Adjustment disorder

Adjustment disorder
Classification and external resources
ICD-10	F43.2
ICD-9	309
DiseasesDB	33765
eMedicine	med/3348
MeSH	D000275

Adjustment disorder (AD) is a psychological response to an identifiable stressor or group of stressors that cause(s) significant emotional or behavioral symptoms that do not meet criteria for anxiety disorder, PTSD, or acute stress disorder. 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. There are nine different types of adjustment disorders listed in the DSM-III-R. In DSM-IV, adjustment disorder was reduced to six types, classified by their clinical features, which characterize the predominant symptoms. Adjustment disorder may also be acute or chronic, depending on whether it lasts more or less than six months. However, the symptoms cannot last longer than six months after the sttressor(s), or its consequences, have terminated. 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, but among children and adolescents, girls and boys are equally likely to receive this diagnosis. Adjustment disorder was introduced into the psychiatric classification systems almost 30 years ago, but the concept was recognized for many years before that. When considering biopsychosocial disorders, an athlete’s overtrained state can be due to an Adjustment Disorder.

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) Some emotional signs of AD are: sadness, hopelessness, lack of enjoyment, crying spells, nervousness, anxiety, worry, desperation, trouble sleeping, difficulty concentrating, feeling overwhelmed and thoughts of suicide Behavioral signs of AD are: fighting, reckless driving, ignoring important tasks such as bills or homework, avoiding family or friends, performing poorly in school, skipping school, or vandalizing property.

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. Asnis et al. (1993) found that AD patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression. Henriksson et al. (2005) states statistically that the stressors are of one half related to parental issues and one third in peer issues</ref>.

Risk factors

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

• younger age
• more identified psychosocial and environmental problems
• increased suicidal behaviour, more likely to be rated as improved by the time of discharge from mental healthcare
• less frequent previous psychiatric history
• shorter length of treatment

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; however, 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, however, 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 p. 279.</ref>

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

Adulthood:

• Marital conflict
• Financial Conflict

Adolescence and childhood:

• Family conflict/parental separation
• School problems/changing schools
• sexuality issues
• death/illness in the family

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 strssor due to the limitations in the criteria for diagnosing AD. In addition, the diagnosis of AD is less clear when patients are exposed to streesor long-term, because this type of exposure is not only associated with AD but also MDD and GAD.

Some signs and criteria used to establish a diagnosis are important, however. 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 or family member or other loved one.

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 these abnormal responses and maximize the use of the individuals 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 also 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, antidepressents, 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. 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. Another study found that AD responded better than major depression to antidepressants. Given the absence of a meaningful evidence base for the treatment of AD per se, watchful waiting should be considered initially, but 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:

• offering encouragement to talk about his/her emotions
• offer support and understanding
• reassure child that their reactions are normal
• involve the child's teachers to check on their progress in school
• let your child make simple decisions at home, such as what to eat for dinner or what show to watch on tv
• Have 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 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.

Adjustment disorder has been classified as being so "vague and all-encompassing...as to be useless," but it has been retained in the DSM-IV 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.

External links

• [1]
• [2]
• [3]
• [4]
• [5]
• Psychiatry Online: Adjustment Disorders
• Psychiatry Online: Differential Diagnosis by the Trees
• Defining Trauma: Terminology and Generic Stressor Dimensions