Adjustment disorder

In psychiatry, 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. 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. In adult clinical samples, women are twice as often as men to be diagnosed, though children and adolescents (girls or boys) are equally likely to receive this diagnosis.

Stressors

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.

Risk factors

Factors that influence the development of adjustment disorder include age, gender, cognitive development, past experiences, and access to healthy coping strategies. 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.

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 reduce internal distress. Coping is generally organized into four categories:

• The first category includes all efforts to handle stressors practically. This category contains two subcategories of problem-focused coping: practical and physical dealing with stressors through active problem solving and 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 that document the effectiveness of various activities in coping with stressful situations.

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.

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 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.

Adjustment disorder link to suicide

Suicidal 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. Asnis et al. (1993) found that AD patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression.

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 (e.g. teachers and parents). 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.