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Introduction

Adjustment disorder (AjD) is a maladaptive response to a psychosocial stressor that occurs when an individual has significant difficulty adjusting to or coping with a stressful psychosocial event. The maladaptive response usually involves otherwise normal emotional and behavioural reactions that manifest more intensely than usual (taking into account contextual and cultural factors), causing marked distress, preoccupation with the stressor and its consequences, and functional impairment.

Diagnosis of AjD is quite common; there is an estimated incidence of 5-21% among psychiatric consultation services for adults. Adult women are diagnosed twice as often as are adult men. Among children and adolescents, girls and boys are equally likely to receive this diagnosis. AjD was introduced into the Diagnostic and Statistical Manual of Mental Disorders in 1980. Prior to that, it was called “transient situational disturbance.”

Signs and Symptoms

Some emotional signs of AjD are:

• Sadness;
• Hopelessness;
• Lack of enjoyment;
• Crying spells;
• Nervousness;
• Anxiety;
• Desperation;
• Feeling overwhelmed and thoughts of suicide; and
• Performing poorly in school/work etc.

Common characteristics of AjD 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 AjD, which are characterised 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. AjD may be acute or chronic, depending on whether it lasts more or less than six months. According to the DSM-5, if the AjD lasts less than six months, then it may be considered acute. If it lasts more than six months, it may be considered chronic. Moreover, the symptoms cannot last longer than six months after the stressor(s), or its consequences, have terminated. However, the stress-related disturbance does not only exist as an exacerbation of a pre-existing mental disorder.

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 behaviour is prominent among people with AjD 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 AjD attempted suicide immediately before their index admission and they remitted faster than a comparison group with major depression. Asnis et al. (1993) found that AjD patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression. According to a study on 82 AjD 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. Pelkonen et al. (2005) states statistically that the stressors are of one-half related to parental issues and one-third in peer issues.

One hypothesis about AjD is that it may represent a sub-threshold clinical syndrome.

Risk Factors

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; children are also less likely to assess the consequences of a potential stressor.

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 neighbourhood. 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 is of secondary importance. Stressors’ most crucial link to their pathogenic potential is their perception by the patient as stressful. The presence of a causal stressor is essential before a diagnosis of adjustment disorder can be made.

There are certain stressors that are more common in different age groups:

• 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.

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 AjD. In addition, the diagnosis of AjD is less clear when patients are exposed to stressors long-term, because this type of exposure is associated with AjD and major depressive disorder (MDD) and generalised anxiety disorder (GAD).

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.

Adjustment disorders have the ability to be self-limiting. Within five years of when they are originally diagnosed, approximately 20-50% of the sufferers go on to be diagnosed with psychiatric disorders that are more serious.

ICD-11 Classification

International Statistical Classification of Diseases and Related Health Problems (ICD), assigns codes to classify diseases, symptoms, complaints, social behaviours, injuries, and such medical-related findings.

ICD-11 classifies Adjustment disorder (6B43) under “Disorders specifically associated with stress”.

Treatment

There has been little systematic research regarding the best way to manage individuals with an adjustment disorder. Because natural recovery is the norm, it has been argued that there is no need to intervene unless levels of risk or distress are high. However, for some individuals treatment may be beneficial. AjD sufferers with depressive or anxiety symptoms may benefit from treatments usually used for depressive or anxiety disorders. One study found that AjD sufferers received similar interventions to those with other psychiatric diagnoses, including psychological therapy and 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 TV; and/or
• 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 health-care field. First, there has been criticism of its classification. It has been criticised for its lack of specificity of symptoms, behavioural parameters, and close links with environmental factors. Relatively little research has been done on this condition.

An editorial in the British Journal of Psychiatry described adjustment disorder as being so “vague and all-encompassing… as to be useless,” 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-stigmatising label, particularly for patients who need a diagnosis for insurance coverage of therapy.

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

References

Asnis, G.M., Friedman, T.A., Sanderson, W.C., Kaplan, M.L., van Praag, H.M. & Harkavy-Friedman, J.M. (1993) Suicidal Behavior in Adult Psychiatric Outpatients, I: Description and Prevalence. American Journal of Psychiatry. 150(1), pp.108-112. doi:10.1176/ajp.150.1.108.

Bolu, A., Doruk, A., Ak, M., Özdemir, B. & Özgen, F. (2012) Suicidal Behavior in Adjustment Disorder Patients. Dusunen Adam. 25(1), pp.58-62.

Bronish, T. & Hecht, H. (1989) Validity of Adjustment Disorder, Comparison with Major Depression. Journal of Affective Disorders. 17, pp.229-236.

Pelkonen, M., Marttunen, M., Henriksson, M. & Lönnqvist, J. (2005) Suicidality in Adjustment Disorder: Clinical Characteristics of Adolescent Outpatients. European Child & Adolescent Psychiatry. 14(3), pp.174-180. doi:10.1007/s00787-005-0457-8.