Adjustment disorder

(psychology) A category of emotional disorder in which an individual exhibits maladaptive reactions to identifiable life events or circumstances.

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Definition

Adjustment disorder is an umbrella term for several mental states characterized by noticeable behavioral and/or emotional symptoms. In order to be classified as an adjustment disorder, these symptoms must be shown to be a response to an identifiable stressor that has occurred within the past three months.

Description

The American Psychiatric Association (APA), in its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), states that the behavioral and/or emotional signs observed must appear excessive for the stressor involved or have significant impact on the child's social and school functioning. The cause of the stress may be a single event affecting only the child, such as starting daycare or school, or an event that involves the entire family, such as a divorce. Multiple simultaneous stressors are also possible, such as starting daycare and having an abusive caretaker at the daycare or a divorce complicated by parental substance abuse. Chronic medical conditions of the child or parents, such as childhood leukemia or cancer, can also be a cause of stress.

Adjustment disorder, in some ways, is a hopeful diagnosis. Many mental health professionals consider it one of the less severe mental illnesses. It is normally a time-limited condition with manifestations arriving almost immediately after the appearance of the pressure-causing event and resolving within six months of the elimination of the stressor. However, the exception to this would be the duration of symptoms related to long-term stressors such as chronic illness or even the fall-out from divorce. Though these may appear within three months of the event, resolution may also take longer than six months.

Demographics

The diagnosis of adjustment disorder is a very common one for both children and teens, with a higher incidence among children than adults. Nearly one third (32%) of all adolescents are estimated to suffer from adjustment disorders during teenage years as opposed to a rate of occurrence of only 10 percent among adults. There is no identified difference between adjustment disorder rates between girls or boys. What provides the precipitating event and the symptoms manifested can vary, according to the culture in which a child lives. However, generally across all cultures, children and adolescents are more apt to experience conduct disorder symptoms manifested by acting out behaviors, while adults are more apt to experience depressive symptoms.

Causes and Symptoms

Few descriptions of any mental illness specify its cause as precisely as the description of adjustment disorders does. An explicit incident or incidents causing stress for the child is always the precipitant. The cause of the stress seen in adjustment disorders can be events that for many children would be within the parameters of normal experience. These incidents are usually not the severe traumas associated with more serious stress-related illnesses such as post-traumatic stress disorder (PTSD). Though adjustment disorder precipitants are usually more "normal" events that can typically occur in the lives of most children, these events are still changes from everyday events. Especially for children, change is often the precursor of stress. For example, for a child who has always had daycare or babysitters, having caregivers other than his or her mother is a normal occurrence, so having a caregiver is not likely to be terribly stressful. However, a child who has never been separated from his or her mother may find going to daycare or kindergarten an extremely traumatic event.

Other examples of such childhood stressors include:

• divorce or separation of parents
• moving to a new place
• birth of a sibling
• natural disasters such as hurricanes or tornadoes
• illness of either the child or another loved one
• loss of a pet
• problems in school
• family conflict
• sexuality issues
• witnessing or being involved in an incidence of violence

Some psychological theorists and researchers consider adjustment disorders in adolescents less of an illness than a stage in establishing an identity. Adolescents may develop adjustment disorders as part of a defense mechanism meant to break their feelings of dependence on parents. This psychological maneuver may precipitate problems in families as adolescents begin seeking individuals outside the family as replacements for their parents. This behavior can be particularly destructive when these feelings of dependence are transferred to involvement with gangs or cults. However, it should be noted that the APA does classify adjustment disorder as a mental illness.

DSM-IV divides adjustment disorders into subgroups, based upon the symptoms manifested most prominently. These subgroups include:

• Adjustment disorder with depressed mood. This is characterized by feelings of sadness or hopelessness of varying degrees. However depression usually interferes with the child's ability to function, i.e. attending school or playing with friends. The sad feelings are sometimes accompanied by feelings of anger or frustration. It is important to note that though depressed mood adjustment disorder is less common among children, when it does occur, suicidal thoughts and even suicide attempts can be one of the symptoms. This symptom requires careful monitoring and the involvement of a mental health professional.
• Adjustment disorder with anxiety. This form typically includes agitation or nervous behavior and/or obsessive worrying. The child may feel or express fear of being separated from parents.
• Adjustment disorder with mixed anxiety and depressed mood. This condition combines the symptoms seen in both adjustment disorders with depression and with anxiety.
• Adjustment disorder with disturbance of conduct. Behavioral signs of this adjustment disorder include primarily actions that show a disregard for rules, laws, and the rights of others, such as picking fights, vandalism, truancy, and reckless driving for teens.
• Adjustment disorder with mixed disturbance of emotions and conduct. This condition combines depression and anxiety symptoms with those of disturbance of conduct.
• Unspecified adjustment disorders. This phrase is the catch-all term to describe any adjustment disorder not showing a predominance of any one set of the above-listed symptoms.

When to Call the Doctor

In order to even establish a diagnosis of adjustment disorder, a mental health professional needs to meet and evaluate the child or teen. As this illness can be debilitating, making it quite difficult for the child to function, that evaluation should take place as soon as possible after symptoms are observed. As noted above, suicidal ideation can be a potential facet of depressed mood adjustment disorders, and untreated adjustment disorder with depressed mood can lead to more serious mental illness, including major depression. These two facts give additional impetus to quickly involving a psychiatrist or psychologist.

Diagnosis

One of the primary measurements used in diagnosing adjustment disorder is the occurrence of the stress-causing event within the past three months. The only usual life-stressor not considered a possible cause for adjustment disorder is bereavement. Adjustment disorders are also differentiated from other reactions to stress such as PTSD by both symptoms and the relative severity of the causative event. Adjustment disorders can be caused by almost any stressor and manifest a wide variety of symptoms, while PTSD is normally associated with severe stress-causing life events and has a more specific set of symptoms.

The child being evaluated for an adjustment disorder needs to meet the following criteria in order to confirm the diagnosis:

• has had a psychological evaluation
• has experienced a psychological stressor within the past three months
• shows symptoms that appear disproportionate to the stressful event
• does not appear to be suffering from any other underlying mental or physical illness

Treatment

The most important goal in the treatment of adjustment disorder is relieving the symptoms a child or teen experiences so that they can return to the same level of functioning they possessed prior to the onset of illness. Treatment depends upon the age and overall health of the child as well as the severity of the symptoms. Medication is only ordered on an extremely limited basis or not ordered at all because psychotropic medications have been shown to have little efficacy in treating adjustment disorders. Age-appropriate cognitive-behavioral individual psychotherapy, focusing on problem solving, communication, impulse control, and stress and anger-management is a usual component of treatment. Family therapy to improve communication between the child or teen and parents and siblings is often helpful, as is group therapy with peers (other children also suffering from adjustment disorder).

Prognosis

Early detection and treatment of adjustment disorders in children has been shown to appreciably reduce the severity of symptoms and improve their quality of life. Most recoveries from adjustment disorder uncomplicated by other mental illness are both rapid and complete returns to the child's former level of functioning.

Prevention

The National Institute for Mental Health (NIMH) notes that there is no way to predict who will develop an adjustment disorder given the appearance of certain life-situation stressors. Since there is also no known way to prevent the occurrence of these stressors, prevention seems impossible. However, it is known that understanding and support from family and friends can help.

Resources

Books

Bell, Susan Givens, et al. Mosby's Pediatric Nursing Reference, 5th ed. Kent, UK: Elsevier Science, 2003.

Organizations

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW Washington, DC 20016–3007. Web site: www.aacap.org.

Federation of Families for Children's Mental Health. 1021 Prince Street, Alexandria, VA 22314–2971. Web site: www.ffcmh.org.

Web Sites

"Adjustment Disorder." National Institute of Mental Health. Available online at www.nimh.nih.gov.htm (accessed October 16, 2004).

Franklin, Donald. "Adjustment Disorders." Psychology Information Online. Available online at www.psychologyinfo.com (accessed October 16, 2004).

[Article by: Joan Schonbeck, R.N.]

Any of a class of disorders that result from an individual's failure to adapt to identifiable stresses in the environment such as divorce, natural disaster, family discord, or retirement, characterized by an impaired ability to function socially or occupationally.

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.^[1] 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. Adjustment disorder may also be acute or chronic, depending on whether it lasts more or less than six months. 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.^[2] Adjustment disorder was introduced into the psychiatric classification systems almost 30 years ago, but the concept was recognized for many years before that.^[3] When considering biopsychosocial disorders, an athlete’s overtrained state can be due to an Adjustment Disorder.^[4]

Contents 1 Signs and symptoms 2 Risk factors 3 Diagnosis 4 Treatment 5 Criticism 6 References 7 External links

Signs and symptoms

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.^[5] Asnis et al. (1993) found that AD patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression.^[6] Henriksson et al. (2005) states statistically that the stressors are of one half related to parental issues and one third in peer issues</ref>. ^[7]

Risk factors

Various factors have been found to be more associated with a diagnosis of AD than other Axis I disorders, including:^[8]

• 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>

Diagnosis

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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. Counseling, psychotherapy, crisis intervention, family therapy, and 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 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.

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.^[9] 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.^[10] Another study found that AD responded better than major depression to antidepressants.^[11] 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.

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.^[12]

Adjustment disorder has been classified as being so "vague and all-encompassing...as to be useless,"^[13][14] 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.

References

1. ^ Pelkonen. “Suicidality in Adjustment Disorder”, p. 174.
2. ^ Diagnostic and Statistical Manual of Mental Disorders -Fourth edition, American Psychatric Association, p. 681
3. ^ 279
4. ^ Jones, C. M., Tenenbaum, G. (2009). Adjustment Disorder: a new way of conceptualizing the overtraining syndrome.International Review of Sport and Exercise Psychology,181-197
5. ^ Bronish, T., & Hecht, H. (1989). Validity of adjustment disorder, comparison with major depression. Journal of Affective Disorders, 17, 229–236.
6. ^ 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.
7. ^ 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
8. ^ Sakhuja, D. (2006-07-01). Adjustment disorders. Psychiatry (Abingdon, England), 5(7), 240-242.doi:10.1053/j.mppsy.2006.04.004
9. ^ Casey P.Adult adjustment disorder: a review of its current diagnostic status. J Psychiatr Pract 2001; 7: 32-40.
10. ^ 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.
11. ^ 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.
12. ^ Casey P (January 2001). "Adult adjustment disorder: a review of its current diagnostic status". J Psychiatr Pract 7 (1): 32–40. PMID 15990499. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1527-4160&volume=7&issue=1&spage=32. 
13. ^ Casey P, Dowrick C, Wilkinson G (December 2001). "Adjustment disorders: fault line in the psychiatric glossary". Br J Psychiatry 179: 479–81. doi:10.1192/bjp.179.6.479. PMID 11731347. http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=11731347. 
14. ^ 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. PMID 727886. http://archpsyc.ama-assn.org/cgi/pmidlookup?view=long&pmid=727886. 

External links

• Psychiatry Online: Adjustment Disorders
• Psychiatry Online: Differential Diagnosis by the Trees
• Defining Trauma: Terminology and Generic Stressor Dimensions

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