Adjustment disorders: the state of the art

The diagnostic category of adjustment disorder was introduced in the DSM-III-R 1. Prior to that, it was called transient situational disturbance. The DSM-IV 2 and ICD-10 3 descriptions of adjustment disorder are broadly similar. The main features are the following: a) the symptoms arise in response to a stressful event; b) the onset of symptoms is within 3 months (DSM-IV) or 1 month (ICD-10) of exposure to the stressor; c) the symptoms must be clinically significant, in that they are distressing and in excess of what would be expected by exposure to the stressor and/or there is significant impairment in social or occupational functioning (the latter is mandatory in ICD-10); d) the symptoms are not due to another axis I disorder (or bereavement in DSM-IV); e) the symptoms resolve within 6 months once the stressor or its consequences are removed. Adjustment disorders are divided into subgroups based on the dominant symptoms of anxiety, depression or behaviour. Since its introduction, the category of adjustment disorder has been the subject of criticism on three fronts. The first was that it constituted an attempt to medicalize problems of living and did not conform to the criteria for traditional disorders such as having a specific symptom profile 4. The second was that it was a “wastebasket diagnosis” which was assigned to those who failed to meet the criteria for other disorders 5. The third was on its diagnostic instability 6 and that its main utility was to serve as a “justification” for diagnosis-based reimbursement operating in the healthcare system of the US. Despite this, the category has been retained in the further classifications, in large measure due to its clinical utility. Adjustment disorder continues to be diagnosed in a range of clinical settings. Consultation-liaison psychiatry is the context in which the diagnosis is most likely to be made. Around 12% of referrals are so diagnosed in university hospitals in the US 7, a figure that resembles that in European hospitals 8. Nevertheless, the frequency with which adjustment disorder is now diagnosed seems to be declining, in parallel with an increase in the diagnosis of major depression 9, possibly due to the availability of psychotropic drugs, especially selective serotonin reuptake inhibitors (SSRIs), that are safer in those who are medically ill than the older agents. So, changes in the prevalence of adjustment disorders may reflect a change in the “culture of prescribing”, stimulating changes in the “culture of diagnosis” 10. 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 11 and to be diagnosed in up to one third of cancer patients experiencing a recurrence 12. In obstetric/gynaecology consultation-liaison 13, adjustment disorders predominated over other mood disorders. Among those assessed in an emergency department following self harm, a diagnosis of adjustment disorder was made in 31.8% of those interviewed, while a diagnosis of major depression was made in 19.5% of cases 14. None of the major epidemiological studies carried out in the community, such as the Epidemiological Catchment Area Study 15, the National Comorbidity Survey Replication 16 or the National Psychiatric Morbidity Surveys 17 included adjustment disorder among the conditions examined. An exception was the Outcome of Depression International Network (ODIN) study 18, which found a prevalence of only 1% for adjustment disorder in five European countries. A possible reason for this was that mild depression was included in the depressive episode category, inflating that category at the expense of adjustment disorder. By contrast, a study of elderly people from the general population 19 found the prevalence of adjustment disorder to be 2.3%, similar to that of major depression. Adjustment disorder is reported to be very common in primary care, but relevant epidemiological studies in this setting are rare and report rates of the disorder range from 1 to 18% 20,21 among consulters with mental health problems. Concerning psychiatric settings, a study of intake diagnoses into outpatient clinics 22, combining clinical evaluation and the use of the Structured Clinical Interview for DSM-IV (SCID, 23), found that adjustment disorder was the most common clinical diagnosis, made in 36% of patients, whereas the diagnosis was made in about 11% of cases using SCID. Among psychiatric inpatients, 9% of consecutive admissions to an acute public sector unit were diagnosed with adjustment disorder 24. Quantifying the prevalence of adjustment disorder in child and adolescent populations is difficult, due to changes in the diagnostic criteria over time 25. In the younger age groups, unlike adults, adjustment disorder carries with it significant morbidity and a poor outcome, frequently developing into major psychiatric illness 25,26. A general population study in Puerto Rico 27 found a rate of 4.2% among 14–16 year old people, while the total psychiatric morbidity was 17.8%. A similar rate was found in children aged 8–9 in Finland 28. Among outpatients, figures of 5.9–7% have been reported 29,30. In child liaison psychiatry, over one third of those with recent onset diabetes were so diagnosed 31, making it the most common psychiatric disorder to follow this well defined stressor. The current diagnosis of adjustment disorder assumes that there is a stressor which acts as a trigger and that the condition is self-limiting. So, adjustment disorder is closer to the definition of a discrete disorder as proposed by Kendell 32 than most other disorders in psychiatry, since its etiology and course are encapsulated within the diagnosis, while the definition of many other mental disorders is cross-sectional and based on symptoms alone. Yet, the current classifications impose a hierarchical model that assumes equivalence in how adjustment disorder and other diagnoses are construed. As currently classified, adjustment disorder is a sub-threshold diagnosis, that is trumped once the symptom threshold for another diagnosis is met. There is an inherent belief that a sub-threshold condition is less severe than a full-blown disorder such as major depression, the diagnosis by which adjustment disorder is most often superseded. Yet, the evidence for this is lacking, and there is empirical data 33 that, when measures of symptom severity or social functioning are examined, there is no difference between those with mood disorders and adjustment disorder. Furthermore, up to 25% of adolescents with a diagnosis of adjustment disorder engage in suicidal behaviour 34, while among adults with this disorder the figure is 60% 35. Adjustment disorder is the diagnosis in up to one third of young people who die by suicide 36, while among all suicide deaths in the developing world it is the most common diagnosis 37. These data show that, far from being a mild condition, adjustment disorder has a significant impact on behaviour. On the other hand, the current classifications fail to distinguish between adaptive and maladaptive reactions to stress. The DSM-IV tries to address this problem by stating that a diagnosis of adjustment disorder is only made when the distress is of clinical significance 38. There are two components to this: the distress must be in excess of what would normally be expected and/or there is an impairment in social or occupational function. In relation to the first of these, one of the most insightful critics of the DSM-IV, J. Wakefield 39, points out that it would allow the top third in the normal distribution of mood reactivity to be classified as disordered, and that it does not take into account the contextual factors that might cause this excess in distress. For example, the loss of a job for one person might be manageable while for another it could heap poverty on a family resulting in distress that might not be inappropriate under the circumstances. Cultural differences in the expression of emotion also need to be considered. In liaison psychiatry, where the diagnosis of adjustment disorder is most frequently made, a knowledge of “normal” coping with illness in that specific culture is essential and the diagnostic process will be guided by the extent to which an individual's symptoms are in excess of this. Some might argue that the fact of visiting a doctor indicates abnormal distress, yet the tendency to consult is also determined by factors additional to illness, including cultural and personal attitudes to symptoms. So, the mere fact of a consultation should not of itself be taken as a proxy measure of excessive distress. Neither should the decision to refer to psychiatric services, since this too is governed by factors that are not always related to symptom severity (e.g., a wish “to do something” under pressure from a patient in the face of continuing distress). Because adjustment disorder is a diagnosis made in the context of a stressor, there is a danger that any distress following such an event might be labelled as a disorder 40. Clinical judgement, therefore, plays a large part in making the diagnosis of adjustment disorder in the current criterion vacuum and future classifications should accord weight to culture, context and personal circumstances in differentiating normal from pathological distress. The second criterion, requiring impairment in functioning, is arguably a more robust indicator of disorder, since it is this which leads to treatment seeking. For example, the inability to work is potentially a significant indicator of impairment. However, there may be situations where functioning is reduced in the presence of non-pathological reactions. For instance, if the circumstances are especially traumatic, such as the loss of a child, the period of impaired function may be longer than anticipated in those with non-pathological responses. The evaluation of functioning in children places special demands on the assessor, since it has to be set against the demands of the developmental stage, and the degree of dependency and autonomy in key relationships. The presence of pre-existing impairment and extant vulnerabilities, such as learning disability and developmental disorders, must also be considered when making the evaluation. The ICD-10, contrary to the DSM-IV, requires the presence of both excessive symptoms and functional impairment for the diagnosis of adjustment disorder, thus narrowing the application of this category. Because of the hierarchical nature of ICD-10 and DSM-IV, adjustment disorder cannot be diagnosed once the criteria for another condition are met. The condition that most frequently trumps adjustment disorder is major depression/depressive episode. This is evident from studies that compare the clinical with the research approach. For example, in a study of those presenting because of self-harm, a clinical diagnosis of adjustment disorder was made in 31.8% and one of major depression in 19.5% of cases, but using SCID the proportions changed to 7.8% and 36.4% respectively 14. However, there is a point of departure between the two conditions when other variables are considered. Suicidal behaviour occurs earlier in the course of adjustment disorder as compared to major depression 41 and the interval from suicidal communication to completion of suicide is shorter 42. The socio-demographic profile and childhood risk variables differ between the two groups 41. Among adolescents dying by suicide, there is much less evidence of prior emotional or behavioural problems 42. In addition, the readmission rates for those with adjustment disorder are significantly lower than for those with major depression, generalized anxiety or dysthymia 43 and hospitalization is also shorter 6. This highlights the need for the clearer operationalization of adjustment disorder in future classifications. A further but lesser area of potential overlap is with post-traumatic stress disorder (PTSD). The conflation is not so much related to the symptoms of these disorders but to the stressors themselves. There has been an expansion in the stressors that are deemed to trigger PTSD, from those that are potentially life threatening, as originally described, to events that are less traumatic, such as financial problems or watching distressing images on television – a phenomenon called “criterion creep” 44. In clinical practice, a diagnosis of PTSD is often made reflexively 45 once such an event is identified, although adjustment disorder might be a more appropriate diagnosis. Overall, it is clear from the data available that adjustment disorder is sufficiently severe and distinct from other disorders, especially major depression, to from its to that of a full-blown and mental disorder. for the DSM-IV have been The Clinical Interview and the International Interview do not adjustment disorder at The for Clinical in do adjustment disorder, but only at the of the in 13, which with and This the criteria for all other disorders have been and there are no specific with to adjustment disorder to the on clinical The SCID also a with adjustment disorder, but the to that this diagnosis is not made if the criteria for any other mental disorder are with the of it to a In of the very threshold for major depression, in studies using SCID and to be of adjustment disorder, major depression will often adjustment disorder, of the context in which the symptoms have The International Interview also a on adjustment disorder as in that disorder is trumped when any other diagnosis is made. So, while have epidemiological research in psychiatry, the that they are having been for use by cannot be This is especially for a diagnosis such as adjustment disorder, which on clinical judgement, context and course than symptoms alone. As a of the problems with the current of diagnostic have been made to for adjustment disorder. Because there is symptom overlap with major depression, there is a that which for depression might people with adjustment disorder. A of have been for this including the Depression which has been to be an for adjustment disorder and major depression but when compared to SCID has and A study of health with an diagnosis but one which the of adjustment disorder most found with the to a using a coping measure have also been The and Depression has been for in cancer patients, but it does not distinguish between major depression and adjustment disorder problems when the Interview and the were for to for adjustment disorder. The of might have a in adjustment disorder from major depression and has been in one study that disorder more symptoms and a to the mood changes compared to disorder of this is Adjustment disorder cannot be diagnosed in the of a stressor. The event must be and in time to the onset of symptoms. The longer the time period between the event and the onset of the less likely is the diagnosis to be adjustment disorder. For this a period between the event and symptom onset of 3 months in DSM-IV and 1 month in ICD-10 is must be when this is for two those who are often significance to that in were in at the in an at may to an of the The 3 month may to be and it is to the empirical data on which this is Concerning the of there is to the in adjustment disorder from major depression. of those with a diagnosis of adjustment disorder have recent life of those with major depression also report such with more related to problems and to occupational or family stressors in the adjustment disorder while significant, are to be clinically in an since they are not as to major depression or adjustment disorder. the events range in severity from those that are as such as a with a to those that are more This will be by In the to the on adjustment disorder, the ICD-10 that and risk plays a than in other such as PTSD or acute stress reactions. However, it is on what evidence this is By contrast, the DSM-IV is on this The that a model is of and is arguably the most There have been studies adjustment disorder against other disorders to allow about the of and is in the current of The relevant studies be classified in two those adjustment disorder and those diagnoses to adjustment disorder. The prevalence of disorder among those with adjustment disorder in to those with other depressive disorders seems to be not although studies are and Among as a to adjustment disorder in a has also been examined, and was found to be a risk for adjustment disorder while was with the severity of the disorder using that a diagnosis of adjustment disorder, such as or depression, are also of although there is a that these conditions may not be to adjustment disorder due to differences in the in the earlier classifications. such study found that the was between and a symptom and evidence of The in relation to and a of symptoms were by in studies of and The of clear criteria for adjustment disorder in DSM-IV or ICD-10 that weight is to clinical than in most other current of anxiety, poor having onset following a recent stressful event are likely of a diagnosis of adjustment disorder, although it must be in that major depression also is often more when the person is with the such as when about while at other times mood is normal and The of the person from the stressful is with a general in symptoms. In the of those who adjustment disorder in response to illness, changes in mood are related to changes in the illness The more the symptoms are loss of mood reactivity the less likely is the diagnosis of adjustment disorder. A family of depression might also a depressive episode. to the symptom threshold for major depression, it is to a diagnosis of this condition than adjustment disorder. the National for Clinical on depression a period of so as to allow for the of under pressure from the patient and or the “to do a diagnosis of major depression (or generalized may be made and also arise when the stressor, and the is and has of may be on as there is no of if the symptoms are likely to or if they are now of the trigger and major depression. The of a response to should the that this is an adjustment disorder, so that are than in of A further is that what to be a stressor (e.g., a diagnosis of a may be with symptoms as of the diagnosis the patient (e.g., the of treatment to that stressors symptoms might to an diagnosis of major depression. The of the consequences of the stressor in symptoms is in the DSM-IV definition of adjustment disorder. on the of adjustment disorder are by DSM-IV and ICD-10 The are broadly similar in the two classifications from adjustment disorder with they have The is the most common in adults, while the with of or of and are more diagnosed among children and The between adjustment disorder and a normal stress response is based on the severity of symptoms and the impact on functioning into account the nature of the stressor; the personal and context in which it has cultural with to such responses. PTSD and acute stress disorder the presence of a stressor of a that would be for almost and the symptom is also although both of these have been 40. not to such events by developing PTSD and the that other disorders follow to be considered. For those not the PTSD diagnostic but with significant symptoms and/or functional adjustment disorder should be considered a possible may to be an adjustment disorder, because of the sub-threshold of the symptoms or the of functional might be an axis I disorder in that only as a a period of the of an diagnosis of adjustment disorder may be at especially if there are symptoms in of of the stressor. studies have the disorders that are with adjustment disorder, an that is by the fact that the criteria for this disorder axis I Yet, a recent study 19 found that almost of patients with major depression or and adjustment disorder were not significantly The between and adjustment disorder is also of since it may the instability of the adjustment disorder diagnosis. may be for of symptoms such as anxiety and depression, which are in adjustment disorder. such as are and may with mood changes to This may in one study 6 patients with an diagnosis of adjustment disorder were on as having a primary diagnosis of The evidence for the treatment of adjustment disorder is due to the of A further problem is that these are so that of may fail to any due to In are as being the most with the exception that, when stressors are measures may be However, there is a for children and adolescents diagnosed with adjustment disorder, since there is evidence that a of adolescents major mental disorders. measures may be to the person in the stressful A person being at work might to an system or may the of the A person in an might a A person on too much work may from family such as social or in a or may distress. or in groups, the range including and symptoms of the of and and the that the stressor has for the might also symptoms. In who engage in self-harm, in that do not may be of and to behaviour has the evidence was found to be of in older patients a including and was in patients with adjustment disorder to was when to patients with adjustment disorder who stress and among with adjustment disorder In a study of cancer patients similar were found in those with adjustment disorder and other psychiatric Some of these have been in specific medically ill groups, such as those with or in coping have been it is if adjustment disorder, were studies (e.g., and and of life than symptoms were the measures in (e.g., The of adjustment disorder of treatment of anxiety and The use of to these is common are by especially if there has been no from there is evidence to Nevertheless, those with and anxiety may have a when are such as in those with a of There are to the treatment of adjustment disorder and these are on with the anxiety A study a with a found that the of were although more to the including from and other and a on symptoms. A study found that and were while a study of cancer patients with and mood found to a study in primary the response of patients with major depression and with adjustment disorder to using reported changes in functional disability based on Overall, the adjustment disorder was as likely to to However, as this was a the of the is study compared and in with adjustment disorder assigned to an a or and found that all significantly Overall, these studies for the of and arguably for any specific in the of adjustment disorder, but further studies are Adjustment disorders are common mental disorders, especially in consultation-liaison prevalence seems to be in children and in they are with significant morbidity and a than in Suicidal behaviour is common in both adolescents and adults with these disorders, and adjustment disorder is the diagnosis in up to one third of young people who die by There are major problems with the diagnostic criteria for adjustment disorder in both ICD-10 and The most of these is the as This has in being the subject of Furthermore, current classifications fail to on these disorders from normal adaptive reactions to and the diagnosis of major depression in people with reactions to for adjustment disorders are although are likely to be the