Adjustment Disorders
The diagnostic category of adjustment disorders is characterized by an emotional response to a stressful event. Typically, the stressor involves financial issues, medical illness, or relationship problems. It is one of the few diagnostic categories in which an external stressful event is linked to the development of symptoms. An adjustment disorder is expected to remit soon after the stressor ceases or, if it persists, a new level of adaptation is achieved.
The development of symptoms as a result of difficult events is widely considered part of the general human experience. Thus, the diagnosis of adjustment disorder is often seen as far less stigmatizing than other psychiatric disorders because symptoms develop in response to an event and are often short lived. Furthermore, the diagnosis is not viewed by medical insurance carriers as a preexisting illness the same way that other diagnoses are.
The diagnostic category of adjustment disorders is widely used among clinicians in practice. However, adjustment disorders can be seen as problematic. The diagnostic criteria describe a syndrome in which a stressful event leads to the development of a symptom complex. However, there are no criteria within the diagnostic construct to qualify or quantify the stressor that leads to the adjustment disorder. It is also difficult to in clinical practice to link an event to the development of a symptom complex. Issues such as these raise questions about the diagnosis of adjustment disorder in general and have contributed to the lack of academic investigation.
Students should study the questions and answers below for a useful review of these disorders.
Helpful Hints
Students should know these terms and types (including case examples) of adjustment.
acute stress reaction
adjustment disorder
with anxiety
with depressed mood
with disturbance of conduct
with mixed anxiety and depressed mood
with mixed disturbance of emotions and conduct
adolescent onset
bereavement
crisis intervention
good-enough mother
maladaptive reaction
mass catastrophes
posttraumatic stress disorder
psychodynamic factors
psychosocial stressor
recovery rate
resilience
secondary gain
severity of stress scale
vulnerability
Donald Winnicott
Questions
Directions
Each of the questions or incomplete statements below is followed by five suggested responses or completions. Select the one that is best in each case.
25.1 Adjustment disorders
A. occur in men twice as often as women
B. are least likely in single women
C. are one of the most common psychiatric diagnoses in hospitalized patients with medical problems
D. are more severe if the stressor is of high severity
E. none of the above
View Answer
25.1 The answer is C
Adjustment disorders are one of the most common psychiatric diagnoses for disorders of patients hospitalized for medical and surgical problems. Women are diagnosed with adjustment disorders twice as often as men, and single women are generally overtly represented as most at risk. By definition, an adjustment disorder is precipitated by one or more stressor. The severity of the stressor or stressors does not always predict the severity of the disorder; the stressor severity is a complex function of degree, quantity, duration, reversibility, environment, and personal context. For example, the loss of a patient is different for a 10-year-old child 10 than for a 40-year-old adult. Personality organization and cultural or group norms and values also contribute to the disproportionate response to stressors.
25.2 The rate of reliability in the diagnosis of adjustment disorders is
A. increased by the absence of any impairment criteria in the diagnostic algorithm that defines maladaptation to stress
B. consistent with the fact that measurement of psychosocial stress on Axis IV has been found to be questionable
C. improved by the variability produced by cultural expectations regarding reactions to and management of stressful events
D. considered good
E. none of the above
View Answer
25.2 The answer is B
The low reliability of adjustment disorders is consistent with the fact that measurement of psychosocial stress on Axis IV has repeatedly been found to be questionable. The few extant studies of reliability in adjustment disorders have produced unimpressive results. Other sources of poor (not improved) reliability include (1) difficulties in determining when subjective distress or observable symptomatology exceeds what would normally be expected for a given stressor in an “average” individual, (2) the absence of any impairment criterion in the diagnostic algorithm that defines maladaptation to stress, and (3) the variability produced by cultural expectations regarding the reaction to and management of stressful events.
25.3 Which of the following is not a classification of adjustment disorder in the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)?
A. With anxiety
B. With depressed mood
C. With disturbance of conduct
D. With mixed disturbance of emotions and conduct
E. With psychotic features
View Answer
25.3 The answer is E
Maladjustment with some subthreshold psychotic features would most likely fall into the adjustment disorder unspecified category because adjustment disorder with psychotic features is not an adjustment disorder classification specified by the DSM-IV-TR.
The clinical presentations of adjustment disorder can vary widely. The DSM-IV-TR lists six adjustment disorders: (1) adjustment disorder with depressed mood; (2) adjustment disorder with anxiety; (3) adjustment disorder with mixed anxiety and depressed mood; (4) adjustment disorder with disturbance of conduct; (5) adjustment disorder with mixed disturbance of emotions and conduct


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