Adjustment disorder

Adjustment disorder
Adjustment disorder
Specialty	Psychiatry, clinical psychology
Complications	Suicide; Progression to more serious psychiatric disorders, e.g., PTSD or Major Depressive Disorder.
Usual onset	Theoretically, within one to three months after a stressful event.
Duration	Theoretically, up to six months unless the stressor or its consequences continue.
Types	Mild, moderate, severe.
Risk factors	History of mental disorder; low social support.
Differential diagnosis	Rule out PTSD, Depressive Disorders, & Anxiety Disorders.
Treatment	Psychotherapy; bibliotherapy; structured paraprofessional help.
Prognosis	Relatively good compared to many other mental disorders, but severity varies.

Adjustment disorder is a maladaptive response to a psychosocial stressor. It is classified as a mental disorder.^[2] The maladaptive response usually involves otherwise normal emotional and behavioral reactions that manifest more intensely than usual (considering contextual and cultural factors), causing marked distress, preoccupation with the stressor and its consequences, and functional impairment.^[3]^[4]^[5]^[6]

Diagnosis of Adjustment disorder is common. Lifetime prevalence estimates for adults range from five percent to 21%.^[7] Adult women are diagnosed twice as often as men. Among children and adolescents, girls and boys are equally likely to be diagnosed with an Adjustment disorder.^[8]

Adjustment disorder was introduced into the Diagnostic and Statistical Manual of Mental Disorders in 1980 (DSM-III).

Signs and symptoms

Some emotional signs of adjustment disorder are: sadness, hopelessness, lack of enjoyment, crying spells, nervousness, anxiety, desperation, feeling overwhelmed and thoughts of suicide, performing poorly in school/work etc.

Common characteristics of Adjustment disorder include mild depressive symptoms, anxiety symptoms, and traumatic stress symptoms or a combination of the three. According to the DSM-5, there are six types of Adjustment disorder, 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.^[8] Adjustment disorder may be acute or chronic, depending on whether it lasts more or less than six months. According to the DSM-5, if the Adjustment disorder lasts less than six months, then it may be considered acute. If it lasts more than six months, it may be considered chronic.^[8] ^[9]Moreover, the symptoms cannot last longer than six months after the stressor(s), or its consequences, have terminated.^[2]^: 679 However, the stress-related disturbance does not only exist as an exacerbation of a pre-existing mental disorder.^[6]

Unlike major depression, the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation. 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.

Suicidal behavior is prominent among people with Adjustment disorder 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 Adjustment disorder attempted suicide immediately before their index admission and they remitted faster than a comparison group with major depression.^[5] Asnis et al. (1993) found that Adjustment disorder patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression.^[4] According to a study on 82 Adjustment disorder 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.^[3] Henriksson et al. (2005) states statistically that the stressors are of one-half related to parental issues and one-third in peer issues.^[10]

One hypothesis about Adjustment disorder is that it may represent a sub-threshold clinical syndrome.^[6]

Risk factors

Those exposed to repeated trauma are at greater risk, even if that trauma is in the past. Age can be a factor due to young children having fewer coping resources and because they are less likely to realize 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. Adjustment disorders can come from a wide range of stressors that can be traumatic or relatively minor, like the loss of a girlfriend/boyfriend, a poor report card, or moving to a new neighborhood. It is thought that the more often the stressor occurs, the more likely it is to produce Adjustment disorder. The objective nature of the stressor is of secondary importance. A stressor gains its pathogenic potential when the patient perceives it as stressful. The identification of a causal stressor is necessary if a diagnosis of adjustment disorder is to be made.^[11]

There are certain stressors that are more common in different age groups:^[12]

Adulthood:

Marital conflict
Financial conflict
Health issues with oneself, partner, or dependent children
Personal tragedy such as death or personal loss
Loss of job or unstable employment conditions e.g., corporate takeover or redundancy

Adolescence and childhood:

Family conflict or parental separation
School problems or changing schools
Sexuality issues
Death, illness, or trauma in the family

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.^[10]

Diagnosis

DSM-5 classification

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 Adjustment disorder. In addition, the diagnosis of Adjustment disorder is less clear when patients are exposed to stressors long-term, because this type of exposure is associated with Adjustment disorder and major depressive disorder (MDD) and generalized anxiety disorder (GAD).^[13]

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.^[11]

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.^[6]

ICD-11 classification

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

ICD-11 classifies Adjustment disorder (6B43) under "Disorders specifically associated with stress".^[14]

Treatment

There has been little systematic research regarding the best way to manage individuals with an adjustment disorder. Adjustment disorder sufferers with depressive or anxiety symptoms may benefit from treatments usually used for depressive or anxiety disorders.

The use of psychotherapy can be very beneficial for any age group. There is also a list of medications that can be used alongside therapy to treat Adjustment disorder. ^[15]

In addition to professional help, parents and caregivers can help their children with their difficulty adjusting by:^[16]

offering encouragement to talk about their emotions;
offering support and understanding;
reassuring the child that their reactions are normal;
involving the child's teachers to check on their progress in school;
letting the child make simple decisions at home, such as what to eat for dinner or what show to watch on TV;
having the child engage in a hobby or activity they enjoy.

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 healthcare 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.^[17]

An editorial in the British Journal of Psychiatry described adjustment disorder as being so "vague and all-encompassing… as to be useless,"^[18]^[19] but it has been retained in the 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.^[20]

In the US military there has been concern about its diagnosis in active duty military personnel.^[21]