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Adjustment disorder

 
Medical Encyclopedia: Adjustment Disorders
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Definition

An adjustment disorder is a debilitating reaction, usually lasting less than six months, to a stressful event or situation. It is not the same thing as post-traumatic stress disorder (PTSD), which usually occurs in reaction to a life-threatening event and can be longer lasting.

Description

An adjustment disorder usually begins within three months of a stressful event, and ends within six months after the stressor stops. There are many different subtypes of adjustment disorders, including adjustment disorder with:

  • depression
  • anxiety
  • mixed anxiety and depression
  • conduct disturbances
  • mixed disturbance of emotions and conduct
  • unspecified

Adjustment disorders are very common and can affect anyone, regardless of gender, age, race, or lifestyle. By definition, an adjustment disorder is short-lived, unless a person is faced with a chronic recurring crisis (such as a child who is repeatedly abused). In such cases, the adjustment disorder may last more than six months.

— Carol A. Turkington


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Sci-Tech Dictionary: adjustment disorder
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(ə′jəst·mənt dis′örd·ər)

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

Children's Health Encyclopedia: Adjustment Disorders
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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.]


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

In psychology, adjustment disorder (AD) is a classification of mental disorder that is a psychological response from an identifiable stressor or group of stressors that causes significant emotional or behavioral symptoms that does not meet criteria for more specific disorders.[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 Disorders 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 have been reports of it being a common and serious condition among adolescents and it has estimated incidences of 5-21% in psychiatric consultation services for adults. In clinical samples of adults, women are given the diagnosis twice as often as men.

Contents

Stressors

A stressor is generally an event of a serious, unusual nature that an individual or group of individuals experience. It should be mentioned that the stressors that cause adjustment disorders are not extreme events which are in the criteria for post-traumatic stress disorder. They may be grossly traumatic but may also be apparently minor, like loss of a boyfriend/girlfriend, 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, yet this is modified greatly by the support the patient receives from those around him or her. Stressors believed to involve a loss usually have particular significance like an interpersonal failure, physical, sexual, or emotional abuse, cognitive impairment, a lengthy duration of frequent recurrence, or cognitive uncertainty. 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. Patients that face a stressor with enthusiasm and view it as a challenge are much less likely to develop a disorder.

Risk factors

Factors that are intrinsic toward the development of Adjustment Disorder include age, gender, ego development, past experiences and coping skills. Age can be a factor because young children have fewer coping resources, however they are less likely to understand a stressor as stressful and are thus less likely to develop a disorder. Women have been shown to be more vulnerable to stressors across all ages and types of stressors (Turner et al, 1995, for example).[2] A poorly developed ego is also a factor that could make one more vulnerable to this disorder, whether it is caused by cerebral impairment or upbringing. Those damaged by repeated trauma also are at greater risk, even if that trauma is in the distant past.

Coping

One important factor that dictates the extent of the emotional or behavioral symptoms displayed in Adjustment Disorder is their method of coping with the stressors. Coping is defined as the strategies and mechanisms that people use to modify their environment or reduce internal distress. Coping is generally organized into four categories.

  • The first category includes all efforts to practically handle stressors. This category contains two subcategories of problem-focused coping, which is the practical and physical dealing with stressors by actively problem solving, and restraint, which is waiting for an appropriate opportunity to act.
  • The second category includes cognitive or internal strategies. This involves avoiding, minimizing, distancing, or seeking value in negative events.
  • The third category includes efforts to diminish stress by utilizing available situational or environmental factors. The most commonly investigated mechanism in this category is social support.
  • The fourth category includes personal approaches or individuals' cognitive orientations. This category includes constructs such as an individual’s hardiness, sense of coherence, and locus of control.

Many studies have been done, documenting the effectiveness of various activities in coping with stressful situations. The effective activities included internet and computer based entertainment, watching television and listening to music.

Diagnostic criteria (DSM-IV)

The diagnostic criteria in the DSM-IV are

  1. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within three months of the onset of the stressor(s).
  2. These symptoms or behaviors are clinically significant as evidenced by either of the following:
    1. marked distress that is in excess of what would be expected from exposure to the stressor
    2. significant impairment in social or occupational (academic) functioning
  3. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.
  4. The symptoms do not represent Bereavement.
  5. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional six months.

Subtypes (DSM-IV)

DSM IV Adjustment disorders

  • 309.0 With Depressed Mood. This subtype should be used when the predominant manifestations are symptoms such as depressed mood, tearfulness, or feelings of hopelessness.
  • 309.24 With Anxiety. This subtype should be used when the predominant manifestations are symptoms such as nervousness, worry, or jitteriness, or, in children, fears of separation from major attachment figures.
  • 309.28 With Mixed Anxiety and Depressed Mood. This subtype should be used when the predominant manifestation is a combination of depression and anxiety.
  • 309.3 With Disturbance of Conduct. This subtype should be used when the predominant manifestation is a disturbance in conduct in which there is violation of the rights of others or of major age-appropriate societal norms and rules (e.g., truancy, vandalism, reckless driving, fighting, defaulting on legal responsibilities).
  • 309.4 With Mixed Disturbance of Emotions and Conduct. This subtype should be used when the predominant manifestations are both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct (see above subtype).
  • 309.9 Unspecified. This subtype should be used for maladaptive reactions (e.g., physical complaints, social withdrawal, or work or academic inhibition) to stressors that are not classifiable as one of the specific subtypes of Adjustment Disorder.

Treatment

The primary treatment for adjustment disorder is talking. This reduces the pressure of the stressor and enhances coping. It allows the patient to put his or her 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 tricyclic antidepressants or buspirone has 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.

Adjustment disorder link to suicide

Suicide behavior is prominent among AD patients 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.[3] Asnis et al. (1993) found that AD patients report persistent ideation or suicide attempts much less frequently than those diagnosed with major depression.[4]

Criticism

Like many of the items in the DSM, Adjustment Disorder receives its fair share of criticism from a minority of the professional community as well as those outside of the health-care field, but in semi-related professions e.g. nurses, teachers and parents. First, there has been some 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.[5]

Adjustment Disorder has been classified as being so “vague and all-encompassing...as to be useless,"[6][7] 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.

The crown princess of Japan, Masako, is declared to be suffering from "Adjustment disorder" while media in Japan reported that she actually suffers from depression.

References

  1. ^ Pelkonen. “Suicidality in Adjustment Disorder”, p. 174.
  2. ^ Turner, R.J., Wheaton, B. & Lloyd, D.A. (1995). The epidemiology of social stress. American Sociological Review, 60, 104-125.
  3. ^ Bronish, T., & Hecht, H. (1989). Validity of adjustment disorder, comparison with major depression. Journal of Affective Disorders, 17, 229–236.
  4. ^ 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.
  5. ^ 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. 
  6. ^ Casey P, Dowrick C, Wilkinson G (December 2001). "Adjustment disorders: fault line in the psychiatric glossary". Br J Psychiatry 179: 479–81. PMID 11731347. http://bjp.rcpsych.org/cgi/pmidlookup?view=long&pmid=11731347. 
  7. ^ 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. 

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