressed people do, such as general loss of interest, feelings of hopelessness and crying, this disorder is sometimes known as situational depression. Unlike major depression the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation.[2] One hypothesis for adjustment disorder is that it may represent a sub-threshold clinical syndrome.[3]

The condition is different from anxiety disorder, which lacks the presence of a stressor, or post-traumatic stress disorder and acute stress disorder, which usually are associated with a more intense stressor.

Common characteristics of adjustment disorder include mild depressive symptoms, anxiety symptoms, and traumatic stress symptoms or a combination of the three. There are nine types of adjustment disorders listed in the DSM-III-R. According to the DSM-IV-TR, there are six types of adjustment disorders, which are characterized by the following predominant symptoms: depressed mood, anxiety, mixed depression and anxiety, disturbance of conduct, mixed disturbance of emotions and conduct, and unspecified. However, the criteria for these symptoms are not specified in greater detail.[4] Adjustment disorder may be acute or chronic, depending on whether it lasts more or less than six months. According to the DSM-IV-TR, if the adjustment disorder lasts less than 6 months, then it may be considered acute. If it lasts more than six months, it may be considered chronic.[4] Moreover, the symptoms cannot last longer than six months after the stressor(s), or its consequences, have terminated.[5] Diagnosis of adjustment disorder is quite common; there is an estimated incidence of 5%–21% among psychiatric consultation services for adults. Adult women are diagnosed twice as often as are adult men. Among children and adolescents, girls and boys are equally likely to receive this diagnosis.[6] Adjustment disorder was introduced into the psychiatric classification systems almost 30 years ago, but the concept was recognized for many years before that.[7]

Signs and symptoms

According to the DSM IV-TR, the development of the emotional or behavioral symptoms of this diagnosis have to occur within three months of the onset of the identifiable stressor(s).[8]
Some emotional signs of adjustment disorder are


Some behavioral signs of AD are


However, the stress-related disturbance does not only exist as an exacerbation of a pre-existing axis I or axis II disorder and cannot be diagnostic as axis 1 disorder.[10]

Suicidal behavior is prominent among people with AD of all ages, and up to one-fifth of adolescent suicide victims may have an adjustment disorder. Bronish and Hecht (1989) found that 70% of a series of patients with AD attempted suicide immediately before their index admission and they remitted faster than a comparison group with major depression.[11] Asnis et al. (1993) found that AD patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression.[12] According to a study on 82 AD patients at a clinic, Bolu et al. (2012) found that 22 (26.8%) of these patients were admitted due to suicide attempt, consistent with previous findings. In addition, it was found that 15 of these 22 patients chose suicide methods that involved high chances of being saved.[13] Henriksson et al. (2005) states statistically that the stressors are of one-half related to parental issues and one-third in peer issues.[14]

Risk factors

Various factors have been found to be more associated with a diagnosis of AD than other axis I disorders, including:[15]

Those exposed to repeated trauma are at greater risk, even if that trauma is in the distant past. Age can be a factor due to young children having fewer coping resources; children are also less likely to assess the consequences of a potential stressor.

A stressor is generally an event of a serious, unusual nature that an individual or group of individuals experience. The stressors that cause adjustment disorders may be grossly traumatic or relatively minor, like loss of a girlfriend/boyfriend, a poor report card, or moving to a new neighborhood. It is thought that the more chronic or recurrent the stressor, the more likely it is to produce a disorder. The objective nature of the stressor is of secondary importance. Stressors' most crucial link to their pathogenic potential is their perception by the patient as stressful. The presence of a causal stressor is essential before a diagnosis of adjustment disorder can be made.[16]

There are certain stressors that are more common in different age groups:[17]

Adulthood:

Adolescence and childhood:

In a study conducted from 1990 to 1994 on 89 psychiatric outpatient adolescents, 25% had attempted suicide in which 37.5% had misused alcohol, 87.5% displayed aggressive behaviour, 12.5% had learning difficulties, and 87.5% had anxiety symptoms.[18]

Diagnosis

The basis of the diagnosis is the presence of a precipitating stressor and a clinical evaluation of the possibility of symptom resolution on removal of the stressor due to the limitations in the criteria for diagnosing AD. In addition, the diagnosis of AD is less clear when patients are exposed to stressors long-term, because this type of exposure is associated with AD and major depressive disorder (MDD) and generalized anxiety disorder (GAD).[19]

Some signs and criteria used to establish a diagnosis are important. First, the symptoms must clearly follow a stressor. The symptoms should be more severe than would be expected. There should not appear to be other underlying disorders. The symptoms that are present are not part of a normal grieving for the death of family member or other loved one.[20]

Adjustment disorders have the ability to be self-limiting. Within five years of when they are originally diagnosed, approximately 20%-50% of the sufferers go on to be diagnosed with psychiatric disorders that are more serious.[10]

Treatment

Often, the recommended treatment for adjustment disorder is psychotherapy. The goal of psychotherapy is symptom relief and behavior change. Anxiety may be presented as "a signal from the body" that something in the patient's life needs to change. Treatment allows the patient to put his or her distress or rage into words rather than into destructive actions. Individual therapy can help a person gain the support they need, identify abnormal responses and maximize the use of the individual's strengths. Counseling, psychotherapy, crisis intervention, family therapy, behavioral therapy and self-help group treatment are often used to encourage the verbalization of fears, anxiety, rage, helplessness, and hopelessness. Sometimes small doses of antidepressants and anxiolytics are used in addition to other forms of treatment. In patients with severe life stresses and a significant anxious component, benzodiazepines are used, although non-addictive alternatives have been recommended for patients with current or past heavy alcohol use, because of the greater risk of dependence. Tianeptine, alprazolam, and mianserin were found to be equally effective in patients with AD with anxiety. Additionally, antidepressants, antipsychotics (rarely) and stimulants (for individuals who became extremely withdrawn) have been used in treatment plans.

There has been little systematic research regarding the best way to manage individuals with an adjustment disorder. Because natural recovery is the norm, it has been argued that there is no need to intervene unless levels of risk or distress are high.[21] However, for some individuals treatment may be beneficial. AD sufferers with depressive and/or anxiety symptoms may benefit from treatments usually used for depressive and/or anxiety disorders. One study found that AD sufferers received similar interventions to those with other psychiatric diagnoses, including psychological therapy and medication.[22] Another study found that AD responded better than major depression to antidepressants.[23] Given the absence of a meaningful evidence base for the treatment of AD per se, watchful waiting should be considered initially; if symptoms are not improving or causing the sufferer marked distress then treatment should be directed at the predominating symptoms.

In addition to professional help, parents and caregivers can help their children with their difficulty adjusting by:[24]

ICD 10 Classification

International Statistical Classification of Diseases and Related Health Problems, mostly known as "ICD", assigns codes to classify diseases, symptoms, complaints, social behaviors, injuries, and such medical-related findings.

ICD 10 classifies adjustment disorders under F40-F48 and under neurotic, stress-related and somatoform disorders.[25]

Criticism

Like many of the items in the DSM, adjustment disorder receives criticism from a minority of the professional community as well as those in semi-related professions outside the health-care field. First, there has been criticism of its classification. It has been criticized for its lack of specificity of symptoms, behavioral parameters, and close links with environmental factors. Relatively little research has been done on this condition.[26]

Adjustment disorder has been classified as being so "vague and all-encompassing...as to be useless,"[27][28] but it has been retained in the DSM-IV and DSM-5 because of the belief that it serves a useful clinical purpose for clinicians seeking a temporary, mild, non-stigmatizing label, particularly for patients who need a diagnosis for insurance coverage of therapy.

References

  1. ↑ Souza, Thomas A. Differential Diagnosis and Management for the Chiropractor: Protocols and Algorithms. 4th ed. Sudbury, Mass.: Jones and Bartlett, 2009. 587. Print.
  2. ↑ An Introduction to Adjustment Disorder. Archived from the original on 2012-09-18.
  3. ↑ Adjustment disorders. Retrieved from http://journals.scholarsportal.info/details?uri=/14761793/v05i0007/240_ad
  4. 1 2 Patricia, C.(2009). Adjustment Disorder: Epidemiology, Diagnosis and Treatment
  5. ↑ Reference-Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, American Psychiatric Association, p.679
  6. ↑ Diagnostic and Statistical Manual of Mental Disorders – Fourth edition, American Psychiatric Association, p. 681
  7. ↑ p. 279
  8. ↑ Rapport, J., & Ismond, D. (1990). DSM IV training guide for diagnosis of childhood disorders. New York: Brunner/Mazzel, 260
  9. ↑ Adjustment disorder: Symptoms (2011, March 17). Retrieved from http://www.mayoclinic.com/health/adjustment-disorders/DS00584/DSECTION=symptoms
  10. 1 2 Bisson JI, Sakhuja D. (2006). "Adjustment disorders". Psychiatry 5 (7): 240-242. Bisson, J. I.; Sakhuja, D. (2006). "Adjustment disorders". Psychiatry 5 (7): 240. doi:10.1053/j.mppsy.2006.04.004.
  11. ↑ Bronish, T., & Hecht, H. (1989). Validity of adjustment disorder, comparison with major depression. Journal of Affective Disorders, 17, 229–236.
  12. ↑ Asnis, G. M., Friedman, T. A., Sanderson, W. C., Kaplan, M. L., van Praag, H. M., & Harkavy-Friedman, J. M. (1993). Suicidal behavior in adult psychiatric outpatients: Description and prevalence. American Journal of Psychiatry, 150, 108–112.
  13. ↑ Bolu, A., Doruk, A., Ak, M., Özdemir, B., & Özgen, F. (2012). Suicidal behavior in adjustment disorder patients. Dusunen Adam, 25(1), 58–62.
  14. ↑ Henriksson, M; Lönnqvist, J; Marttunen, M; Pelkonen, M; (2005). Suicidality in adjustment disorder: Clinical characteristics of adolescent outpatients. European Child & Adolescent Psychiatry 14 (3), pg. 174–180 doi:10.1007/s00787-005-0457-8
  15. ↑ Bisson, Jonathan I.; Sakhuja, Divya (2006). "Adjustment disorders". Psychiatry 5 (7): 240–2. doi:10.1053/j.mppsy.2006.04.004.
  16. ↑ p. 279.
  17. ↑ Powell, Alicia D. (2015). "Grief, Bereavement, and Adjustment Disorders". In Stern, Theodore A.; Fava, Maurizio; Wilens, Timothy E.; et al. Massachusetts General Hospital Comprehensive Clinical Psychiatry (2nd ed.). Elsevier. pp. 428–32. ISBN 978-0-323-32899-9.
  18. ↑ Pelkonen, Mirjami; Marttunen, Mauri; Henriksson, Markus; Lönnqvist, Jouko (2005). "Suicidality in adjustment disorder: Clinical characteristics of adolescent outpatients". European Child & Adolescent Psychiatry 14 (3): 174–80. doi:10.1007/s00787-005-0457-8. PMID 15959663.
  19. ↑ Casey, Patricia; Doherty, Anne (2012). "Adjustment disorder: Diagnostic and treatment issues". Psychiatric Times 29: 43–6.
  20. ↑ Adjustment Disorders at eMedicine
  21. ↑ Casey P. Adult adjustment disorder: a review of its current diagnostic status. J Psychiatr Pract 2001; 7: 32–40.
  22. ↑ Strain J, Smith G, Hammer J et al. Adjustment disorder: a multisite study of its utilization and interventions in the consultation-liaison psychiatry setting. Gen Hosp Psychiatry 1998; 20: 139–49.
  23. ↑ Hameed U, Schwartz T, Malhotra K. Antidepressant treatment in the primary care office: outcomes for adjustment disorder versus major depression. Ann Clin Psychiatry 2005; 17: 77–81.
  24. ↑ Adjustment disorder: Symptoms (2011, March 17). Retrieved from http://www.mayoclinic.com/health/adjustment-disorders/DS00584/DSECTION=lifestyleandhomeremedies
  25. ↑ Adjustment disorder: ICD Classification. Retrieved from http://www.adjustmentdisorder.org/icd-10-classification-of-adjustment-disorder.php
  26. ↑ Casey P (January 2001). "Adult adjustment disorder: a review of its current diagnostic status". J Psychiatr Pract 7 (1): 32–40. doi:10.1097/00131746-200101000-00004. PMID 15990499.
  27. ↑ Casey P, Dowrick C, Wilkinson G (December 2001). "Adjustment disorders: fault line in the psychiatric glossary". Br J Psychiatry 179 (6): 479–81. doi:10.1192/bjp.179.6.479. PMID 11731347.
  28. ↑ Fard K, Hudgens RW, Welner A (March 1978). "Undiagnosed psychiatric illness in adolescents. A prospective study and seven-year follow-up". Arch. Gen. Psychiatry 35 (3): 279–82. doi:10.1001/archpsyc.1978.01770270029002. PMID 727886.

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