Phenomenological Psychology

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What Is Adjustment Disorder?

May 26th, 2009 by David Kronemyer · No Comments

Overview of Disorder

Classification.  Adjustment disorders are a psychological reaction to stress.  They were not recognized as a distinct pathology until DSM-II (1968).  The diagnostic criteria now are set forth at DSM-IV-TR 309 (1994) as follows:

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant as evidenced by either of the following:

(1) marked distress that is in excess of what would be expected from exposure to the stressor

(2) significant impairment in social or occupational (academic) functioning

C. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

D. The symptoms do not represent Bereavement.

E. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.

Specify if:

Acute: if the disturbance lasts less than 6 months

Chronic: if the disturbance lasts for 6 months or longer.

Adjustment Disorders are coded based on the subtype, which is selected according to the predominant symptoms.  The specific stressor(s) can be specified on Axis IV.

309.0: With Depressed Mood

309.24: With Anxiety

309.28: With Mixed Anxiety and Depressed Mood

309.3: With Disturbance of Conduct 309.4: With Mixed Disturbance of Emotions and Conduct

309.9: Unspecified

Epidemiology

Research regarding AD is scarce.  The few studies that exist show high correlation with physical illness such as cancer, HIV and epilepsy (Baumeister et al., 2009).  This makes sense because (a) chronic illness is stressful and (b) persons with chronic illness may be immuno-compromised; they are particularly vulnerable and lack emotional resiliency.  Other at-risk populations include children (4.2% – 7.6%); adolescent suicides (14%); suicide attempters (24.4%); gunshot wounds (10%); consultation series (11.5%); geriatric (15%); outpatient psychiatric clinic (12.3%); inpatient psychiatric hospital (5%); and bone marrow transplantation (34.7%) (Yates, 2008).  It is not hard to see why younger children are at greater risk because they have not yet had a chance to develop coping skills.  While the symptoms of AD are different from post-traumatic stress disorder it is likely that (since both involve stress) AD patients will experience some overlap of symptoms with PTSD patients.  This suggests that any situation where judgment or cognition is impaired as a result of stress or trauma also could give rise to AD.

Symptomatology, Behavioral Presentation

Symptoms are variable and depend primarily on age.  Adolescents, for example, develop behavioral problems with acting-out symptoms; adults are maladaptive with anxiety and depression (Yates, 2008).  Symptoms present two basic concerns: under-diagnosing due to symptom overlap with other disorders; and pathologizing normal distress as AD.  The diagnosis of AD in practice requires clinical judgment regarding the context of the symptoms, their cultural and individual appropriateness as well as their longitudinal course (Casey, 2008).  Given the elusive nature of the DSM diagnostic criteria it follows there should be a high degree of comorbidity with other Axis I disorders, in particular, cyclothymic disorder; generalized anxiety disorder; acute stress disorder; dissociative amnesia; and (on Axis II) borderline personality disorder.

Etiological Considerations

The primary trigger for AD is a stressful real-world situation.  This can include events such as breaking up with a person of romantic interest, job change, economic challenges or catastrophic events such as natural disasters or being attacked (Doruk et al., 2008).  One review argues that persons who witnessed or survived the 9/11 terrorist attack in New York are particularly vulnerable to AD (Franz et al., 2009).  While there are no credible studies developing a link between AD and genetic factors it follows one might be diathetically predisposed to AD with abnormal heritable stress response.  Given the right triggers a stressful family environment also could result in AD.  For example one study showed that children of Holocaust survivors are particularly vulnerable (Yehuda et al., 2007). 

Neurologic Factors

Although there are no specific studies it seems likely that patients with AD will experience neurologic effects similar to other stress-related disorders.  PET and fMRI most likely will show the amygdala receives increased blood flow during periods of intense reexperiencing of the stressful situation or rumination.   They also will experience progressive loss of hippocampal functioning due to poor cortisol regulation by the sympathetic nervous system.  This high allostatic load with resulting cytotoxicity should be one of the main neurochemical consequences of AD.  AD is insidious in that it implicates a somatic-psychological relationship between body and mind; emotional problems engender physical disorders and vice versa.

Treatment Considerations

Psychotherapeutic treatment orientations.  The current view is that AD best is diagnosed with structured interviews and treated with psychodynamic therapy and CBT (Casey, 2008).  This makes sense because of the variability of behavioral presentation; laxness of DSM criteria with resulting possibility of over/under diagnosis; and comorbidity with other closely-related conditions fundamentally involving emotional disturbance or dysregulation.  A clinician will face significant challenges if applying psychodynamic therapy, which requires a high level of engaged, interactive cognitive functioning.  It is unlikely, for example, that young patients will have the ability to achieve insights into their psychological state.  Suicidal and severely depressed patients most likely will be experiencing powerful neurochemical imbalance which will make psychodynamic therapy ineffective (although it may be a moderately useful adjunct to psychopharmacological treatment).  CBT is subject to the same caveats.

Psychopharmacological treatment.  Given there are substantial barriers to psychodynamic therapy it follows that psychopharmacological treatment will be more effective.  AD subtypes include depression and anxiety.  It therefore makes sense to conclude each could be treated with antidepressants (SSRIs) or anxiolytics (tianeptine, alprazolam and mianserin) respectively.

References

Baumeister, H., Maercker, A. & Casey, P. (2009).  “Adjustment Disorder with Depressed Mood.”  Psychopathology, 42, 139 – 147.

Casey, P. (2008).  “Diagnosing adjustment disorder with depressive features.”  Expert Review of Neurotherapeutics, 8(8), 1203 – 1208.

Doruk, A., Celik, C., Ozdemir, B. & Ozsahin, A. (2008).  “Adjustment disorder and life events.”  Anatolian J. Psychiatry, 9, 197 – 202.

Franz, V., Glass, C., Arnkoff, D. & Dutton, M.  “The impact of the September 11th terrorist attacks on psychiatric patients: A review.”  Clinical Psychology Review 29, 339 – 347.

Yates, W. (2008).  “Other Psychiatric Syndromes: Adjustment Disorder, Factitious Disorder, Illicit Steroid Abuse, and Cultural Syndromes.”  In Fatemi, S. & Clayton, P. (eds.) (2008).  The Medical Basis of Psychiatry, p. 285 – 298.  Totowa, NJ: Humana Press.

Yehuda, R., Bell, A., Bierer, L. & Schmeidler, J. (2007).  “Maternal, not paternal, PTSD is related to increased risk for PTSD in offspring of Holocaust survivors.”  J. Psychiatric Research, 42(13), 1104 – 1111.