10 Casey 01-01.qxd      1/8/01      1:19 PM       Page 32         Adult Adjustment Disorder: A Review of         Its Curre...
10 Casey 01-01.qxd     1/8/01     1:19 PM   Page 33                                               ADULT ADJUSTMENT DISORDE...
10 Casey 01-01.qxd      1/8/01    1:19 PM    Page 34                                                 ADULT ADJUSTMENT DISO...
10 Casey 01-01.qxd     1/8/01     1:19 PM   Page 35                                               ADULT ADJUSTMENT DISORDE...
10 Casey 01-01.qxd    1/8/01    1:19 PM     Page 36                                                ADULT ADJUSTMENT DISORD...
10 Casey 01-01.qxd     1/8/01     1:19 PM   Page 37                                              ADULT ADJUSTMENT DISORDER...
10 Casey 01-01.qxd    1/8/01    1:19 PM    Page 38                                               ADULT ADJUSTMENT DISORDER...
10 Casey 01-01.qxd     1/8/01     1:19 PM   Page 39                                               ADULT ADJUSTMENT DISORDE...
10 Casey 01-01.qxd         1/8/01      1:19 PM        Page 40                                                          ADU...
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Adult adjustment disorder__a_review

  1. 1. 10 Casey 01-01.qxd 1/8/01 1:19 PM Page 32 Adult Adjustment Disorder: A Review of Its Current Diagnostic Status PATRICIA CASEY, FRCPSYCH, FRCPI, MD Adjustment disorder is a diagnosis that is com- djustment disorder is a common diagnosis, par- monly used, particularly in primary care and gen- eral medical settings. However, there has been relatively little research done on this disorder. In this article, the author reviews the information that is available on the epidemiology, clinical fea- A ticularly in primary care and general medical settings. However, surprisingly little has been written to guide the clinician about adjustment disorder, in part because this disorder has not been the subject of much research. In this article, I collate the tures, validity, measurement, and treatment of available information on the epidemiology, clinical fea- adjustment disorder. She first reviews the histori- tures, validity, measurement, and treatment of adjust- cal development of the diagnosis from transient ment disorder. I also outline the controversies concerning situational personality disorder in DSM-I to its adjustment disorder and highlight the many lacunae that current definition in DSM-IV. The author also con- exist in our understanding of this disorder. siders similarities and differences in how adjust- ment disorder is defined in the DSM and ICD DEFINITION AND HISTORY OF THE systems. The clinical features of the disorder that ADJUSTMENT DISORDER DIAGNOSIS distinguish it from disorders such as major depres- sive disorder, generalized anxiety disorder, post- Diagnostic and Statistical Manual traumatic stress disorder, and acute stress The concept of adjustment disorder has been some time disorder are described. The author highlights a in evolution. In DSM-I, it was characterized as transient number of the common controversies concerning situational personality disorder, to be replaced in DSM-II adjustment disorder, especially criticisms that the by transient situational disturbance, and then by the diagnostic criteria are often poorly applied and term adjustment disorder in DSM-III.1 It has been that the disorder itself involves the medicalizing of retained and refined in subsequent editions and is now problems of living. Evidence in support of the defined in DSM-IV2 as follows: validity of the adjustment disorder diagnosis is Occurring within 3 months after the onset of a stressor. reviewed and the author concludes that the find- Marked by distress that is in excess of what would be ings support the content and predictive validity of expected, given the nature of the stressor, or by signifi- the diagnosis. The author then discusses the epi- cant impairment in social or occupational functioning. demiology of adjustment disorders, their comor- Should not be diagnosed if the disturbance meets the bidity with other conditions, including personality criteria for another Axis I disorder or if it is an exacer- disorders, substance abuse, and suicidal behavior, bation of a pre-existing Axis I or II condition. and their treatment and outcome. The article con- Should not be made when the symptoms represent cludes with a discussion of the special problems bereavement. involved in evaluating for and measuring adjust- The symptoms must resolve within 6 months of the ter- ment disorder. (Journal of Psychiatric Practice 2001;7: mination of the stressor but may persist for a prolonged 32–40) period (longer than 6 months) if they occur in response to a chronic stressor or to a stressor that has enduring KEY WORDS: adjustment disorder, DSM-IV, ICD-10, epi- consequences. demiology, prevalence, major depressive disorder, gener- alized anxiety disorder, substance abuse, posttraumatic If the stressor is an acute event, the onset of symptoms stress disorder, acute stress disorder is usually immediate or within a few days and the dura- tion of symptoms is also brief. The DSM-IV text that CASEY: Professor of Psychiatry, University College Dublin, and Mater accompanies the diagnostic criteria states that there is Hospital, Dublin, Ireland. an increased risk of suicide attempts and suicide associ- Copyright © Lippincott Williams & Wilkins Inc. ated with adjustment disorder. It also states that an Please send correspondence and reprint requests to: Patricia Casey, adjustment disorder may complicate the course of a gen- FRCPsych, FRCPI, MD, Mater Hospital, Eccles St, Dublin 7, Ireland. eral medical condition. DSM-IV lists several subtypes of 32 January 2001 Journal of Psychiatric Practice
  2. 2. 10 Casey 01-01.qxd 1/8/01 1:19 PM Page 33 ADULT ADJUSTMENT DISORDER adjustment disorder: these include with depressed mood as in DSM-IV. This suggests that there may not be con- (309.0), with anxiety (309.34), with mixed anxiety and cordance between the classifications—a view that has depressed mood (309.28), with disturbance of conduct been confirmed6 for PTSD among others. It is therefore (309.3), with mixed disturbance of emotions and conduct possible that the more rigid application of the duration (309.4), and unspecified (309.9). The acute specifier rep- and symptom thresholds in DSM-IV would also affect the resents symptoms that last less than 6 months, while the concordance between the related diagnoses of adjustment chronic specifier indicates those that persist for longer in disorder. response to a chronic stressor. International Classification of Diseases The history of the adjustment disorder diagnosis in the The core feature of adjustment disorder is European classification is similar, although the actual diagnosis was introduced later. ICD-93 included transient that the symptoms can present in individu- situational disturbances and divided them into two sub- groups: 1) acute reactions to stress and 2) adjustment dis- als of any age without any pre-existing orders. This addition was in response to the confusion generated by the older concept of reactive depression—a term that was much criticized4 as being an amalgam of mental disorder and occur in close tempo- depressive illness which had a life event precipitant or alternatively as an exaggerated but time-limited ral relationship to stressful events. response to stressful events. The new distinction between illness and reaction was very welcome. The current clas- sification, ICD-10,5 places adjustment disorder in a cate- Clinical Features gory of is own, separate from acute stress reactions and The core feature of adjustment disorder is that the symp- defines it as: toms can present in individuals of any age without any Occurring within 1 month of a psychosocial stressor pre-existing mental disorder and occur in close temporal that is not of an unusual or catastrophic type. relationship to stressful events. The symptoms are time- The duration of symptoms does not usually exceed 6 limited and last only a few months. Although subtypes of months except for prolonged depressive reaction (in adjustment disorder are enumerated in both DSM-IV and response to prolonged exposure to a stressful situa- ICD-10, there is no research demonstrating their individ- tion). ual validity or clinical merit. The symptoms or behavior disturbances are of a type The algorithm for the diagnosis of adjustment disorder found in any of the affective disorders but the criteria in DSM-IV is a mix of stressor, symptom threshold, and for an individual disorder are not fulfilled. duration. Thus, a period with severe symptoms lasting Symptoms vary in severity and form. just a week following a stressor would be classified as adjustment disorder; similarly, a patient who had had In the introduction to the diagnosis, ICD-10 states that fewer than five symptoms of major depressive disorder individual predisposition or vulnerability plays a greater (MDD) for several weeks following a life event would be role in the etiology of adjustment disorder than in that of diagnosed with adjustment disorder. However, once five other disorders in that section of ICD-10 (e.g., acute symptoms of major depression have been present for stress, posttraumatic stress disorder [PTSD]). The classi- longer than 2 weeks, even if they were precipitated by a fication of adjustment disorder in ICD-10 (F43.2) is very life event, the diagnosis would change to MDD using the similar to that of DSM-IV and the categories include brief DSM-IV system. In the ICD-10 system, in contrast, a depressive reaction (F43.20), prolonged depressive reac- patient with these features would still continue to be tion (F43.21), mixed anxiety and depressive reaction diagnosed with adjustment disorder. (F43.22), predominant disturbance of other emotions (F43.23), predominant disturbance of conduct (F43.24), Case History 1 mixed disturbance of emotions and conduct (F43.25), and Mrs. A, a 58-year-old lady, referred herself to the out- with other specified predominant symptoms (F43.28). As patient clinic. Her 30-year-old son had told her 1 in DSM-IV, ICD-10 states that none of the symptoms is of month earlier that he was leaving his wife to live with sufficient severity or prominence to warrant a more spe- another women. He had moved abroad and was not cific diagnosis. However, since ICD-10 allows for clinical paying maintenance to his wife and child, and Mrs. A. judgement, stating “a degree of flexibility is retained for had to provide financial and emotional support to her diagnostic decisions in clinical work,” the threshold for daughter-in-law and her grandchild, who had devel- duration or number of symptoms is not applied as rigidly oped enuresis. Mrs. A was tearful and sad about this. Journal of Psychiatric Practice January 2001 33
  3. 3. 10 Casey 01-01.qxd 1/8/01 1:19 PM Page 34 ADULT ADJUSTMENT DISORDER She and her son were both deeply religious and she time of presentation, but rapidly resolved. Although some could not understand why this had happened. She symptoms were present following discharge, there was no had initial insomnia but her concentration remained functional incapacity. good, especially for reading religious material. She had difficulty meeting friends and did not enjoy fam- Overlap with Other Disorders ily gatherings and avoided both. She continued to Clearly there is symptom overlap with other disorders. express her belief that everything would work out. She MDD is the most obvious, but the threshold and duration was seen once every 2 weeks at the clinic and dis- specifier should assist in distinguishing one from the cussed strategies for dealing with problems as they other. Similarly, generalized anxiety disorder can be dis- arose. After 2 months, Mrs. A was feeling much better tinguished from adjustment disorder by the requirement and felt she had the resources to continue to support that three of six symptoms of anxiety be present more her daughter-in-law. She had also begun socializing days than not for a period of 6 months. Both acute stress again. disorder and PTSD also require a stressor, however the stressor must be extreme as distinct from the more com- Commentary. This patient’s history illustrates the close monplace stressor associated with adjustment disorder. temporal relationship between mood changes and a life Acute stress disorder is associated with characteristic stressor. It also shows the ongoing association between symptoms such as depersonalization, numbing, and dis- mood and an event whose consequences are enduring— sociation, and resolves within 4 weeks. If symptoms last in this case, the effect of the separation on her daughter- longer than this, the diagnosis changes to PTSD. in-law and grandchild. Of note is the functional incapaci- ty this patient experienced, in that she avoided social CONTROVERSIES gatherings. However, at no point did Mrs. A meet the cri- Since first included in modern classifications, adjustment teria for MDD and, as time passed, her symptoms disorder has been the subject of controversy. Two themes improved with basic support and she was discharged dominate the criticisms—the poor application of the diag- from treatment. nostic criteria and the medicalizing of problems of living. The first type of criticism was expressed by an investiga- Case History 2 tor who examined the use of the adjustment disorder Mr. B, a 48-year-old man, was brought to the emer- diagnosis among adolescents and described it as a “waste- gency department by his wife. She had found him basket diagnosis” that was all encompassing and vague.7 writing a suicide note and he admitted forming a sui- The second approach has been to challenge adjustment cide plan after receiving the news 2 days before that disorder as “ontologically unsound and outside the field of his 18-year-old son had been remanded into custody medicine, lacking the elements that enable a clinician to on a serious criminal charge. He was distraught decide whether a person is ill or not ill, with any clarity.”8 about this since his son had no prior problems and In their provocative essay, Fabrega and Mezzich argue was due to begin university. He had not slept for the that the inclusion of adjustment disorder in modern clas- previous 24 hours and paced constantly. He had eaten sification represents a shunting away “from a spiritual, nothing and could speak about nothing else. He felt moral and socially inevitable human adjustment prob- the future was bleak and had decided the shame was lem” into what is largely a biological discipline, in which too much to bear, refusing to speak with friends or adjustment disorders are designated as “cryptic forms of family about it and unable to go to work. Mr. B was disease entities.”8 They argue that adjustment disorder admitted to the psychiatric unit and, over the follow- does not conform to the criteria for “traditional disor- ing 5 days, his agitation lessened; he began to speak ders,” such as having a specific symptom profile or bio- about the problem, and his hopelessness and suicidal logical correlates; they also raise the issue of the ideation decreased. Upon discharge 1 week later, Mr. interaction between personal vulnerability and the stres- B was eating and his mood and concentration had sor necessary for the development of adjustment disor- improved to the point that he was able to return to der—i.e., are individuals with adjustment disorder highly work. At follow-up, Mr. B reported that he continued vulnerable to ordinary stressors or are ordinary individu- to worry about his son’s future and to be sad about als vulnerable to high stressor levels? what had occurred, but that this did not impinge There has been no criticism of the inclusion of a cate- upon his ability to work. gory defined by etiology rather than symptom profile, nor has anyone questioned the failure to provide any criteria Commentary. Mr. B man is typical of many patients who for evaluating the “significant impairment in social and are given a diagnosis of adjustment disorder. The symp- occupational (academic) functioning” that is essential to toms showed a very close temporal relationship to a the distinction between normal and abnormal reactions major family crisis. The symptoms were severe at the to stress. 34 January 2001 Journal of Psychiatric Practice
  4. 4. 10 Casey 01-01.qxd 1/8/01 1:19 PM Page 35 ADULT ADJUSTMENT DISORDER It is clear from the paucity of research on adjustment adjustment disorder group should more closely resemble disorder, with fewer than 30 papers in English on the the depressive disorder group than the “no diagnosis” subject published since the introduction of the diagnosis, group on a number of parameters.9 The results of this that some of these questions cannot be answered. comparison showed that the adjustment disorder group was much closer to the heterogeneous depressive disorder VALIDITY: CAN ADJUSTMENT DISORDERS group than to the no diagnosis group: the sex ratio was BE DISTINGUISHED FROM OTHER AXIS I similar, the comorbidity of substance abuse was compa- DISORDERS? rable, and there was a similarly high frequency of stres- There is little point in devising diagnostic labels unless sors. However, there were differences in the type of the validity of the symptom cluster/syndrome they repre- stressor, with patients with adjustment disorder having sent has been demonstrated. This means showing not only more stressors related to marital problems and fewer that the clinical features of the syndrome differ from those related to family matters and occupation when compared of other disorders but also that the course, sociodemo- to those with other diagnoses. However, length of treat- graphic background, response to treatment, etiology, and ment was much shorter in the adjustment disorder laboratory markers are distinguishable from those found group, although it did extend beyond the 6-month period in other disorders. Validity studies of adjustment disorder specified in DSM. A study of medical inpatients10 found have thus far focused almost exclusively on the course of that adjustment disorder and major depression were dis- the disorder, which is not surprising, since there is tacit tinguishable on a number of features. Those with adjust- acknowledgment in DSM-IV that there are similarities ment disorder were likely to be older, widowed, and living between adjustment disorder and depressive episodes. alone and adjustment disorder was associated with less The instructions state that, if the criteria for any other severe symptoms than major depression. Rapid sympto- disorder are fulfilled, then that diagnosis must be made matic improvement was the norm. Among psychiatric rather than adjustment disorder. In other words, adjust- outpatients who were evaluated using the SF-36,11 a ment disorder is subordinate to other diagnoses, so that measure of social functioning, quality of life, and health symptom distinctions between adjustment disorder and status, those with a diagnosis of adjustment disorder had MDD will not be relevant to the validity debate unless the significantly less impairment on all scales at the time of symptom threshold is altered in future editions. initial assessment when compared to groups with depres- sive disorders.12 At follow-up, the patients with adjust- ment disorder also manifested further improvement in scores, equivalent to that seen in major depression and The adjustment disorder group was much dysthymia when the variance in baselines scores was eliminated. closer to the heterogeneous depressive Temporal Reliability and Predictive Validity disorder group than to the no diagnosis The stability of the adjustment disorder diagnosis is another issue that has been raised by investigators, group: the sex ratio was similar, the because variations in diagnosis over time among those with an index diagnosis of adjustment disorder would call into question its validity. One of the earliest investi- comorbidity of substance abuse was com- gations into adjustment disorder (termed transient situ- ational disturbance at the time) examined index parable, and there was a similarly high admission and readmission diagnoses over a 3-year fol- low-up period and found that the diagnosis was changed frequency of stressors. to personality disorder in 47% of cases.13 The authors suggested that the failure to record the presence of a per- sonality disorder at the index admission may have been due to choosing the less stigmatizing label of adjustment Content Validity disorder. They correctly argued that “it seems unlikely One approach to dealing with the criticisms of the adjust- that it would be in the patient’s interest to…substitute a ment disorder diagnosis discussed above was to compare more benign diagnosis for a more serious one.” They also those who met the criteria for adjustment disorder, those pointed to the lack of precision in the criteria and advo- who were diagnosed with depressive disorders, and those cated grater clarity. who were given no diagnosis in a psychiatric outpatient Despite the introduction of more specific criteria, a setting. If adjustment disorder constituted a valid clinical recent study demonstrated that the diagnosis remained category as distinct from a normal reaction, then the unstable:14 of 59 adolescents admitted with with a diag- Journal of Psychiatric Practice January 2001 35
  5. 5. 10 Casey 01-01.qxd 1/8/01 1:19 PM Page 36 ADULT ADJUSTMENT DISORDER nosis of adjustment disorder, 21 were discharged with a Studies have suggested that adjustment disorders are different diagnosis, most commonly conduct disorder; of particularly common in primary care settings. A British 102 adults admitted with a diagnosis of adjustment dis- two-stage screening study20 found that patients with order, 41 were discharged with a different diagnosis, adjustment disorder constituted 17.9% of those with Axis mainly substance use disorder. Of 29 adults who were I disorders in this setting. A somewhat lower figure was readmitted, only 18% received the same diagnosis. obtained in another study,21 although this difference may However, this was a study with significant methodologi- be explained by the methods used, since in this study it cal weaknesses, not least the fact that adjustment disor- was the general practitioner who screened for psychiatric der may have been diagnosed pending further disorders. However, in both of these studies, the diagnosis information. More recently, other researchers have sup- was a clinical one, based on ICD-9 following detailed per- ported the temporal stability of the adjustment disorder sonality, social, and symptomatic assessments by a diagnosis and confirmed the good prognosis associated research psychiatrist. Among patients being treated in an with the diagnosis in a 5-year follow-up study of patients outpatient clinic and diagnosed by a psychiatrist accord- admitted to a crisis intervention unit, which showed that ing to strict DSM-III-R22 criteria, adjustment disorder only 17% developed a chronic course15 (see also the dis- was the most frequent diagnosis, being made in 23% of cussions of “Comorbidity” and “Outcome” below). patients, and was more common than “disorders linked to Taken together, these studies support the content and psychoactive substances” (19.8%) or “thymic disorders” predictive validity of the adjustment disorder diagnosis. (19.6%).9 In a retrospective evaluation of case notes of emergency admissions, adjustment disorder was the clin- EPIDEMIOLOGY ical diagnosis in 7.1% of adults and 34.4% of adolescents Adjustment disorders are said to be common, particular- admitted as emergencies, although it is not clear who ly in the general population and in primary care. made the diagnosis or how rigidly the DSM criteria were However, most large-scale studies of psychiatric disorders applied.14 conducted in the general population, including the Adjustment disorder is a diagnosis that is made most Epidemiological Catchment Area (ECA) study,16 the U.S. frequently in general medical settings. In a recent study National Comorbidity survey (NCS),17 and the National of over 1,000 consultation-liaison referrals,23 an adjust- Psychiatric Morbidity Survey of Great Britain,18 have not ment disorder diagnosis was made in 12% of patients, examined the prevalence of adjustment disorder. The only adjustment disorder was comorbid with personality dis- large study that included adjustment disorder was the order or organic disorder in an additional 4.2% of Outcome of Depression International Network (ODIN) patients, and was a rule-out diagnosis in 10.6% of project.19 The goal of the ODIN project was to identify patients. A smaller study24 of 313 consecutively admitted those with depressive disorders (including adjustment medical inpatients found that adjustment disorder was disorder with depressed mood, persistent bipolar mood present in 13.7% of patients and was the most common disorder, and single and recurrent depressive episodes diagnosis. classified according to ICD-10) in both urban and rural sites in five European countries. Using a two-stage COMORBIDITY WITH OTHER BEHAVIORS screening method, the researchers found that adjustment AND DISORDERS disorder was the diagnosis in fewer than 1% of those with depressive disorders (Casey et al., unpublished data). Personality Disorder This was a surprisingly low figure and might give comfort There is a view, stated specifically in ICD-10, that per- to the critics of the diagnosis. However, there may be sonal vulnerability plays a particularly prominent role in explanations for this low prevalence that are related to the etiology of adjustment disorders, and statements con- problems inherent in commonly used diagnostic tools and cerning personal vulnerability are common in the major are extraneous to the adjustment disorder diagnosis postgraduate textbooks,25 although evidence for these itself. This will be discussed below (see “Measurement”). assertions is lacking. There is no literature on the nature DSM-IV acknowledges that adjustment disorders are of this vulnerability or the mechanism by which it oper- “apparently common although epidemiological figures ates; however, at least one British postgraduate textbook vary widely as a function of the population studied.” It links it to personality disorder.26 Although there is an states that, among psychiatric outpatients, 5%–20% have extensive literature on personal and personality vulnera- a principal diagnosis of adjustment disorder and that bility to depressive illness,27 this type of investigation has those from disadvantaged backgrounds may be at not been extended to adjustment disorder. increased risk for the disorder. The basis for this figure is The comorbidity of personality disorder and adjust- unclear; although adjustment disorder is a common diag- ment disorder has been the subject of some studies. One nosis in some settings, figures such as those cited above investigator28 examined 116 male outpatients and found have not been described among psychiatric outpatients. that the prevalence of personality disorder increased 36 January 2001 Journal of Psychiatric Practice
  6. 6. 10 Casey 01-01.qxd 1/8/01 1:19 PM Page 37 ADULT ADJUSTMENT DISORDER progressively across the three categories of adjustment adjustment disorder is short-lived and therefore most disorder, major depression, and dysthymic disorder, likely to arise in the context of personal crises. Moreover, reaching a prevalence of 15%, 22%, and 43%, respective- a 5-year follow-up of patients with a diagnosis of adjust- ly. These findings replicated the pattern found in other ment disorder15 showed that 2% committed suicide. Thus, outpatient populations, with personality disorder found although DSM-IV is correct in stating that there is an in 66% of patients with adjustment disorder, 85% of increased risk of completed suicide, the risk would seem those with major depression, and 88% of those with dys- to be substantially lower than in other Axis I disorders. thymia.29 In other treatment settings, such as primary Finally, how often is adjustment disorder a diagnosis care settings, patients with adjustment disorders have among those who completed suicide? Most studies using been found to have a lower prevalence of associated per- the psychological autopsy method suggest that MDD is sonality disorder than those with depressive illness.30 the most common diagnosis made in this group. However, In non-clinical populations (e.g., the general popula- this is at variance with clinical impressions, particularly tion), the relationship between Axis I and Axis II has concerning youth suicide, where the suicide often follows received little attention; however, the one study that some stressful event that occurred in the preceding days explored this relationship replicated the pattern or weeks in an otherwise mentally healthy young person. described in clinical populations. The ODIN19 project One of the few studies to examine this question specifi- found that 11.8% of those with adjustment disorder with cally found that adjustment disorder was the diagnosis in depressive features, 22.2% of those with a depressive 28% of young men who died by suicide,32 while major episode, 19.4% of those with recurrent depression, and depression was more common among women. Although 32.6% of those with dysthymia had a comorbid personal- some investigators have found that suicide in young peo- ity disorder (Casey et al., unpublished data). ple is linked to major depressive disorder and alcohol In view of the paucity of studies and the conflation of abuse,33 others have found an association with adjust- personal vulnerability with personality disorder, there is ment disorder, as described above, a finding that if repli- an argument in favor of clarifying the association cated in other studies has implications for suicide between personality disorder and adjustment disorder in prevention that differ from the usual guidelines relating future classifications. to recognition of “depression” and antidepressant pre- scribing. Other Diagnoses In summary, although adjustment disorder and MDD The issue of comorbidity is not limited to personality dis- bear a superficial resemblance to each other, when con- order but extends to other conditions such as substance sidered in the context of the comorbid conditions and sui- abuse. One study found that, among those admitted with cidal behavior associated with each of them, it is clear a diagnosis of adjustment disorder, 59% had a new pri- that a distinction exists between the two, thus lending mary diagnosis of substance use disorder at discharge further weight to the validity of the adjustment disorder and that, overall, 76% had either a primary or secondary diagnosis. diagnosis of substance abuse at discharge.14 Suicidal Behavior Studies among psychiatric patients have found that sui- cidal behavior varies according to diagnosis. In one study By definition, adjustment disorders are of Axis I disorders, suicidal behavior was found to be highest in major depression (27%), followed by dysthymic short-lived and resolve with the passage disorder (17%) and adjustment disorder (4%).31 This study also confirmed that major depression and dys- of time: for this reason it is unlikely that thymia were associated with a longer period from the onset of the disorder until the episode of self-harm and involved more planned acts than the adjustment disorder any specific intervention is required, group. Another investigation demonstrated the opposite and found that suicidal behavior was a presenting fea- unless the individual is acutely suicidal. ture in adults (78%) and adolescents (89%) with adjust- ment disorder significantly more often than in patients with other psychiatric diagnoses (21%).14 However, this did not present a barrier to early discharge and the TREATMENT ISSUES patients with adjustment disorder who presented with By definition, adjustment disorders are short-lived and suicidal behavior had somewhat shorter admissions than resolve with the passage of time: for this reason it is nonsuicidal patients, suggesting that the suicidality in unlikely that any specific intervention is required, unless Journal of Psychiatric Practice January 2001 37
  7. 7. 10 Casey 01-01.qxd 1/8/01 1:19 PM Page 38 ADULT ADJUSTMENT DISORDER the individual is acutely suicidal, in which case appropri- significantly fewer psychiatric readmissions and fewer ate intervention should be taken. This may explain the total days in hospital. paucity of research concerning this disorder. However one study of antidepressant prescribing patterns in psychi- MEASUREMENT atric outpatients between 1985 and 1993/94 found that One of the problems with the diagnosis of adjustment dis- there was an increase in antidepressant prescribing in a order is that it is difficult to measure using diagnostic number of groups, including those with adjustment disor- algorithms based on symptom thresholds. On the surface, der.34 Another study reported that, in a general medical the symptoms resemble those of MDD or generalized anx- setting, antidepressants were prescribed for adjustment iety disorder and are distinguished only by the prompt disorder in a manner similar to that in other Axis I dis- remission of symptoms when the stressor is removed or a orders.23 These studies suggest that there is a failure to new level of adaptation is reached. Since many depres- grasp the concept of adjustment disorder as time-limited sive episodes also are precipitated by life events, the dis- and point to a lack of clarity in distinguishing symptom, tinction based on the stressor criterion is problematic. In syndrome, and illness. It is likely that antidepressants general, adjustment disorders are less severe than were being prescribed on the basis of depression as a depressive illness; however, in a clinical setting, this symptom rather than as an illness, thus conflating two severity construct is unlikely to be helpful since the superficially similar, but prognostically different, condi- patient is likely to have been referred because of a level tions. of symptoms or incapacity that appears to warrant psy- The only trial that has evaluated psychological and chiatric evaluation and treatment rather than manage- pharmacological interventions in adjustment disorder35 ment in a primary care setting. found that, after 4 weeks, four different treatments—sup- It is striking that the main diagnostic tools used in cur- portive psychotherapy, an antidepressant, a benzodi- rent epidemiological research either pay little attention azepine, and a methyl donor— all produced a significant to adjustment disorder or do not incorporate it at all. For improvement. A study that compared placebo with plant example, the Structured Clinical Interview for DSM-IV extract36 in adjustment disorder demonstrated the supe- (SCID)39 says, “In most cases this section is skipped dur- riority of plant over placebo. A study comparing tra- ing the administration of SCID-IV because another more zodone and a benzodiazepine in cancer patients with specific diagnosis has been made.” It goes on to state: adjustment disorder (which did not include a placebo “The border between adjustment disorder and ordinary group) found no statistically significant difference problems of life may be clarified by the notion that between treatments.37 These studies all suffer from the adjustment disorder implies that the severity of the dis- limitations of small sample size. Clearly, further studies turbance is sufficient to justify clinical attention or treat- are required to ascertain if interventions, particularly ment.” It is surprising that the application of a diagnostic psychological and social, shorten the duration or severity label should be determined by treatment-seeking behav- of adjustment disorder symptoms. ior and not by objective criteria such as dysfunction. This theoretical approach, if generally applied, would raise OUTCOME huge philosophical and diagnostic problems, not least for Few follow-up studies of adjustment disorder have been the concept of hidden psychiatric morbidity.40 done. By definition, there is an expectation of good out- Problems also exist with the other diagnostic sched- come in adjustment disorder, with symptoms remitting ules. Although the Schedules for Clinical Assessment in once the stressor is removed. Such outcomes were demon- Neuropsychiatry (SCAN)41 incorporates adjustment dis- strated in a seminal study, which showed that, at 5-year order, it does so at the end of the interview in Section 13, follow-up, 71% of patients diagnosed with adjustment dealing with Inferences and Attribution, after all other disorder did not meet Research Diagnostic Criteria sections have been completed. Placing this section at the (RDC) criteria for any diagnosis, only 13% had a diagno- end sends a clear message that this section is not as sis of major depression and/or alcoholism, and 8% met the important as others. The effect of this on the diagnosis of criteria for antisocial personality disorder.38 adjustment disorder in epidemiological studies that use A 5-year follow-up study15 of 76 patients from a crisis the SCAN is obvious. Confirmation of this comes from the intervention ward who were given an ICD-9 diagnosis of ODIN study,19 in which adjustment disorder was exam- adjustment disorder confirmed the good prognosis associ- ined for but in which a prevalence of less than 1% was ated with this condition, with only 17% developing a found, with some sites failing to find any cases, notwith- chronic or severe course and the number who committed standing the fact that the study was conducted in the suicide also low (2%). Moreover, utilization of outpatient general population in whom this condition is said to be services during the follow-up period was low, a finding con- common. firmed by a 2-year follow-up study14 showing that adults Two other prestigious schedules, the Clinical Interview with an admission diagnosis of adjustment disorder had Schedule-Revised (CIS-R)42 which was used in the British 38 January 2001 Journal of Psychiatric Practice
  8. 8. 10 Casey 01-01.qxd 1/8/01 1:19 PM Page 39 ADULT ADJUSTMENT DISORDER National Psychiatric Morbidity Survey18 and the aspirations, the gloom of despair, , the accidie of disillu- Composite International Diagnostic Interview43 which sion, the demoralization of the long suffering and the was used in the U.S. National Comorbidity Study,17 failed cynical outlook of the pessimist.” Including in this mix of to incorporate adjustment disorder in their assessments. emotions are the emotions associated with depressive ill- ness, those biological states that require pharmacological WHERE HAVE ALL THE ADJUSTMENT treatments, among other interventions. As psychiatry DISORDERS GONE? has increasingly allied itself with the biological sciences, The investigation of adjustment disorders is of more than it is predictable but deeply regrettable that all mood theoretical importance. It is possible that the failure to states described as depression will be seen as a single incorporate adjustment disorders into recent studies may entity requiring “treatment.” The subtlety of language have caused the prevalence of depressive disorders to be has no current biological marker. This conflation of misrepresented, an issue that was highlighted by Regier unhappiness with illness is not the fault of the pharma- et al.44 when he pointed out the very different prevalence ceutical industry so much as of the lack of descriptive rates in the first and second wave ECA studies and the rigor in which there is confusion between symptoms, syn- first and second wave NCS studies. For example, in these drome, and illness. four studies, the 12-month prevalence rates for a major depressive episode were calculated at 4.2%, 6.4%, 10.6%, SUMMARY AND IMPLICATIONS and 10.7%, respectively. Regier pointed out the implica- What is known about adjustment disorder is limited but tions of this, suggesting that variations in prevalence includes its clinical utility, brief duration, and good prog- may be explained by the mislabeling of short-lived home- nosis. Although the suicide risk associated with adjust- ostatic responses that are “not in need of treatment” as ment disorder is higher than in the general population, it “mental syndromes.” If it is correct that adjustment dis- is lower than in most other psychiatric disorders, and, order has been incorporated into major depression in epi- when suicidal ideation is present in adjustment disorder, demiological studies, then the development and inclusion it resolves rapidly. On the basis of the studies outlined in of scientifically sound algorithms for distinguishing these this review, there is now enough evidence to confirm the short-term responses (adjustment disorders) from illness- descriptive and prognostic validity of adjustment disor- es (major depression) is imperative. The implications are der, but little or no evaluation of the merits of its sub- not just theoretical but also clinical since they may have types. Some of the details outlined in both DSM-IV and an impact on funding for mental health care. ICD-10 related to personal vulnerability require modifi- cation in light of the absence of further research on these issues. Moreover, the failure to give clear guidance for dis- tinguishing adjustment disorder from problems of living It is possible that the failure to incorporate is a shortcoming that needs to be addressed. The potential for viewing major depression and adjust- adjustment disorders into recent studies ment disorder as a single unit on the basis of superficial- ly similar symptoms and the treatment habits that flow may have caused the prevalence of from this perspective has provided fodder for criticism from the vocal anti-psychiatry lobby. In a powerful essay, depressive disorders to be misrepresented. Snaith45 ponders these matters and arrives at the nub of the challenge when he opines: “Considering the vastness of the sea of human unhappiness and the huge number of people attempting to fish souls out of it, the definition (of Undoubtedly, another problem with the adjustment biological depression) is perhaps the most urgent prob- disorder diagnosis is linguistic. 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