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Adjustment Disorders

Adjustment disorders

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.

KEY TERMS

Anxiety Worry or tension in response to real or imagined stress, danger, or dreaded situations. Physical reactions, such as fast pulse, sweating, trembling, fatigue, and weakness, may accompany anxiety.

Cognitive-behavioral therapy A type of psychotherapy in which people learn to recognize and change negative and self-defeating patterns of thinking and behavior.

Defense mechanisms Indirect strategies used to reduce anxiety rather than directly facing the issues causing the anxiety.

Depression A mental condition in which a person feels extremely sad and loses interest in life. A person with depression may also have sleep problems and loss of appetite and may have trouble concentrating and carrying out everyday activities.

Post-traumatic stress disorder (PTSD) A disorder that occurs among survivors of extremely stressful or traumatic events, such as a natural disaster, an airplane crash, rape, or military combat. Symptoms include anxiety, insomnia, flashbacks, and nightmares. Patients with PTSD are unnecessarily vigilant; they may experience survivor guilt, and they sometimes cannot concentrate or experience joy.

Psychological evaluation Examination of a patient by a psychologist through interviews, observation of behavior, and psychological testing with the goal of determining personality adjustment, identifying problems, and helping to diagnose and plan treatment for a mental disorder.

Psychotherapy Psychological counseling that seeks to determine the underlying causes of a patient's depression. The form of this counseling may be cognitive/behavioral, interpersonal, or psychodynamic.

Psychotropic drug Any medication that has an effect on the mind, brain, behavior, perceptions, or emotions. Psychotropic medications are used to treat mental illnesses because they affect a patients moods and perceptions.

Stressor A stimulus, or event, that provokes a stress response in an organism. Stressors can be categorized as acute or chronic, and as external or internal to the organism.

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 200163007. Web site: <www.aacap.org>.

Federation of Families for Children's Mental Health. 1021 Prince Street, Alexandria, VA 223142971. 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).

Joan Schonbeck, R.N.

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Adjustment Disorders

Adjustment Disorders

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 life-style. 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.

Causes and symptoms

An adjustment disorder occurs when a person can't cope with a stressful event and develops emotional or behavioral symptoms. The stressful event can be anything: it might be just one isolated incident, or a string of problems that wears the person down. The stress might be anything from a car accident or illness, to a divorce, or even a certain time of year (such as Christmas or summer).

People with adjustment disorder may have a wide variety of symptoms. How those symptoms combine depend on the particular subtype of adjustment disorder and on the individual's personality and psychological defenses. Symptoms normally include some (but not all) of the following:

  • hopelessness
  • sadness
  • crying
  • anxiety
  • worry
  • headaches or stomachaches
  • withdrawal
  • inhibition
  • truancy
  • vandalism
  • reckless driving
  • fighting
  • other destructive acts

Diagnosis

It is extremely important that a thorough evaluation rule out other more serious mental disorders, since the treatment for adjustment disorder may be very different than for other mental problems.

In order to be diagnosed as a true adjustment disorder, the level of distress must be more severe than what would normally be expected in response to the stressor, or the symptoms must significantly interfere with a person's social, job, or school functioning. Normal expression of grief, in bereavement for instance, is not considered an adjustment disorder.

KEY TERMS

Multiple sclerosis A progressive disorder of the central nervous system in which scattered patches of the protective sheath covering the nerves is destroyed. The disease, which causes progressive paralysis, is marked by periods of exacerbation and remission. There is no cure.

Post-traumatic stress disorder (PTSD) A specific form of anxiety that begins after a life-threatening event, such as rape, a natural disaster, or combat-related trauma.

Treatment

Psychotherapy (counseling) is the treatment of choice for adjustment disorders, since the symptoms are an understandable reaction to a specific stress. The type of therapy depends on the mental health expert, but it usually is short-term treatment that focuses on resolving the immediate problem.

Therapy usually will help clients:

  • develop coping skills
  • understand how the stressor has affected their lives
  • develop alternate social or recreational activities

Family or couples therapy may be helpful in some cases. Medications are not usually used to treat adjustment disorders, although sometimes a few days or weeks of an anti-anxiety drug can control anxiety or sleeping problems.

Self-help groups aimed at a specific problem (such as recovering from divorce or job loss) can be extremely helpful to people suffering from an adjustment disorder. Social support, which is usually an important part of self-help groups, can lead to a quicker recovery.

Prognosis

Most people recover completely from adjustment disorders, especially if they had no previous history of mental problems, and have a stable home life with strong social support. People with progressive or cyclic disorders (such as multiple sclerosis) may experience an adjustment disorder with each exacerbation period.

Resources

BOOKS

Luther, Suniya G., Jacob A. Burack, and Dante Cicchetti. Developmental Psychopathology: Perspectives on Adjustment, Risk, and Disorder. London: Cambridge University Press, 1997.

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Adjustment Disorders

Adjustment disorders

The development of significant emotional or behavioral symptoms in response to an identifiable event that precipitated significant psychological or social stress.

Adjustment disorders are maladpative, or unhealthy, responses to stressful or psychologically distressing life events, such as the end of a romantic relationship or being terminated from a job.

The American Psychiatric Association has identified and categorized several varieties of adjustment disorders, depending on accompanying symptoms and their duration. These subtypes include adjustment disorder with depressed mood , with anxiety, with anxiety and depressed mood, and with disturbances of conduct. The disorders can additionally be classified as acute or chronic. It is thought that adjustment disorders are fairly common; recent figures estimate that 5 to 20 percent of persons seeking outpatient psychological treatment suffer from one of these disorders. Psychiatrists rigidly define the time frames in which these disorders can occur to differentiate them from other types of responses to stressful events, such as post-traumatic stress disorder and acute stress disorder. Adjustment disorders must occur within three months of the stressful event and can, by definition, last no longer than six months.

Symptoms of these various adjustment disorders include a decrease in performance at work or school, and withdrawal from social relationships. These disorders can lead to suicide or suicidal thinking and can complicate the course of other diseases when, for instance, a sufferer loses interest in taking medication as prescribed or adhering to difficult diets or exercise regimens.

Adjustment disorders can occur at any stage of life. In early adolescence , individuals with adjustment disorders tend to be angry, aggressive, and defiant. Temper tantrums are common and are usually well out of balance with the event that caused them. Other adolescents with adjustment disorders may, alternately, become passive and withdrawn, and older teens often experience intense anxiety or depression . They may experience what psychologists call "depersonalization," a state in which a person feels he or she can observe their body interacting with others, but feels nothing.

Many psychological theorists and researchers consider adjustment disorders in adolescents as 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 their parents. This sort of psychological maneuver may precipitate problems in families as adolescents begin seeking individuals outside the family as replacements for their parents. This can be particularly destructive when these feelings of dependence are transferred to involvement with gangs or cults .

Further Reading

Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994.

Nicholi, Armand, ed. The New Harvard Guide to Psychiatry. Cambridge, MA: Harvard University Press, 1988.

"The Not-So Maddening Crowd: Crowding Stress Leads to Coping Behavior in Primates." Discover (February 1994): 14.

Shanok, Rebecca. "Coping with Crisis." Parents Magazine (October 1991): 169.

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Adjustment Disorders

Adjustment Disorders

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Adjustment disorders are a group of disorders in which a person’s psychological response to a stressor elicits symptoms that warrant clinical attention. This uniting feature of the adjustment disorders can manifest as emotional distress that exceeds what is an expected norm or by notable impairment of the person’s functioning in the world, socially, academically, and/or occupationally.

Description

Often, a person experiences a stressful event as one that changes his or her world in some fundamental way. An adjustment disorder represents significant difficulty in adjusting to the new reality. Subsets of this disorder make up the most frequent psychiatric diagnoses among mentally ill populations, with features that include depression and anxiety. Many clinicians believe that it is difficult to discern a difference between a reaction to stress that falls within a population norm and when the line has been crossed into symptoms warranting a diagnosis of adjustment disorder. This difficulty, according to some experts, lies in the presentation of disorders in the Diagnostic and Statistical Manual of Mental Disorders-IV, Text Revision (also known as the DSM-IV-TR) as a dichotomy between what happens in the mind and what occurs physically in the body. Research results increasingly support that the dichotomy may not be tenable.

The DSM-IV-TR lists six subtypes of adjustment disorder, generally based on what feature best characterizes the person’s symptoms. These six subtypes are adjustment disorder with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with disturbance of emotions and conduct, or adjustment disorder unspecified. This last subtype is applied when one of the other five simply does not fit the manifestations.

The criteria for these disorders also include time parameters. One of the criteria for diagnosing an adjustment disorder is that it is an acute response, lasting six or fewer months. However, in some special cases, the response can be chronic, lasting longer than six months, usually when the stressor has lasting consequences.

The stressful events that precipitate an adjustment disorder vary widely. They may include the loss of a job; the end of a romantic relationship; a life transition such as a career change or retirement; or a serious accident or sickness. Some are acute “one-time” stressors, such as relocating to a new area, while others are chronic, such as caring for a child with mental retardation.

In spite of the disagreement among professionals about the validity of the diagnosis of adjustment disorder, many researchers consider the category useful for two reasons: (1) an adjustment disorder may be an early sign of a major mental disorder and allow for early treatment and intervention; and (2) adjustment disorders are “situational” or “reactive” and do not imply that the patient has an underlying brain disease.

Causes and symptoms

Causes

In the initial edition of the DSM-IV, the identifiable stressor was described as being “psychosocial,” a category that excludes physical illnesses and natural disasters. In the DSM-IV-TR, the word “psychosocial” was deleted to make the point that any stressful event can lead to an adjustment disorder. It is important to recognize, however, that while adjustment disorders are triggered by external stressors, the symptoms result from the person’s interpretation of and adaptation to the stressful event or circumstances. Beliefs, perceptions, fears, and expectations influence the development of an adjustment disorder.

People with chronic physical illnesses appear to have an increased risk of developing adjustment disorders, particularly one with depressed mood. This connection has been demonstrated among cancer patients. The relationship between chronic pain (as is commonly experienced by cancer patients) and depressive symptoms is still being studied.

Symptoms

Unlike many other disorders categorized in the DMS-IV-TR, adjustment disorders do not have an accompanying clearly delineated symptom profile, which has led to its being perceived as a “transitional” diagnosis, awaiting the manifestation of symptoms more clearly related to some other, better-defined disorder. This ambiguity arises from the difficulty in establishing what defines a reaction within the norms of a population. The DSM-IV-TR states that the symptoms of an adjustment disorder must appear within three months of a stressor; and that they must meet at least one of the following criteria: (1) the distress is greater than what would be expected in response to that particular stressor; or (2) the patient experiences significant impairment in social relationships or in occupational or academic settings. Moreover, the symptoms cannot represent bereavement, as normally experienced after the death of a loved one and cannot be an exacerbation of another, preexisting disorder and does not meet the criteria for another disorder.

Each of the six subtypes of adjustment disorder is characterized by its own predominant symptoms:

  • With depressed mood: The chief manifestations are feelings of sadness and depression, with a sense of accompanying hopelessness. The patient may be tearful and have uncontrollable bouts of crying.
  • With anxiety: The patient is troubled by feelings of apprehension, nervousness, and worry. He or she may also feel jittery and unable to control his or her thoughts of doom. Children with this subtype may express fears of separation from parents or other significant people, and refuse to go to sleep alone or attend school.
  • With mixed anxiety and depressed mood: The patient has a combination of symptoms from the previous two subtypes.
  • With disturbance of conduct: This subtype involves such noticeable behavioral changes as shoplifting, truancy, reckless driving, aggressive outbursts, or sexual promiscuity. The patient disregards the rights of others or previously followed rules of conduct with little concern, guilt or remorse.
  • With mixed disturbance of emotions and conduct: The patient exhibits sudden changes in behavior combined with feelings of depression or anxiety. He or she may feel or express guilt about the behavior, but then repeat it shortly thereafter.
  • Unspecified: This subtype covers patients who are adjusting poorly to stress but who do not fit into the other categories. These patients may complain of physical illness and pull away from social contact.

Adjustment disorders may lead to suicide or suicidal thinking. They may also complicate the treatment of other diseases when, for instance, a sufferer loses interest in taking medication as prescribed or adhering to diets or exercise regimens.

An adjustment disorder can occur at any stage of life.

Demographics

Even though this disorder is so commonly diagnosed, there have been few large-scale epidemiological studies targeting adjustment disorders. Adjustment disorder appears to be fairly common in the American population; recent figures estimate that 5-20% of adults seeking outpatient psychological treatment have one of the subtypes of this disorder. As many as 70% of children in psychiatric inpatient settings may be diagnosed with an adjustment disorder. In a questionnaire sent to child psychiatrists in the early 1990s, 55% admitted to giving children the diagnosis of an adjustment disorder to avoid the stigma associated with other disorders.

Women are diagnosed with adjustment disorder twice as often as men, and diagnosis is also more frequent in females among adolescents.

There are no current studies of differences in the frequency of adjustment disorder in different racial or ethnic groups. There is, however, some potential for bias in diagnosis, particularly when the diagnostic criteria concern abnormal responses to stressors. The DSM-IV-TR specifies that clinicians must take a patient’s cultural background into account when evaluating his or her responses to stressors.

Diagnosis

Adjustment disorders are almost always diagnosed as the result of an interview with a psychiatrist. The psychiatrist will take a history, including identification of the stressor that has triggered the adjustment disorder, and evaluate the patient’s responses to the stressor. The patient’s primary physician may give him or her a thorough physical examination to rule out a previously undiagnosed medical illness.

The American Psychiatric Association considers adjustment disorder to be a residual category, meaning that the diagnosis is given only when an individual does not meet the criteria for a major mental disorder. For example, if a person fits the more stringent criteria for major depressive disorder, the diagnosis of adjustment disorder is not given. If the patient is diagnosed with an adjustment disorder but continues to have symptoms for more than six months after the stressor and its consequences have ceased, the diagnosis is changed to another mental disorder. The one exception to this time limit is situations in which the stressor itself is chronic or has enduring consequences. In that case, the adjustment disorder would be considered chronic and the diagnosis could stand beyond six months.

The lack of a diagnostic checklist distinguishes adjustment disorders from either post-traumatic stress disorder or acute stress disorder. All three require the presence of a stressor, but the latter two define the extreme stressor and specific patterns of symptoms. With adjustment disorder, the stressor may be any event that is significant to the patient, and the disorder may take very different forms in different patients.

Adjustment disorders must also be distinguished from personality disorders, which are caused by enduring personality traits that are inflexible and cause impairment. A personality disorder that has not yet surfaced may be made worse by a stressor and may mimic an adjustment disorder. A clinician must separate relatively stable traits in a patient’s personality from passing disturbances. In some cases, however, the patient may be given both diagnoses. Again, it is important for psychiatrists to be sensitive to the role of cultural factors in the presentation of the patient’s symptoms.

If the stressor is a physical illness, diagnosis is further complicated. It is important to recognize the difference between an adjustment disorder and the direct physiological effects of a general medical condition (e.g. the usual temporary functional impairment associated with chemotherapy). This distinction can be clarified through communication with the patient’s physician or by education about the medical condition and its treatment. For some individuals, however, both may occur and reinforce each other.

Treatments

There have been few research studies of significant scope to compare the efficacy of different treatments for adjustment disorder. The relative lack of outcome studies is partially due to the lack of specificity in the diagnosis itself. Because there is such variability in the types of stressors involved in adjustment disorders, it has proven difficult to design effective studies. As a result, there is no consensus regarding the most effective treatments for adjustment disorder.

Psychological and social interventions

There are, however, guidelines for effective treatment of people with adjustment disorders. Effective treatments include stress-reduction approaches; therapies that teach coping strategies for stressors that cannot be reduced or removed; and those that help patients build support networks of friends, family, and people in similar circumstances. Psychodynamic psychotherapy may be helpful in clarifying and interpreting the meaning of the stressor for a particular patient. For example, if the person has cancer, he or she may become more dependent on others, which may be threatening for people who place a high value on self-sufficiency. By exploring those feelings, the patient can then begin to recognize all that is not lost and regain a sense of self-worth.

Therapies that encourage the patient to express the fear, anxiety, rage, helplessness, and hopelessness of dealing with the stressful situation may be helpful. These approaches include journaling, certain types of art therapy, and movement or dance therapy. Support groups and group therapy allow patients to gain perspective on the adversity and establish relationships with others who share their problem. Psychoeducation and medical crisis counseling can assist individuals and families facing stress caused by a medical illness.

Such types of brief therapy as family therapy, cognitive-behavioral therapy, solution-focused therapy, and interpersonal therapy have all met with some success in treating adjustment disorder.

Medications

Clinicians do not agree on the role of medications in treating adjustment disorder. Some argue that medication is not necessary for adjustment disorders because of their brief duration. In addition, they maintain that medications may be counterproductive by undercutting the patient’s sense of responsibility and his or her motivation to find effective solutions. At the other end of the spectrum, other clinicians maintain that medication by itself is the best form of treatment, particularly for patients with medical conditions, those who are terminally ill, and those resistant to psychotherapy. Others advocate a middle ground of treatment that combines medication and psychotherapy.

Alternative therapies

Spiritual and religious counseling can be helpful, particularly for people coping with existential issues related to physical illness.

Some herbal remedies appear to be helpful to some patients with adjustment disorders. For adjustment disorder with anxiety, a randomized controlled trial found that the 91 patients receiving Euphytose (an herbal preparation containing a combination of plant extracts including Crataegus, Ballota, Passiflora, Valeriana, Cola, and Paullinia) showed significant improvement over the 91 patients taking a placebo. There have been no reported follow-up studies confirming these findings.

Prognosis

Most adults who are diagnosed with adjustment disorder have a favorable prognosis. For most people, an adjustment disorder is temporary and will either resolve by itself or respond to treatment. For some, however, the stressor will remain chronic and the symptoms may worsen. Still other patients may develop a major depressive disorder even in the absence of an additional stressor.

Studies have been conducted to follow up on patients five years after their initial diagnosis. At that time, 71% of adults were completely well with no residual symptoms, while 21% had developed a major depressive disorder or alcoholism. For children aged 8-13, adjustment disorder did not predict future psychiatric disturbances. For adolescents, the prognosis is grimmer. After five years, 43% had developed a major psychiatric disorder, often of far greater severity. These disorders included schizophrenia, schizoaffective disorder, major depression, substance use disorders, or personality disorders. In contrast with adults, the adolescents’ behavioral symptoms and the type of adjustment disorder predicted future mental disorders.

Researchers have noted that once an adjustment disorder is diagnosed, psychotherapy, medication, or both can prevent the development of a more serious mental disorder. Effective treatment is critical, as adjustment disorder is associated with an increased risk of suicide attempts, completed suicide, substance abuse, and various unexplained physical complaints. Patients with chronic stressors may require ongoing treatment for continued symptom management. While

KEY TERMS

Cognitive-behavioral therapy —An approach to psychotherapy that emphasizes the correction of distorted thinking patterns and changing one’s behaviors accordingly.

Group therapy —Group interaction designed to provide support, correction through feedback, constructive criticism, and a forum for consultation and reference.

Interpersonal therapy —An approach that includes psychoeducation about the sick role, and emphasis on the present and improving interpersonal dynamics and relationships. Interpersonal therapy is effective in treating adjustment disorders related to physical illness.

Psychosocial —A term that refers to the emotional and social aspects of psychological disorders.

Solution-focused therapy —A type of therapy that involves concrete goals and an emphasis on future direction rather than past experiences.

Stressor —A stimulus or event that provokes a stress response in an organism. Stressors can be categorized as acute or chronic, and as external or internal to the organism.

Support group —A group whose primary purpose is the provision of empathy and emotional support for its members. Support groups are less formal and less goal-directed than group therapy.

patients may not become symptom-free, treatment can halt the progression toward a more serious mental disorder by enhancing the patient’s ability to cope.

Prevention

In many cases, there is little possibility of preventing the stressors that trigger adjustment disorders. One preventive strategy that is helpful to many patients, however, is learning to be proactive in managing ordinary life stress, and maximizing their problem-solving abilities when they are not in crisis. In addition, the general availability of counseling following a large-scale stressful event may ameliorate some stress responses.

See alsoAnxiety-reduction techniques; Bodywork therapies; Cognitive retraining techniques; Generalized anxiety disorder; Cognitive problem-solving skills training.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.

Araoz, Daniel L., and Marie Carrese. Solution-Oriented Brief Therapy for Adjustment Disorders: A Guide for Providers Under Managed Care. New York: Brunner/Mazel, 1996.

Gabbard, Glen O., MD. “Adjustment Disorders.” Treatment of Psychiatric Disorders, written by James. J. Strain, MD, Anwarul Karim, MD, and Angela Cartagena Rochas, MA. 3rd ed, Vol. 2. Washington, D.C.: American Psychiatric Press, 2001.

Nicholi, Armand, ed. The New Harvard Guide to Psychiatry. Cambridge, MA: Harvard University Press, 1988.

PERIODICALS

Angelino, Andrew F., and Glenn J. Treisman. “Major Depression and Demoralization in Cancer Patients: Diagnostic and Treatment Considerations.” Supportive Cancer Care (November 2000): 344–49.

Casey, P., and others. “Can Adjustment Disorder and Depressive Episode Be Distinguished?” Journal of Affective Disorders 92 (2006): 291–97.

Grassi, Luigi, and others. “Psychosomatic Characterization of Adjustment Disorders in the Medical Setting: Some Suggestions for DSM-V.” Journal of Affective Disorders (2006).

Jones, Rick, and others. “Outcome for Adjustment Disorder with Depressed Mood: Comparison with Other Mood Disorders.” Journal of Affective Disorders (1999): 55.

Pelkonen, Mirjami, and others. “Adolescent Adjustment Disorder: Precipitant Stressors and Distress Symptoms of 89 Outpatients.” European Psychiatry (2006).

Strain, James J., and others. “Adjustment Disorder: A Multisite Study of its Utilization and Interventions in the Consultation-Liaison Psychiatry Setting.” General Hospital Psychiatry (1998): 20.

ORGANIZATIONS

National Institute of Mental Health. 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD 20892-9663. Telephone: (301) 443-4513. <http://nimh.nih.gov>.

OTHER

National Cancer Institute. National Institutes of Health. “The Adjustment Disorders.” <http://www.cancer.gov/cancertopics/pdq/supportivecare/adjustment/HealthProfessional/page4>.

National Library of Medicine. National Institutes of Health. <http://www.nlm.nih.gov/medlineplus/ency/article/000932.htm>.

Holly Scherstuhl, M.Ed.

Emily Jane Willingham, PhD

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Adjustment Disorders

Adjustment disorders

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 posttraumatic 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. In such cases, the adjustment disorder may last more than six months.

Causes and symptoms

An adjustment disorder occurs when a person can't cope with a stressful event and develops emotional or behavioral symptoms. The stressful event can be anything: it might be just one isolated incident, or a string of problems that wears the person down. The stress might be anything from the loss of a loved one or spouse, to a divorce, or even a certain time of year (such as Christmas or summer).

KEY TERMS

Multiple sclerosis —A progressive disorder of the central nervous system in which scattered patches of the protective sheath covering the nerves is destroyed. The disease, which causes progressive paralysis, is marked by periods of exacerbation and remission. There is no cure.

Post-traumatic stress disorder (PTSD) —A specific form of anxiety that begins after a life-threatening event, such as rape, a natural disaster, or combat related trauma.

People with adjustment disorder may have a wide variety of symptoms. How those symptoms combine depending on the particular subtype of adjustment disorder and on the individual's personality and psychological defenses. Symptoms normally include some (but not all) of the following:

  • hopelessness
  • sadness
  • crying
  • anxiety
  • worry
  • headaches or stomachaches
  • withdrawal
  • inhibition
  • truancy
  • vandalism
  • reckless driving
  • fighting
  • other destructive acts

Diagnosis

It is extremely important that a thorough evaluation rule out other more serious mental disorders, since the treatment for adjustment disorder may be very different than for other mental problems.

In order to be diagnosed as a true adjustment disorder, the level of distress must be more severe than what would normally be expected in response to the stressor, or the symptoms must significantly interfere with a person's social or daily functioning. Normal expression of grief, in bereavement for instance, is not considered an adjustment disorder.

Treatment

Psychotherapy (counseling) is the treatment of choice for adjustment disorders, since the symptoms are an understandable reaction to a specific stress. The type of therapy depends on the mental health expert, but it usually is short-term treatment that focuses on resolving the immediate problem.

Therapy usually will help clients:

  • develop coping skills
  • understand how the stressor has affected their lives
  • develop alternate social or recreational activities

Family or couples therapy may be helpful in some cases. Medications are not usually used to treat adjustment disorders, although sometimes a few days or weeks of an anti-anxiety drug can control anxiety or sleeping problems.

Self-help groups aimed at a specific problem (such as recovering from divorce or job loss) can be extremely helpful to people suffering from an adjustment disorder. Social support, which is usually an important part of self-help groups, can lead to a quicker recovery.

Prognosis

Most people recover completely from adjustment disorders, especially if they had no previous history of mental problems, and have a stable home life with strong social support. People with progressive or cyclic disorders (such as multiple sclerosis ) may experience an adjustment disorder with each exacerbation period.

Resources

BOOKS

Luther, Suniya G., Jacob A. Burack, and Dante Cicchetti. Developmental Psychopathology: Perspectives on Adjustment, Risk, and Disorder. London: Cambridge University Press, 1997.

Carol A. Turkington

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