Adjustment Disorders
James J. Strain
Kimberly Klipstein
Jeffrey Newcorm
Introduction
The psychiatric diagnoses that arise between normal behaviour and major psychiatric morbidities constitute the problematic subthreshold disorders. These subthreshold entities are also juxtaposed between problem-level diagnoses and more clearly defined disorders. Adjustment disorder (AD) would ‘trump’ problem-level disorders, but would be ‘trumped’ by a specific diagnosis even if it were in the NOS category. The subthreshold disorders present major taxonomical and diagnostic dilemmas in that they are often poorly defined, overlap with other diagnostic groupings, and have indefinite symptomatology. It is therefore not surprising that issues of reliability and validity prevail. One of the most commonly employed subthreshold diagnosis that has undergone a major evolution since 1952 is AD (Table 4.6.4.1). The advantage of the indefiniteness of these subthreshold disorders is that they permit the classification of early or prodromal states when the clinical picture is vague and indistinct, and yet the morbid state is in excess of that expected in a normal reaction and this morbidity needs to be identified and often treated. Therefore, AD has an essential place in the psychiatric taxonomy.
Many questions prevail with regard to the concept of the AD diagnosis: (1) the role of stressors and the place of specific stressors; (2) the importance of age; (3) the role of concurrent medical morbidity, for example comorbidity of Axis I and/or Axis III disorders; (4) the lack of specificity of the diagnostic criteria; (5) the absence of a symptom checklist; (6) uncertainty as to optimal treatment protocols; and (7) undocumented prognosis or outcomes. Research data regarding these questions will be examined.
The DSM was conceptually designed with an atheoretical framework to encourage psychiatric diagnoses to be derived on phenomenological grounds with an avowed dismissal of pathogenesis or aetiology as diagnostic imperatives. In frank contradiction to this atheoretical conceptual framework, the stress-induced disorders require the inclusion of an aetiological significance to a life event—a stressor—and the need to relate the stressor’s effect on the patient in clinical terms. However, the stress-related disorders are unique in that they are psychiatric diagnoses with a known aetiology—the stressor—and thus aetiology is essential for the diagnosis. Four other diagnostic categories also invoke aetiology in their diagnostic criteria: (1) organic mental disorders (aetiology-physical abnormality); (2) substance abuse disorders (aetiology-ingestion of substances); (3) post-traumatic; and (4) acute stress disorders
Table 4.6.4.1 DSM-IV Evolution of the diagnosis for adjustment disorder | ||||||||||||||||||||||||||||||
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AD is a stress-related phenomenon in which the stressor precipitates maladaptation and symptoms that are time limited until either the stressor is diminished or eliminated, or a new state of adaptation to the stressor occurs (Table 4.6.4.2). At the same time that AD was evolving, other stress-related disorders, for example, post-traumatic stress disorder and acute stress disorder were described. (Acute stress disorder was formulated by Spiegel during the development of the DSM-IV.(1,2)) Acute stress reactions could result from involvement in a natural disaster such as a flood, or an avalanche, or a cataclysmic personal event, for example, loss of a body part (aetiology-an identifiable stressor).
The diagnosis of AD also requires a careful titration of the timing of the stressor in relation to the adverse psychological sequelae that ensue. Maladaptation and disturbance of mood should occur within 3 months of the patient experiencing the stressor. Until the DSM-IV criteria, the ADs were regarded as transitory diagnoses that should not exceed 6 months in duration. Thereafter, that diagnostic appellation could not be employed and had to be changed to a major psychiatric disorder or discontinued.
Definition and history
With the opportunity in 1994 to develop another evolutionary step of the DSM, i.e. DSM-IV,(3) the authors were asked to re-examine the subthreshold diagnostic category of AD with the goal of
improving its acknowledged ‘shortcomings’. The research included: review of the literature, reanalysis of existing studies of AD and their data sets, and examination of field studies (e.g. minor depression, minor anxiety) to observe if there was sufficient differentiation among these minor disorders from the ADs (e.g. how often was a stressor identified in those patients assigned the diagnosis; minor depression or minor anxiety?). From these three sources and consultations, modifications for DSM-IV and their rationale were formulated based on the best evidence extant.
improving its acknowledged ‘shortcomings’. The research included: review of the literature, reanalysis of existing studies of AD and their data sets, and examination of field studies (e.g. minor depression, minor anxiety) to observe if there was sufficient differentiation among these minor disorders from the ADs (e.g. how often was a stressor identified in those patients assigned the diagnosis; minor depression or minor anxiety?). From these three sources and consultations, modifications for DSM-IV and their rationale were formulated based on the best evidence extant.
Table 4.6.4.2 ICD-10 definition of adjustment disorder | ||||||||||||||||||||||
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Changes in the criteria for adjustment disorder in DSM-IV
The review of the literature, the reanalysis of the Western Psychiatric Institute and Clinic data (University of Pittsburgh), and consultations with experts supported the following changes in DSM-IV.
1 Enhance the understanding of the language.
2 Describe the timing of the reaction to reflect the duration of the AD: acute (less than 6 months) or chronic (6 months or greater).
3 Allow for the continuation of the stressor for an indefinite period; psychological reactions to chronic stress states (e.g. chronic arthritis, HIV, abuse by an alcoholic spouse) do not necessarily terminate at 6 months, nor do they necessarily lead to a major psychiatric disorder.
4 Eliminate the subtypes of mixed emotional features, work (or academic) inhibition, withdrawal, and physical complaints (as they were rarely employed by diagnosticians).
Although it might be argued that ADs could be placed in a new category of ‘stress response syndromes’, the literature and research reports did not support such a taxonomical organization. Another possibility was that AD could be eliminated altogether, with the advantage of maintaining the atheoretical approach of the DSM conceptual framework, and substitute in its place the appropriate minor or NOS categories as established by the accompanying mood states or behaviours. However, these solutions do not seem appropriate with recent findings that demonstrate AD to be a valid and frequently employed diagnosis.(4) AD was diagnosed in over 60 per cent of burned inpatients,(5) over 20 per cent of patients in early stages of multiple sclerosis,(6) and over 40 per cent of poststroke patients.(7) Furthermore, evaluations of patients in a psychiatric walk-in clinic showed a significant difference in the symptom profile of those assigned AD and the other diagnosis, including minor diagnoses.(8) (The McArthur field trials on the prospective assessment of minor depressive and anxiety disorders which collected data on the occurrence of stressors immediately preceding the outbreak of symptoms are important databases that need further study to establish whether stress per se is a distinguishing characteristic between AD and the other minor mood disorders.)
Problems with the adjustment disorder diagnosis
(a) The symptom profile
Critics of the AD diagnosis argue that the symptom complex is too subjective or ‘depends structurally on clinical judgement’ as opposed to sound, operational criteria.(9,10) Because of the lack of any quantitative behavioural or operational criteria, the problem of reliability and validity are obvious. Criterion reference was evaluated by Aoki et al.(11) who reported that three psychological tests, Zung’s Self-Rating Anxiety Scale,(12) Zung’s Self-Rating Depression Scale,(13) and the Profile of Mood States,(14) were useful tools for the diagnosis of AD in physical rehabilitation patients. While these measures succeeded in reliably differentiating AD patients from normal patients, they were not able to distinguish them from patients with major depression or post-traumatic stress disorders. Thus, the construct of AD is designed as a means for classifying psychiatric conditions having a symptom profile that is at the time of its application insufficient to meet the more specifically operationalized criteria for the major syndromes but is:
1 clinically significant and deemed to be in excess of a normal reaction to the stressor in question;
2 associated with impaired vocational or interpersonal functioning;
3 not solely the result of a psychosocial problem (V Code) requiring medical attention (e.g. non-compliance, phase of life problem, etc.).
However, field studies are being performed(15) to assess whether a reliable checklist from an elaborate list of symptoms associated with AD can be constructed (Table 4.6.4.3). (The V Codes—a problem level of diagnoses—are understandably devoid of a symptom-based diagnostic schema.)
Table 4.6.4.3 DSM-IV subtypes of adjustment disorders | ||||||
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(b) The meaning of ‘maladaptive’
The imprecision of the diagnostic criteria for AD is immediately apparent in the DSM-IV description of this disorder as a maladaptive reaction to an identifiable psychosocial stressor, or stressors that occurs within 3 months after onset of the stressor. It is assumed that the disturbance will remit soon after the stressor ceases or, if the stressor persists, when a new level of adaptation is achieved.(1) In addition to the problem of no symptom checklist, difficulties are inherent within each of these diagnostic elements.
First, with regard to the ‘maladaptive reaction’, it is unclear how this concept can or should be operationalized. Is the assessment of maladaptation subjective or objective? Who makes the decision—a third party, a mental health professional, the patients themselves, or an admixture of these? Is this decision ‘culture bound’? Succinctly when does an individual cross the threshold into ‘patienthood’, and who will make the decision? Powell and McCone (2004) make this point in their case report of the treatment of a patient with AD secondary to the stressors of the 11 September terrorist attacks. Since there has never before been a large-scale terrorist attack in United States, how are clinicians to know what a ‘normal’ response to such an event would be?(16)
(c) The stressor
Most recently, in the DSM-IV text revision (DSM-IV-TR; American Psychiatric Association, 2000),(17) the term psychosocial stressor was changed to the broader concept of stressor. Emotional reactions to physical stress, such as the Chernobyl reactor incident(18) or cardiac surgery(19) are well documented in literature and suggest that psychosocial stressor as a criterion is too restrictive. Moreover, the concept of ‘psychosocial’ versus ‘physical’ stressors has led to confusion.(20)
Obviously, the stressor and its effect are central to the AD diagnosis. The second major confound emanates from the fact that the DSM-IV presents no criteria or ‘guidelines’ to quantify stressors or to assess their effect or meaning for a particular individual at a given time. Furthermore, the assessment of stress is not linked by an algorithm to Axis IV—a statement of stress—during the previous year and so internal consistency or reinforcement within the diagnostic lexicon is not mandated (D. Schafer, personal communication, 1990). Mezzich et al.(8) attempted to classify and quantify the psychosocial stressors in 13 specific domains: health, bereavement, love and marriage, parental, family stressors for children and adolescents, other familial relationships, other relationships outside the family, work, school, financial, legal, housing, and miscellaneous. Such specificity has not been defined in DSM-IV and the construct is vague and generic with minimal opportunity to achieve quantification. Despland et al.(21) observed that the type of stressor may indeed be of help in diagnosing AD. His study demonstrated that AD with depressed mood and mixed mood was associated with more marital problems than major depressive disorders. AD with anxiety could be distinguished from the major anxiety disorders by the quantity of family and marital problems.
(d) The time course
The time course and chronicity of both stressors and their consequent symptoms were left vague in DSM-IIIR and were not consistent with the clinical situation. The modifications introduced in DSM-IV, which differentiate between acute and chronic forms of AD, solved the problem of the 6-month limitation of the AD diagnosis in DSM-IIIR and is more in keeping with what is observed in the clinical situation. This change was validated by Despland et al.(21) who observed that 16 per cent of patients with AD required treatment longer than 1 year—the mean exceeded the prior limitation of 6 months.
Other problems of definition
Even serious symptomatology (e.g. suicidal behaviour) that is not regarded as part of a major mental disorder requires treatment and a ‘diagnosis’ under which it can be placed, for example a V Code, ‘Phase of Life Problem’, AD, acute stress response, etc. De Leo et al.(22,23) reported on AD and suicidality. Recent life events, which would constitute an acute stress, were commonly found to correlate with suicidal behaviour in a patient cohort which included those with AD.(24) Spalletta et al.(25) observed the assessment of suicidal behaviour to be an important tool in the differentiation among major depression, dysthymia, and AD. AD patients were found to be among the most common recipients of a deliberate self-harm diagnosis, with the majority involving self-poisoning.(26) Thus deliberate self-harm is more common in AD patients,(26) while the percentage of suicidal behaviour was found to be higher in AD patients with depressed mood.(25)
The AD DSM-IV Work Group suggested that suicide and deliberate self-harm could be subtypes of AD. However, there were concerns that patients with other diagnoses, for example major affective disorder, borderline personality disorder, etc. and suicide behaviour, would be assigned the AD diagnosis since there was a specific placement for suicidal ideation and behaviour and that would be a predominant reason to use AD. The final decision was to place the problem of suicidal symptomatology without a psychiatric diagnosis in the DSM-IV F Code section for other problems ‘that may be a focus of clinical attention’. Obviously a subthreshold diagnosis, AD, does not necessarily imply the presence of subthreshold symptomatology!
Recognizing some of the limitations of the diagnosis including the aforementioned lack of specificity of symptoms and the lack of clarity of the role of the stressor, the authors of a recent article proposed adding an additional ‘A-Criterion’ to the DSM IV diagnosis of AD. They studied 328 young conscripts diagnosed by DSM IV with AD secondary to non-combat military stress. The diagnosis was closely associated with undisturbed psychosocial function outside of military life but with marked symptoms within military life.(9) Thus, location-specific stress was associated with location-specific symptoms, a phenomenon that the authors found helpful in distinguishing AD from other psychiatric diagnoses. Whether or not this finding would be consistent in non-military populations requires further evaluation.
‘Splitting’ and ‘lumping’ continue, for example, the subthreshold diagnosis of mixed anxiety-depressive disorder is a new category included in the DSM-IV. This disorder is very similar to AD with mixed mood; a boundary between the two is difficult to demarcate. The main difference between the two diagnoses was the chronicity of the mixed anxiety-depressive disorder (as was noted in the mixed anxiety-depression field trial).(27) The change in criterion C for AD—allowing a chronic or recurrent disturbance—confounds the differentiation of these two subthreshold diagnoses. This uncertainty is further complicated by the question of treatment. Is this
an anxiety accompanied by depression, which should be treated with anxiolytics, such as benzodiazepines, or is this a depression accompanied by anxiety, which should be treated with an antidepressant, such as a selective serotonin reuptake inhibitor (SSRI)? Furthermore, it is commonly viewed that the majority of patients with AD should be treated with psychotherapy or counselling as the initial approach.
an anxiety accompanied by depression, which should be treated with anxiolytics, such as benzodiazepines, or is this a depression accompanied by anxiety, which should be treated with an antidepressant, such as a selective serotonin reuptake inhibitor (SSRI)? Furthermore, it is commonly viewed that the majority of patients with AD should be treated with psychotherapy or counselling as the initial approach.
Another potential mood disorder, subsyndromal symptomatic depression (SSD), has been suggested.(28) It joins AD in the grey area of subthreshold diagnoses. However, there are two critical differences between SSD and AD: SSD employs a symptom checklist, and is not associated with a stressor. By definition, SSD is the simultaneous presence of any two or more symptoms of depression, persistent for most or all of the time for a duratio of at least 2 weeks, associated with social dysfunction, and occurring in patients who do not meet the criteria for minor depression (which also requires two symptoms), major depression, and/or dysthymia.(28) In some cases, the SSD diagnosis is the same as the DSM-IV diagnosis for minor depression, termed by the authors ‘SSD with mood disturbance’, and has to be documented as such. In other cases, the disorder is ‘SSD without mood disturbance’.
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