The diagnosis of adjustment disorder would seem relatively straightforward, provided the clinician considers a wide range of stressors and other Axis I diagnoses, but it can present a number of pitfalls. Challenging diagnostic situations can arise when the stressor is subtle, for example, in a change of a previously stable life situation without any obvious stressor. The clinician should exclude any specified symptom complex that meets diagnostic criteria for another Axis I disorder even if it may be related to a specific stressor. Only the other Axis I diagnoses should be recorded if its criteria are met. However, if a discrete recent stressor has been identified, an adjustment disorder diagnosis may be more appropriate than, for example, anxiety disorder not otherwise specified or depressive disorder not otherwise specified.

The normal challenges of a life cycle are usually taken in stride with socially and culturally prescribed ranges of expected responses. However, commonly encountered events can disrupt an unusually crucial part of an individual’s self-view (Table 29–1), and provoke symptoms outside of expected norms. Stressors leading to adjustment disorders are often termed “problems in coping.” Among adolescents, adjustment disorders frequently emerge following disappointment(s) in relationships with family members or friends. Especially complex difficulties may be encountered among homosexual teens. In adult crime victims, early detection of adverse responses was shown to improve outcome.

Individuals of all ages may encounter adjustment disorders following psychiatric hospitalization, or after treatment for another, otherwise unrelated, psychiatric disorder. For example, after being hospitalized for severe obsessive–compulsive disorder (OCD), a patient may express a conduct disturbance that is otherwise atypical for OCD. It may then be appropriate to add the diagnosis of adjustment disorder. Exceptionally severe or extreme stressors may precipitate maladaptive responses. Retirement and aging can bring feelings of loss, depleted health and vigor, and fear of the future. If the symptoms and gravity of the stressor are less than those required for acute stress disorder, the diagnosis of adjustment disorder may be appropriate.

Lacking clear behavioral or emotional symptom criteria, the validity of the diagnostic label of adjustment disorder is sometimes questioned. Diagnostic recording allows communication with patients, insurers, and other clinicians. It assists in disease control by focusing research and guiding therapeutic selection. Contemporary knowledge of differential diagnosis, prognosis, course, and future risks may be illuminated by naming a disorder. Even though more studies are needed, the adjustment disorder diagnosis fulfills these expectations. The therapist will find criteria easily met, defensible, and practical. However, the adjustment disorder diagnosis must not become a conciliatory label aimed to avoid controversies. A diagnostic label cannot reconcile societal and individual standards of response to a stressor. Examples include the societal acceptance of requests for death, euthanasia, or “rational suicide;” the differentiation between biological and functional (purely psychological) disorders; or other similar contemporary issues. They must remain foci of controversy rather than indications of underlying psychopathology. When used with poor specificity or to evade controversy, the application of a diagnosis of adjustment disorder effectively undermines psychological and organic pathological correlates and diminishes the credibility of psychiatric nosology.

Clinical use of the diagnosis of adjustment disorder diagnosis may be less prevalent in other countries, even though the true prevalence is similar. The description of these symptoms in International Classification of Diseases, 10th edition, (ICD-10) largely overlaps with Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision (DSM-IV-TR). In ICD-9, the term “adjustment reaction” was used for disturbances lasting weeks to months, and symptoms lasting hours to days were labeled “acute reaction to stress.” This system required a retrospective view because duration cannot be established at the onset of symptoms. There are other possible reasons for intercultural differences in the use of the diagnosis of adjustment disorder. In some European countries, reimbursement for treatment does not cover extensive care for minor conditions. Culture-specific syndromes, such as the Latino ataque de nervios, apply to a variety of symptom presentations, many of which do not come to psychiatric attention. Appendix I of DSM-IV-TR is devoted to cultural syndromes. In addition, substance abuse and alcoholism are often comorbid in patients with adjustment disorders. Because thresholds for the diagnosis of substance abuse are interpreted differently from one country to the next, an international standardization of the diagnosis may be difficult to achieve.

DSM-IV-TR Diagnostic Criteria

1. 
   

   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).

   
   
2. 
   

   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

   
   
3. 
   

   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.

   
   
4. 
   

   The symptoms do not represent bereavement.

   
   
5. 
   

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

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington DC: American Psychiatric Association, 2000.)

Epidemiology

In the United States, adjustment disorder diagnoses are quite common. Among psychiatric admissions, one estimate suggests that 7.1% of adults and 34.4% of adolescents had adjustment disorders. Among adults in France seen in general practice settings, a similar rate of 13.7% of those with psychological problems was observed. This was 1% of all patients consecutively seen with or without psychological problems. Many of these individuals merit substance abuse and conduct disorder diagnoses. Among university students receiving psychiatric assessments, a very high proportion was diagnosed as having adjustment disorders. Large population studies such as the Epidemiologic Catchment Area study have not assessed adjustment disorders because of a lack of sensitivity in the instrument used, that is, the Diagnostic Interview Schedule. Further studies are needed to better understand cultural, reimbursement, and records-confidentiality influences on true population rates and clinician utilization rates for the adjustment disorder diagnosis.

Etiology

Adjustment disorders appear to occur more often in individuals who are at risk for other psychiatric disorders, implying that etiologic factors may be shared. As in posttraumatic stress disorder (PTSD), neurobiological characteristics (e.g., elevated corticosteroid blood levels in response to stress) have been associated with the development of adjustment disorders.

A commonplace stressor may not be immediately clear, or it may be paradoxical. Adaptation difficulties in marriage, pregnancy, or childbirth can provoke feelings of guilt because the experience “should” be welcomed, not shunned. Natural preferences for lifestyle stability may be difficult to reconcile with goals requiring change. For example, a stably married individual unexpectedly confronted by parenthood faces role change, increased responsibility, and loss of freedom. Improved coping may result if the individual develops insight into a long-standing fear of being thrust into the role of single parent, as may have happened in his or her own family.

Risk Factors for the General Population

Major early risk factors include prior stress exposure, stressful early childhood experiences, and a history of mood or eating disorder. Family unity disruptions or frequent family relocations predispose children to adjustment disorders. The incidence of adjustment disorders is greater in children of divorced families following a subsequent, independent stressor. The death of a parent predisposes children to adjustment disorders. A high-suicide risk has been reported, especially after the loss of the father. Adjustments to living with the extended family (e.g., in-laws, step-parents) are additional predisposing factors. The outlet of symptom expression—be it depressed mood, conduct disturbance, or anxiety—may be determined by prior experience or biological constitution. Prior exposure to war, without meeting criteria for PTSD; (see Chapter 20), is a risk factor.

Factors that increase susceptibility in one situation can decrease it in another. For example, a high educational level can protect an individual who faces one stressor, but it can pose a risk factor for adjustment disorders in another context. Small-town life can predispose by providing too much shelter from stress yet limited support networks.

Risk Factors in Special Populations

Immigrant populations are at risk for adjustment disorder. It is simplistic to regard the entire immigration process as a precipitant; rather, precipitant stressors should be identified separately. For example, among new immigrants to Israel, stress responses to missile attacks during the Gulf War could be predicted by the immigrants’ adaptation prior to the attacks. Laotian Hmong immigrants in Minnesota were the focus of highly informative investigations that showed the need for studies of preventive intervention. Acculturation may be similar to other novel situations in many ways, but it also presents a large number of unique difficulties, all at the same time (Table 29–2). Any or all of these factors may require attention in treatment.

Among prison populations, adjustment disorder contributes heavily to suicide, which is frequently preceded by inmate-to-inmate conflict, disciplinary action, fear, physical illness, and the receipt of bad news. For a substantial number, the provision of mental health services within 3 days of the event was not sufficient to prevent suicide.

Chronic illness increases the need for medical contact and may constitute a major challenge to usual coping. Illness appears to be a precipitant rather than a predisposing factor. Adjustment disorders are not more prevalent among those with medical illnesses. On the other hand, should an adjustment disorder occur, it will often affect the clinical course of a somatic illness. The detection of adjustment disorder is remarkably poor, even on oncology services. It might improve with universal screening on admission. Early psychiatric consultation is associated with shorter length of stay. The course of asthma, chronic obstructive pulmonary disease, diabetes mellitus, end-stage renal disease, systemic lupus erythematosus, stroke, coronary artery disease, HIV/AIDS, chronic pain or headache, or cancer can be affected by the individual adjustment. Illness behavior, the give and take between patient and caregiver, and secondary gain all affect assessments of adjustment. The distinction between lifestyle versus coping style and then the setting of expectations for treatment compliance require skilled clinical judgment. For example, the asthmatic adolescent who rebels by skipping a scheduled inhaler dose does not need as rigid a guideline as one with “brittle” diabetes who skips insulin shots.

Also observed in the medical setting, complaints or lawsuits against physicians frequently result in adjustment disorder.

Genetics

Other than a global suggestion that a family history of psychiatric disorder is a risk factor for adjustment disorder, little is known about genetic inheritance or determinants of this condition, not surprising given the potential heterogeneity of a disorder defined by stressor rather than symptom.