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, alcohol and substance abuse
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).^[9]^[10]

Other names for adjustment disorder are stress response syndrome (new name as of 2013) and situational depression since it is one of the most common symptoms.^[11]

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.^[12]

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]^[13] 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.^[14]

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

The syndrome of occupational burnout is considered to be adjustment disorder by some national health authorities.^[15]^[16]^[17]

Subtypes and their symptoms

Adjustment disorder has six different subtypes, and they are all based on what the main symptoms are.^[18]^[19]

Those subtypes are as follows:^[18]

With depressed mood: depression, hopelessness, lack of interest or joy from previously enjoyed hobbies, tearfulness
With anxiety: anxiousness, being overwhelmed, trouble concentrating, worry, separation anxiety (common in children)
With anxiety and depressed mood: combination of symptoms from both subtypes above
With disturbance of conduct: acting destructive, reckless behavior, rebellious
With mixed disturbance of emotions and conduct: combination of symptoms from both subtypes above
Unspecified: symptoms that do not fall into above subtypes; often include physical symptoms and withdrawal from everyday activities

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.^[8]

A stressor is generally an event of a serious, unusual nature that an individual or group of individuals experience.^[20] 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.^[21]

There are certain stressors that are more common in different age groups:^[22]

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.^[14]

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).^[23]

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.^[21]

Adjustment disorders have the ability to be self-limiting. Within five years of when they are originally diagnosed, approximately 20–50% 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".^[24]

Treatment

Individuals with an adjustment disorder and depressive or anxiety symptoms may benefit from treatments usually used for depressive or anxiety disorders. The use of different therapies can be beneficial for any age group. There is also a list of medications that can be used to help people with adjustment disorder whose symptoms are too severe for therapy alone. If a person is considering taking medication, they should talk to their doctor.^[18] Specific treatment is based on factors of each individual separately. These factors include but are not limited to age, severity of symptoms, type of adjustment disorder, and personal preference.^[18]^[19]

Different ways to help with the disorder include:

individual psychotherapy
family therapy
peer group therapy
medication

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

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 television
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.^[25]

An editorial in the British Journal of Psychiatry described adjustment disorder as being so "vague and all-encompassing… as to be useless,"^[26]^[27] 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.^[28]

In the US military there has been concern about its diagnosis in active duty military personnel.^[29]

When the cause of substantial distress is harm caused by unjust social systems, it may be considered that the true disorder requiring intervention lies in the systems causing the problem rather than in the individual who is distressed by them.^[30]

In relation to the COVID-19 pandemic

A study was conducted in Poland during the first phase of the pandemic. The study used self-report surveys to measure the prevalence and severity of symptoms of adjustment disorder compared to PTSD, depression, and anxiety. The data was collected in the first quarantine period between March 25 to April 27, 2020.^[31]

Results from the study:^[31]

The COVID-19 pandemic was a highly stressful event for 75% of the participants and the most powerful predictor of adjustment disorder.
49% reported an increase in adjustment disorder symptoms, which were more common among females and those without a full-time job; 14% of the sample met the criteria for a diagnosis of adjustment disorder.
A significant proportion of the sample was also positive for generalized anxiety (44%) and depression (26%): the presumptive diagnosis rate of PTSD was 2.4%

References

^ "Adjustment disorders - Symptoms and causes". Mayo Clinic. Retrieved 30 May 2019.
^ ^a ^b American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). pp. 271–281.
^ ^a ^b Bolu A, Doruk A, Ak M, Özdemir B, Özgen F (2012). "Suicidal behavior in adjustment disorder patients". Dusunen Adam the Journal of Psychiatry and Neurological Sciences. 25 (1): 58–62. doi:10.5350/DAJPN2012250107.
^ ^a ^b Asnis GM, Friedman TA, Sanderson WC, Kaplan ML, van Praag HM, Harkavy-Friedman JM (January 1993). "Suicidal behaviors in adult psychiatric outpatients, I: Description and prevalence". The American Journal of Psychiatry. 150 (1): 108–112. doi:10.1176/ajp.150.1.108. PMID 8417551.
^ ^a ^b Bronisch T, Hecht H (1989). "Validity of adjustment disorder, comparison with major depression". Journal of Affective Disorders. 17 (3): 229–36. doi:10.1016/0165-0327(89)90004-9. PMID 2529290.
^ ^a ^b ^c ^d Bisson JI, Sakhuja D (July 2006). "Adjustment disorders". Psychiatry. 5 (7): 240–242. doi:10.1053/j.mppsy.2006.04.004.
^ Portzky G, Audenaert K, van Heeringen K (August 2005). "Adjustment disorder and the course of the suicidal process in adolescents". Journal of Affective Disorders. 87 (2–3): 265–270. doi:10.1016/j.jad.2005.04.009. hdl:1854/LU-337403. PMID 16005078.
^ ^a ^b ^c ^d "Adjustment Disorders". 8 August 2021.
^ "DSM-5 Diagnostic Codes". Psych Central. 2021-05-13. Retrieved 2022-04-10.
^ Substance Abuse and Mental Health Services Administration (June 2016). "Table 3.19, DSM-IV to DSM-5 Adjustment Disorders Comparison". www.ncbi.nlm.nih.gov. Retrieved 2022-04-10.
^ "What Is Adjustment Disorder?". WebMD. Retrieved 2022-04-10.
^ "Adjustment disorders - Symptoms and causes". Mayo Clinic. Retrieved 2022-03-07.
^ Carta MG, Balestrieri M, Murru A, Hardoy MC (June 2009). "Adjustment Disorder: epidemiology, diagnosis and treatment". Clinical Practice and Epidemiology in Mental Health. 5: 15. doi:10.1186/1745-0179-5-15. PMC 2710332. PMID 19558652.
^ ^a ^b Pelkonen M, Marttunen M, Henriksson M, Lönnqvist J (May 2005). "Suicidality in adjustment disorder--clinical characteristics of adolescent outpatients". European Child & Adolescent Psychiatry. 14 (3): 174–180. doi:10.1007/s00787-005-0457-8. PMID 15959663. S2CID 33646901.
^ van der Klink JJ, van Dijk FJ (December 2003). "Dutch practice guidelines for managing adjustment disorders in occupational and primary health care". Scandinavian Journal of Work, Environment & Health. 29 (6): 478–487. doi:10.5271/sjweh.756. JSTOR 40967326. PMID 14712856.
^ Lastovkova A, Carder M, Rasmussen HM, Sjoberg L, Groene GJ, Sauni R, et al. (April 2018). "Burnout syndrome as an occupational disease in the European Union: an exploratory study". Industrial Health. 56 (2): 160–165. doi:10.2486/indhealth.2017-0132. PMC 5889935. PMID 29109358.
^ van Dam A (2021-09-03). "A clinical perspective on burnout: diagnosis, classification, and treatment of clinical burnout". European Journal of Work and Organizational Psychology. 30 (5): 732–741. doi:10.1080/1359432X.2021.1948400. ISSN 1359-432X. S2CID 237829018.
^ ^a ^b ^c ^d "Adjustment Disorders". www.hopkinsmedicine.org. 8 August 2021. Retrieved 2022-04-10.
^ ^a ^b "Adjustment Disorder: All You Need to Know". Psych Central. 2021-08-27. Retrieved 2022-04-10.
^ Zelviene P, Kazlauskas E, Maercker A (2020-01-10). "Risk factors of ICD-11 adjustment disorder in the Lithuanian general population exposed to life stressors". European Journal of Psychotraumatology. 11 (1): 1708617. doi:10.1080/20008198.2019.1708617. PMC 6968697. PMID 32002141.
^ ^a ^b Adjustment Disorders at eMedicine
^ Powell AD (2015). "Grief, Bereavement, and Adjustment Disorders". In Stern TA, Fava M, Wilens TE, Rosenbaum JF (eds.). Massachusetts General Hospital Comprehensive Clinical Psychiatry (2nd ed.). Elsevier. pp. 428–32. ISBN 978-0-323-32899-9.
^ Casey P, Doherty A (2012). "Adjustment disorder: Diagnostic and treatment issues". Psychiatric Times. 29: 43–46.
^ "6B43 Adjustment disorder". ICD-11 - Mortality and Morbidity Statistics. Retrieved 2019-08-28.
^ Casey P (January 2001). "Adult adjustment disorder: a review of its current diagnostic status". Journal of Psychiatric Practice. 7 (1): 32–40. doi:10.1097/00131746-200101000-00004. PMID 15990499. S2CID 24932443.
^ Casey P, Dowrick C, Wilkinson G (December 2001). "Adjustment disorders: fault line in the psychiatric glossary". The British Journal of Psychiatry. 179 (6): 479–481. doi:10.1192/bjp.179.6.479. PMID 11731347.
^ Fard K, Hudgens RW, Welner A (March 1978). "Undiagnosed psychiatric illness in adolescents. A prospective study and seven-year follow-up". Archives of General Psychiatry. 35 (3): 279–282. doi:10.1001/archpsyc.1978.01770270029002. PMID 727886.
^ Baumeister H, Kufner K (July 2009). "It is time to adjust the adjustment disorder category". Current Opinion in Psychiatry. 22 (4): 409–12. doi:10.1097/YCO.0b013e32832cae5e. PMID 19436201. S2CID 8610912.
^ "Discharges for adjustment disorder soar". 29 March 2013. Retrieved 31 July 2018.
^ Morris, N. P. (1 December 2022). "Injustice Disorder". The New England Journal of Medicine. 387 (22): 2017–2019. doi:10.1056/NEJMp2211154. ISSN 0028-4793. PMID 36440897. S2CID 254034917.
^ ^a ^b Dragan M, Grajewski P, Shevlin M (2021-01-01). "Adjustment disorder, traumatic stress, depression and anxiety in Poland during an early phase of the COVID-19 pandemic". European Journal of Psychotraumatology. 12 (1): 1860356. doi:10.1080/20008198.2020.1860356. PMC 8725738. PMID 34992743.