Adjustment disorders

Adjustment Disorders
A brief overview
-Presenter: Dr. Utkarsh Modi

Overview
• Introduction
• Evolution of the concept
• Etiology
• Epidemiology
• Diagnostic guidelines
• Reliability
• Validity
• Cultural perspective
• Clinical presentation
• Co-morbidities
• Course and prognosis
• Differential diagnosis
• Management
• Challenges/Issues
• Future prospect

Introduction
• Adjustment disorders are conceived of as developing in response to a
variety of causal stressful events, the symptoms representing an
adaptation to these stressors or to their continuing effects.
• Strays from the general phenomenological approach [Etiological
model]
• Seen as far less stigmatizing
Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9E

• Adjustment disorders have been seen as problematic for a number of
reasons:
• no criteria to qualify or quantify the stressor for an adjustment disorder in
anyway
• the symptom complex that develops has been criticized as lacking specificity.
• it is difficult in clinical practice to link an event to the development of a
symptom complex
• The temporal course between the stressor and the development of symptoms
lacks rigorous scientific evidence
• Why some individuals develop symptoms in response to a stressful
event while others do not.

Evolution of the concept
• Avicenna 11th century
• The DSM-I (1952) : Transient situational personality disorder
• DSM II : Transient situational disorder
• DSM III : “Adjustment disorder”
III R : specified that symptoms of an adjustment disorder could
not exceed 6 months.

• The DSM-IV :
• The subtypes of mixed emotional features, work inhibition,
withdrawal, and physical complaints were eliminated.
• The stressor was allowed to persist for an indefinite period of
time.
• A descriptor of chronicity was specified, whereby symptoms
persisting for greater than 6 months were deemed chronic.
DSM IV-TR

• In DSM-5,
• Now included in the Trauma- and Stressor-Related Disorders
section of the DSM-5.
• No change in the diagnostic guidelines
DSM 5

Epidemiology
• Principal diagnosis in OPD : 5% - 20%
• According to DSM-5, estimates approach 50% in hospital psychiatric
consultation settings.
• Women are more likely to be diagnosed with AD compared to men.
• Outcome of Depression International Network (ODIN) study (18),
which found a prevalence of only 1% for adjustment disorder in five
European countries
DSM 5

Prevalence of Adjustment Disorder
Adjustment Disorder: A Review of Diagnostic Pitfalls, Shay Gur
MD, Haggai Hermesh MD, Neil Laufer MD, Michal Gogol BA and
Ruth Gross-Isseroff DSc

• Studies have also found a higher rate of adjustment disorder among
persons exhibiting suicidal behavior, particularly adolescents and
young adults.
• Studies of soldiers psychiatrically evacuated from Iraq and
Afghanistan over a 3-year period found that adjustment disorder was
the most common diagnosis made in 37 percent of evacuees.
• Adjustment disorder has been reported to be almost three times as
common as major depression (13.7 vs. 5.1%) in acutely ill medical in-
patients
Adjustment disorders: the state of the art
Patricia Casey, Susan Bailey

Etiology
• Many authors in the field of adjustment disorders criticize the idea of
linking a single stressor to a symptom complex.
• The stressor The individual
Interaction
Adjustment disorders: the state of the art

Psychological vulnerability1)
• A person’s “ego strength” determines his or her vulnerability to
stressors.
• Studies of children have revealed a consistent pattern of individual
characteristics associated with successful adaptation.
• Early experience with diminished control may foster a cognitive
style characterized by an increased probability of interpreting or
processing subsequent events as out of one’s control

2) Theory of associative network formation following a
significant stressful experience.
Stimulus information about the stressor
Information about cognitive,
behavioral, and physiological
reactions to the stressor
Meaning elements representing basic
assumptions and their violation

3) Contemporary psychodynamic theory
• Focuses on the context in which an event occurs and how this
leads to symptom formation.
• A stressor leads to the generation of an affective experience.
• Which in turn leads to the desire for understanding of this
affect.
• If others fail to attune to this affect but rather criticize, reject,
or neglect the individual, then he or she is left to cope on his or
her own, leading to symptom formation.

Realization that a stressful event has occurred
Suppression of this information
Alternating intrusion of the event and attempts at suppressing it and a
working through of the information
integration of the material into one’s cognitive schema
4)

• Postulates that changes following acute stressful experiences may
lead to long-term risk factors for the future capacity to cope with
stress.
• “Allostatic load” of neurochemical networks may relate to
individual resilience
5) Biological theorists
Highest measure Lowest quartile
HPA axis DHEA
CRH Neuropeptide Y
Locus ceruleus: norepinephrine and
dopamine
5-HT1A receptor and BZD receptor
function
Estrogen activity Testosterone
Galanin

Diagnostic Criteria
• DSM 5
• ICD 10

ICD 10
• Stressor:
• significant life change or to the consequences of a stressful life event
(including the presence or possibility of serious physical illness)
• may have affected the integrity of an individual's social network or wider
system of social supports
• may involve only the individual or also his or her group or community.
• Individual predisposition or vulnerability plays a role.
• The manifestations vary.

• The onset is usually within 1 month, duration of symptoms does not
usually exceed 6 months, except in the case of prolonged depressive
reaction.
• Diagnosis depends on a careful evaluation of the relationship
between:
(a)form, content, and severity of symptoms;
(b)previous history and personality; and
(c)stressful event, situation, or life crisis.
• Normal bereavement reactions by code from Chapter XXI of ICD-10
such as Z63.4 (disappearance or death of family member) or Z73.3
(stress not elsewhere classified)

• ICD-10 points to "usually interfering with social functioning and
performance" and "some degree of disability in the performance of
daily routines" whereas
• DSM-IV/5 points to "marked distress that is in excess of what would
be expected given the nature of the stressor by significant
impairment in social or occupational functioning“
• Difference of onset duration.

Reliability
• One study showed an interrater agreement for adjustment disorders
to be 0.05 (p = not significant) in a survey of psychiatrists and
psychologists using 27 child and adolescent case histories. The results
of the UK–World Health Organization (UK-WHO) study of reliability of
the ICD-9 categories in children and adolescents were consistent with
this.
• The difficulties in differentiating between AD and MDD are
underscored in a study of Malt and colleagues.

Validity
• European Outcome of Depression International Network (ODIN)
research failed to demonstrate content validity.
• Another study to assess the predictive validity of the diagnosis
revealed that 79% percent of adults in the study were well at 5-year
follow-up. The diagnosis was not as predictive for adolescents with 57
percent well at 5 years
• As per the findings of a recent study, patients with adjustment
disorders had higher mental quality-of-life scores than patients with
major depressive disorder but lower than patients without mental
disorder.

• Those with adjustment disorder had shorter duration of
hospitalizations, more presented suicidality, fewer psychiatric
readmissions, and re-hospitalization days 2 years after discharge
• Diagnostic stability of Adjustment disorder – A retrospective two year
follow up, done in our setup, highlighted the importance of the need
of adjustment disorder to remain a separate entity.

Cultural perspectives
• It is important to consider diverse idioms of distress
• This parallels the lay concept of a “nervous breakdown” within a
particular cultural setting. In this sense, the adjustment disorders
share features with other culture-bound syndromes such as susto,
koro, and Arctic hysteria.

• The particular cultural variety of adjustment disorder will be affected
by
(1) the nature, intensity, and meaning of the stressor in question;
(2) the nature of the modal personality configuration of the people involved,
which includes style and/or rules about behavior and emotional expression;
(3) idiosyncratic features of the self in question;
(4) the meaning that adjustment disorder has in the culture.
• Modern medical culture often uses adjustment disorder as a means
of simultaneously destigmatizing and legitimatizing psychic distress.

• A 46-year-old pediatric nurse receives a negative evaluation at work
• Development of a back injury and one of her sons being diagnosed
with bipolar disorder had impaired her ability to perform adequately.
• After the evaluation she became unable to get out of bed and often
called in sick. Her mood was irritable and depressed, and she was
unable to concentrate or make decisions either at work or home, was
found crying by her children.
• Her therapist indicated that she felt that the patient was suffering
from major depression.
• The therapist agreed to use the DSM-IV-TR diagnosis for adjustment
disorder in her clinical notes and for billing purposes and that
depression would provide further evidence that she is unfit for work.
Case vignette

Clinical presentation
• The premise of an adjustment disorder is the psychological response
to an identifiable stressor that results in the development of clinically
significant emotional or behavioral symptoms within 3 months time.
• The challenge for the clinician in these situations is to differentiate a
reasonable and expected response to psychosocial stressors.
• Adjustment disorders may occur in any age group.

• Common symptoms of adjustment disorders identified in a large
study of adjustment disorder included
• depressed mood,
• low self esteem,
• suicidal behavior,
• increased motor activity,
• hypervigilance, impulsivity, and substance use.
• There is no impairment of emotional modulation, and patients may
find joy in thoughts of revenge.

• Additional symptoms may include feelings of helplessness, self-
blame, rejection of help, suicidal ideation, dysphoria, aggression,
downheartedness, seeming melancholic depression, unspecific
somatic complaints, loss of appetite, sleep disturbance, pain, phobic
symptoms in respect to the place or to persons related to the event,
and reduced drive.

Co-morbidities
• Few research studies have examined the disorders that are comorbid with
AD.
• About 70 percent of patients with adjustment disorders had at least one
additional Axis I diagnosis.
• Personality disorder was commonly co-morbid (15%) with adjustment
disorder (Strain et al., 1998).
• Distinguishing between adjustment disorder and depressive episode in
clinical practice: The role of personality disorder

• Suicidality:
• Thirty percent of AD patients have suicidal thoughts, 58% of suicide
attempters have AD, and 9–19% of those completing suicide have this
disorder.
• Several studies have reported a significant association of adjustment
disorders with suicidal ideation.
• In another study in an urban hospital setting, 56 percent of all admissions for
suicidal behavior were classified as having transient situational disorders
using the DSM-II criteria.

Differential diagnoses
• Sub-syndromal symptoms coupled with an identified psychosocial
stressor distinguish adjustment disorder from other Axis I disorders in
the DSM-IV-TR.
• Depressive disorders:
• Severity of symptoms and the degree of functional impairment. [Sub-
syndromal]
• Demographic comparisons failed to show any consistent differences, except
for younger age for AD.
• “disorder not otherwise specified” only in the absence of a preceding stressor.
The presence of a stressor warrants the diagnosis of AD. Change to the
appropriate NOS category after 6 months.

• PTSD and Acute Stress Reaction:
• The nature of the stressor and the accompanying constellation of affective
and autonomic symptoms have been far better defined and characterized for
both stress disorders.
• There are both timing and symptom profile considerations.
• With regard to symptom profiles, an adjustment disorder may be diagnosed
following a traumatic event when an individual exhibits symptoms of either
acute stress disorder or PTSD that do not meet or exceed the diagnostic
threshold for either disorder.

• Personality disorders:
• Lifetime history of personality functioning
• In the presence of a personality disorder, if the symptom criteria for an
adjustment disorder are met, and the stress-related disturbance exceeds
what may be attributable to maladaptive personality disorder symptoms (i.e..
Criterion C is met), then the diagnosis of an adjustment disorder should be
made.
DSM 5

Course and Prognosis
• The symptoms therefore have two prognostic courses: Either they resolve
or progress to amore serious illness.
• A 5-year follow-up study at the University of Iowa showed a recovery rate
of 71 percent in adults versus 44 percent in adolescents.
• While most of the adults developed major depressive disorder and alcohol
abuse, the adolescents developed a wider range of major psychiatric
disorders including schizophrenia, bipolar disorder, antisocial personality
disorder, drug abuse, and major depressive disorder.

• In 1978, Looney said that AD was found to be less severe and
disabling than other major psychiatric disorders in terms of chronicity,
length of hospitalization, and disposition.
• In a Danish survey the role of psychotropic drugs seems to be of
negative impact on the outcome of the occupational rehabilitation of
patients with stress-related adjustment disorders

• A 16-year-old high school senior experienced rejection in his first
serious relationship.
• Dysphoric mood accompanied by anxiety and psychomotor agitation.
• He had received counseling in junior-high school when his parents
divorced and he began using alcohol and marijuana.
• A month after the breakup, he began to tell his parents that life was
no longer worth living without his former girlfriend.
• Two months later his parents came home from work and found him
hanging in the garage with a note stating he could not go on alone.
Case vignette

Assessment
• Important to collect clinically relevant information through interview
and collateral informant reports.
• Adjustment Disorder module of the Mini- International
Neuropsychiatric Interview (Sheehan et al., 1998)
• Schedules for Clinical Assessment in Neuropsychiatry (Wing et al.,
1990)
• Adjustment Disorder module of the Structured Clinical Interview for
DSM-IV-TR (First et al., 1994)

• Development and validation of the Diagnostic Interview Adjustment
Disorder (DIAD) L. R. Cornelius, S. Brouwer, M. R. De Boer, J. W.
Groothoff & J. J. L. Vanderklink

Management
• Because it is conceptualized as a transitory diagnosis, brief therapies
may be most appropriate.
• There is no single treatment intervention approach for the
heterogeneous clinical manifestation of the disorder.
• The primary goals of treatment are to relieve symptoms and the
achievement of a level of adaptive functioning that is comparable to,
or in some situations better than, the level of premorbid functioning.

• Supportive psychological approaches and cognitive-behavioral and
psychodynamic interventions.
• Relaxation techniques can reduce symptoms of anxiety.
• In persons who engage in deliberate self-harm, assistance in finding
alternative responses that do not involve self-destruction may be of
benefit and to date dialectical behavior therapy (DBT) has the best
evidence base.
• Practical measures may be useful to assist the person in managing the
stressful situation.
Adjustment Disorder: epidemiology, diagnosis and treatment
Mauro Giovanni Carta, Matteo Balestrieri, Andrea Murru1 and
Maria Carolina Hardoy

• Ego enhancing therapy was found to be useful during periods of
transition in older patients. This approach promotes the coping
strategy and the and helps the patient acknowledge the stressors.
[Frankel]
• “Mirror therapy”, a therapy including psychocorporeal, cognitive, and
neurolinguistics components, was effective in patients with
adjustment disorder secondary to myocardial infarction
• Other studies have demonstrated efficacy for Kava-Kava and Ginkgo
Biloba.

• The basic pharmacological management of adjustment disorder
consists of symptomatic treatment of insomnia, anxiety and panic
attacks.
• Agents commonly used : benzodiazepines and antidepressants.
• Nguyen [80] in 2006 explored the differences in treating Adjustment
Disorder with Anxiety with etifoxine (a nonbenzodiazepine anxiolytic
drug) and lorazepam.
• A pilot study of cancer patients with anxious and depressed mood
found trazodone superior to a benzodiazepine

• It is a shared opinion that currently, psychotherapy remains the
treatment of choice for adjustment disorders.
• Maina et al. [68] in 1999 effectiveness of brief dynamic
psychotherapy and brief supportive psychotherapy in the treatment
of minor depressive episodes.
• Interpersonal psychotherapy : include psychoeducation about the
patient's role, a here and now frame work, formulation of the
problems from an interpersonal perspective, exploration of options
for changing dysfunctional behavior pattern

• Cochrane review for Interventions to facilitate return to work in
adults with adjustment disorders revealed
• Moderate-quality evidence that CBT did not significantly reduce time until
partial RTW and low-quality evidence that it did not significantly reduce time
to full RTW compared with no treatment.
• Moderate-quality evidence showed that PST significantly enhanced partial
RTW at one-year follow-up compared to non-guideline based care but did not
significantly enhance time to full RTW at one-year follow-up.
• Limitation of small number of studies included in the meta-analyses and the
small number of participants, which lowered the power of the analyses.

• The only Randomized Controlled Trial found in literature about
efficacy of Psychotherapy in AD was the study of Van der Klink ad coll.
They concluded that the experimental intervention for adjustment
disorders was successful in shortening sick leave duration, mainly by
decreasing long term problems. Based on Dutch guidelines.

Dutch Guidelines for Occupational Health physicians and GPs
Dutch practice guidelines for managing adjustment disorders in
occupational and primary health care by van der Klink JJL, van
Dijk FJH

Dutch practice guidelines for managing adjustment disorders in
occupational and primary health care by van der Klink JJL, van
Dijk FJH

Challenges/Issues
• Criticized as “wastebasket” or “afterthought” diagnosis.
• As another manifestation of the increased medicalization of life problems as
well as the hegemony of biological models in psychiatry at the expense of
social, psychological, cultural, and spiritual conceptualizations and responses
to illness.
• Failure of diagnosis to present an essential relationship of an external stressor
and internal diathesis.
• Use of AD for presentations that fail to meet the criteria of other Axis I
diagnoses, particularly major or minor depressions.
• Main utility was to serve as a “justification” for diagnosis-based
reimbursement operating in the healthcare system of the US.

• Stressor criteria :
• The DSM-IV-TR states only that the stressor is identifiable but
makes no mention as to what would qualify as a stressor.
• Duration criteria:
• The diagnosis of adjustment disorder specifies that the symptoms
do not persist for more than 6 months once the stressor—or its
consequences—have terminated. It is extremely difficult for a
clinician to gauge when a stressor is no longer a stressor.

• Anti-theoretical framework the DSM and ICD classifications
• Which were designed conceptually to encourage psychiatric diagnoses to be
derived on phenomenological grounds with an avowed dismissal of
pathogenesis or etiology as diagnostic imperatives.
• The application of the diagnosis based not just on objective criteria
but on attempts to find a treatment opens up a deontological
problem, and points out the limits of resolution in detecting
psychiatric morbidity
Casey P: Adult adjustment disorder: a review of its current

Future direction
• Creating an interactive model that takes into account both stress and
resiliency factors that are responsive to individual and cultural differences
remains challenging.
• Obstacles are linked to the inadequate operationalization of adjustment
disorders, we need to adjust the adjustment disorder category to
overcome the present shortcomings.
• Although has been widely criticized diagnosis with vague criteria and
questionable reliability/validity, it remains as one of the most commonly
diagnosed disorder.
It is time to adjust the adjustment disorder category
Harald Baumeister and Katharina Kufner

Summary
• Definition: Cluster of symptoms which are in excess of the normal
reaction to a stressor. Types or stressors and subtypes of AD.
• Etiological model
• Often used to protect patients for medical, life and disability
insurances.
• Evolution from DSM I to DSM 5, starting off with WW II.
• A common diagnosis in consultation liaison setting and OPD as well.
Although no large epidemiological study supporting the figures due to
poor assessment tools.

• Various etiological models
• Diagnostic guidelines – DSM 5 and ICD 10 and the differences.
• Doubts regarding validity and reliability of the diagnosis with
insufficient and varying data to support either claims.
• Cultural perspectives
• Clinical presentation/Differential diagnoses to be considered
• Association with suicidality, personality disorders and substance use.
• Variable course, but mainly seen as a self limiting disorder.
• Management – Psychotherapy, pharmacotherapy and practical
changes. Dutch guidelines for GPs and occupational therapists.
• Challenges and issues with the diagnosis

References
• Kaplan and Sadock’s Comprehensive Textbook of Psychiatry
• Adjustment disorders: the state of the art: Patricia Casey, Susan Bailey
• Adjustment Disorder: epidemiology, diagnosis and treatment: Mauro
Giovanni Carta, Matteo Balestrieri, Andrea Murru and Maria Carolina
Hardoy
• Interventions to facilitate return to work in adults with adjustment
disorders (Review) Arends I, Bruinvels DJ, Rebergen DS, Nieuwenhuijsen K,
Madan I Neumeyer-Gromen A, Bültmann U, Verbeek JH
• Development and validation of the Diagnostic Interview Adjustment
Disorder (DIAD) L. R. Cornelius, S. Brouwer, M. R. De Boer, J. W. Groothoff
& j. J. L. Vanderklink

• Adjustment Disorder: A Review of Diagnostic Pitfalls: Shay Gur MD,
Haggai Hermesh MD, Neil Laufer MD, Michal Gogol BA and Ruth
Gross-Isseroff DSc
• It is too early for adjusting the adjustment disorder category Jonathan
Laugharne, Gillian van der Watt and Aleksandar Janca
• It is time to adjust the adjustment disorder category: Harald
Baumeister and Katharina Kufner
• Adjustment disorder: implications for ICD-11 and DSM-5{ Patricia
Casey and Anne Doherty
• Dutch practice guidelines for managing adjustment disorders in
occupational and primary health care by van der Klink JJL, van Dijk FJH

Adjustment disorders

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