A. The development of emotional behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
B. Marked distress that is in excess of what would be proportionate to the stressor or
Significant impairment in social, occupational or other areas of functioning.
C. Does not meet criteria for another Axis I disorder and is not merely an exacerbation of a preexisting Axis I or II disorder.
D. Does not include normal bereavement
E. Symptoms do not persist more than 6 months after removal of stressor (or its consequences).
Specify if:
Acute: If disturbance lasts <6 months
Chronic: If disturbance lasts >6 months
Subtypes:
With Depressed Mood
With Anxiety
With Mixed Anxiety and Depression
With Disturbance of Conduct
With Mixed Disturbance of Emotions and Conduct
17.3.1 Specificity vs. Nonspecificity
AD was deliberately designed to be phenomenologically nonspecific (Strain and Friedman 2011). Only alterations in mood, anxiety, or conduct (or combinations of these) which are associated with distress and/or dysfunction in work, or school, or relationships in excess of what would be culturally acceptable for the stressor involved are required. And, these are subjective assessments with no severity guidelines as to when they can be counted as criteria. Furthermore, the AD can be characterized by type: depressive, anxious, conduct disorder, mixed moods and behavior. This is in marked contrast to the current proposal by Maercker for AD in the ICD-11 which requires both distress and dysfunction and three specific symptoms: failure to adapt, intrusions, and avoidance behavior (Maercker 2012). These workers have reconceptualized AD as a stress response syndrome so that it fits into a theoretical context that places AD at one end of the spectrum and PTSD and ASD at the other. Furthermore, persons who do not fulfill all the criteria for PTSD and ASD should be placed in the Other Specified Trauma and Stressor-Related Disorder category (309.89) since the primary diagnoses do not have a partial/subsyndromal PTSD or ASD option within DSM-5.
This nonspecificity has had great clinical utility since it offers a diagnosis for those patients with significantly clinical distress and dysfunction—who qualify for a psychiatric disorder—but who do not meet the criteria for other diagnoses in the DSM-5. This also allows for prodromal expressions of more discreet disorders that are in early stages and could benefit from clinical intervention (Strain and Friedman 2011). However, the down side to this lack of specificity signals the issue of reliability and validity of the diagnosis which may account for the difficulty in crafting a measure for its assessment, and the lack of research for this diagnostic entity (Baumeister and Kufner 2009; Linden et al. 2004; Casey et al. 2006). To our knowledge Einsle et al. are the only group of investigators who attempted to develop and validate a schedule for screening AD (Einsle et al. 2010). Such an instrument is essential if there is to be an evidence base that might inform future revisions of the AD criteria. However, employing the current Einsle instrument would eliminate many of the patients diagnosed as AD using the DSM-IV-TR and now the DSM-5 criteria. The trained clinician remains the “gold standard” with the current DSM-5 taxonomy.
One significant change in the DSM-5AD D criterion was adding “normal” to the bereavement exclusion. If bereavement is not normal, i.e., lasting more than 12 months for adults, and 6 months for children than it enters into the new category: Other Specified Trauma and Stressor-Related Disorder category (309.89) sub type “persistent complex bereavement disorder.”
I am almost sure I am dying, and I hope I have a few more months to enjoy my young sons. They are only 4 and 6. I am concerned what other people may have said to them, When I leave the hospital will they be afraid to hug me, touch me, tell me how they feel. I hope they do not think I am a “Typhoid Mary.” I have always managed unpleasant events before but having terminal cancer with maybe 4–6 months to live is distressing. I hope I can function as their mother, and do my routine up to the end. That is what is scary and makes me so sad; can I function as their mom. My sister is going to care for them when I am gone. They like her and she will be great with them, but what pain to know I won’t be here for them. The C-L, psychiatrist assured the patient it was important to share her feelings and her worries, and that she should share with her sister that she hoped they would remember her birthday, keep a picture of their mother in their room, and that she would share stories about their mother. The care team would do all they could to make her pain free, be ambulatory as long as possible and be happy to talk with her when the worries and sadness became over-whelming. She should also talk to her husband about helping the children remember her. She would not be forgotten.
17.3.2 History of the Adjustment Disorders
The diagnosis of AD has undergone a major evolution since DSM-1 in which it was considered a “transient situational personality disorder” (Table 17.2) (American Psychiatric Association: Diagnostic and Statistical Manual: Mental. American Psychiatric Association 1952; American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition. American Psychiatric Association 1980; American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. American Psychiatric Association 1987; American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. American Psychiatric Association 2000).
Table 17.2
DSM Classifications
DSM-I (1952): Transient situational personality disorder |
Gross stress reaction |
Adult situational reaction |
Adjustment reaction of infancy |
Adjustment reaction of childhood |
Adjustment reaction of Adolescence |
Adjustment reaction of late life |
Other transient situational personality disturbance |
DSM-II (1968): Transient situational disturbance |
Adjustment reaction of infancy |
Adjustment reaction of childhood |
Adjustment reaction of adolescence |
Adjustment reaction of late life |
DSM-III (1980): Adjustment disorder |
Adjustment disorder with depressed mood |
Adjustment disorder with anxious mood |
Adjustment disorder with mixed emotional features |
Adjustment disorder with disturbance of conduct |
Adjustment disorder with mixed disturbance of emotions and conduct |
Adjustment disorder with work (or acADemic) inhibition |
Adjustment disorder with withdrawal |
Adjustment disorder with atypical features |
DSM-III-R (1987): Adjustment disorder |
Adjustment disorder with depressed mood |
Adjustment disorder with anxious mood |
Adjustment disorder with mixed emotional features |
Adjustment disorder with disturbance of conduct |
Adjustment disorder with mixed disturbance of emotions and conduct |
Adjustment disorder with work (or academic) inhibition |
Adjustment disorder with withdrawal |
Adjustment disorder with physical complaints |
Adjustment disorder not otherwise specified |
DSM-IV (1994) and DSM-IV-TR (2000): Adjustment disorder |
Adjustment disorder with depressed mood |
Adjustment disorder with anxiety |
Adjustment disorder with mixed anxiety and depressed mood |
Adjustment disorder with disturbance of conduct |
Adjustment disorder with mixed disturbance of emotions and conduct |
Adjustment disorder unspecified |
Furthermore with regard to the AD in the DSM-IV-TR the term psychosocial stressor was changed to the broader concept of stressor. (Note the extension to the new Trauma and Stress Related Disorders chapter in DSM-5.) What is a stressor, and what is a traumatic stressor? Psychosocial is too restrictive when one considers the Chernobyl reactor incident (Havenaar et al 1996) or cardiac surgery (Oxman et al. 1994). Critics of the AD diagnosis state that the symptom complex is too subjective or “depends structurally on clinical judgment” in contrast to sound operational criteria (Casey et al. 2001a, b). First the definition of the stressor, and secondly how to determine when a situation is clinically significant for distress and/or dysfunction cause uncertainty. And, the definition of both must take into account age (child), culture, and personality factors (e.g., degree of neuroticism). Powell and McCone (2004) raise the question in their treatment of a patient with an AD secondary to the September 11th terrorist attacks: “What is a normal response to a terrorist attack in the US from a foreign adversary?” Finally, the complex interplay between external events and internal resources (e.g., resilience) varies considerably from one individual to the next so that one person’s threat is another’s challenge (Charney 2004).
The AD diagnosis has clinical appeal to both doctors and patients: The idea of temporary emotional symptoms resulting directly from a stressful life event is viewed as a more normal human reaction than an idiopathic pathological psychiatric state and is therefore regarded as less stigmatizing. Additionally, the disorder’s more benign course (especially in adults) encourages a clinician to be more prognostically optimistic (Slavney 1999). This optimism is shared by medical insurance carriers, who do not consider the diagnosis to be a preexisting condition.
AD may be associated with suicide attempts, completed suicide, substance abuse, somatic complaints, other mental disorders, and with a general or medical surgical illness. An AD may complicate the course of illness by impairing compliance with the medical regimen or increasing the length of hospital stay.
The AD diagnosis can be employed with a second psychiatric diagnosis if the symptoms of that diagnosis meet criteria for another disorder. The AD diagnosis cannot be employed if the symptoms are secondary to the physiological effects of a general medical illness or its treatment. Nor is it to be utilized for normal bereavement. Finally, demoralization should be distinguished from AD (Slavney 1999; Diagnostic and Statistical Manual Fifth Edition 2013).
17.3.3 Etiology
Stress is the etiological agent for AD. However, diverse variables, modifiers, and features of resilience are involved regarding who will experience an AD following stress. Cohen argued that (1) acute stresses are different from chronic ones in both psychological and physiological terms; (2) the meaning of the stress is affected by “modifiers” (e.g., ego strengths, support systems, prior mastery, resilience, genetic predisposition); and (3) the manifest and latent meanings of the stressor(s) must be differentiated (e.g., loss of job may be a relief or a catastrophe) (Cohen 1981). AD with maladaptive denial of pregnancy, for example, can be a consequence of a stressor such as separation from a partner (Brezinka et al. 1994). An objectively overwhelming stressor may have little effect on one individual, whereas a minor one could be regarded as cataclysmic by another. A recent minor stress superimposed on a previous underlying (major) stress that had no observable effect on its own may have a significant additive effect and foster the outbreak of symptoms (i.e., concatenation of events; B. Hamburg, personal communication, April 1990).
Andreasen and Wasek described the differences between the chronicity of stressors found in adolescents and those observed in adults: 59 % and 35 %, respectively, of the stressors had been present for 1 year or more and 9 and 39 % for 3 months or less (Andreasen and Wasek 1980). Popkin et al. (1990) stated that in 68.6 % of the cases in their Consultation-Liaison (CL) cohort, the medical illness itself was judged to be the primary stressor. Snyder and Strain (1989) observed that stressors as assessed on Axis IV were significantly higher (P = 0.0001) for CL patients with AD than for patients with other diagnostic disorders supporting the construct that a stressor was the mechanism of the AD disorder.
Although more attention has been directed toward the current precipitating stressor in the diagnosis of AD, recent investigations highlight the role of childhood experiences in the later development of these disorders. Several recent studies of young male soldiers with AD secondary to conscription revealed that stress at a young age, such as abusive and overprotective parenting or adverse early family events, are risk factors for the later development of AD (For-Wey et al. 2002; Giotakos and Konstantakopoulos 2002). In a similar cohort, a history of childhood separation anxiety was found to be correlated with the later development of AD.
17.3.4 Prevalence of the Adjustment Disorders
AD occur in children, adolescents, and the elderly (2–8 % in community samples): In acute care general hospital inpatients (12 %), in mental health outpatient settings (10–30 %), and in special settings, e.g., following cardiac surgery (up to 50 %) (Oxman et al. 1994). Women are given the diagnosis of AD twice as often as men, but in adolescents and children there is no gender difference.
Andreasen and Wasek (1980) observed that 5 % of inpatient and outpatient cohorts were diagnosed with AD. Fabrega et al. (1987) noted that 2.3 % of walk-in clinic (a diagnostic and evaluation center) patients met criteria for AD, with no other psychiatric diagnoses. When patients with other psychiatric diagnoses were included, 20 % had the diagnosis of AD. In general hospital psychiatric consultation populations, AD were diagnosed in separate studies 21.5 % (Popkin et al. 1990), 18.5 % (Foster and Oxman 1994), and 11.5 % (Snyder and Strain 1989).
Strain et al. (1998b) examined the consultation-liaison (CL) psychiatric data from seven university teaching hospitals in the USA, Canada, and Australia. All hospitals employed a common computerized clinical database to examine 1,039 consecutive psychiatric referrals—the MICRO-CARES software system. AD was diagnosed in 125 patients (12.0 %): It was the sole diagnosis in 81 (7.8 %) and comorbid with other psychiatric diagnoses in 44 (4.2 %). It was considered a “rule-out” diagnosis in an additional 110 (10.6 %). AD with depressed mood, anxious mood, or mixed emotions were the most common subtypes. AD was diagnosed comorbidly most frequently with personality disorder and organic mental disorder. AD patients were referred for problems of anxiety, coping, and depression; had less past psychiatric illness; and were rated as previously functioning better than those patients with major mental disorders—all of which is consistent with the construct of AD as a contemporary maladaptation to a stressor.
Psychiatric interventions were similar to those utilized for other psychiatric diagnoses, in particular, the prescription of antidepressant medications. (This finding was in contrast to the consensus that the treatment of choice for AD is psychotherapy and/or counseling, at least initially.) Patients with AD required a similar amount of clinical treatment time and resident supervision time when compared with other psychiatric disorders. Thus, AD were not performing like a subthreshold—less serious mental disorder—in the psychiatric consultation with medically and surgically ill inpatients.
Oxman et al. (1994) reported that 50.7 % of elderly patients (age 55 years or older) receiving elective surgery for coronary artery disease developed AD from the stress of surgery. Thirty percent had symptomatic and functional impairment 6 months after surgery. Kellermann et al. (1999) reported that 27 % of elderly patients examined 5–9 days after a cerebrovascular accident fulfilled the criteria for AD. Spiegel (1996) describes that half of all cancer patients he studied have a psychiatric disorder, usually an AD with depression. AD are frequently diagnosed in patients with head and neck surgery 16.8 %; (Kugaya et al. 2000), with HIV (dementia and AD), 73 %; (Pozzi et al 1999); cancer (from a multicenter survey of CL psychiatry in oncology) (27 %): (Grassi et al 2000); dermatology (29 % of the 9 % who had psychiatric diagnoses); (Pulimood et al 1996), and suicide attempters examined in an emergency department 22 % (Schnyder and Valach 1997). Other studies include the diagnosis of AD in more than 60 % of burn inpatients, (Perez-Jimenez et al 1994); 20 % of patients in early stages of multiple sclerosis (Sullivan et al. 1995); and 40 % of post-stroke patients (Shima et al 1994). Faulstich et al. (1986) reported the prevalence 12.5 % of DSM-III AD and conduct issues for adolescent psychiatric inpatients.
17.3.5 Course and Prognosis of Adjustment Disorder
DSM-IV-TR criterion E for AD implies a good long-term outcome by stating “once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.” American Psychiatric Association (1994); Andreasen and Hoenk’s (1982) landmark study demonstrated this by showing that prognosis was favorable for adults, but that in adolescents, many major psychiatric illnesses eventually occur as they age. At a 5-year follow-up, 71 % of the adults were completely well, 8 % had an intervening problem, and 21 % had developed a major depressive disorder or alcoholism. In adolescents at 5-year follow-up, only 44 % were without a psychiatric diagnosis, 13 % had an intervening psychiatric illness, and 43 % had developed major psychiatric morbidity (e.g., schizophrenia, schizoaffective disorder, major depression, bipolar disorder, substance abuse, personality disorders). In contrast to the predictors for major pathology in adults, the chronicity of the illness and the presence of behavioral symptoms in the adolescents were the strongest predictors for major pathology at the 5-year follow-up. The number and type of symptoms were less useful as predictors of future outcome than the length of treatment and chronicity of symptoms.
AD with disturbance of conduct, regardless of age, has a more guarded outcome. Just as Andreasen and Wasek (1980) observed, Chess and Thomas (1984) underscored that a significant number of AD patients either do not improve or grow worse in adolescence and early adult life. Kovacs et al. (1994) also examined children and youth (ages 8–13 years) for up to 8 years and observed that, controlling for the effects of comorbidity, AD does not predict later dysfunction. Jones et al. (2002) described 10 years of readmission data for various psychiatric diagnoses, including the AD and observed that AD had the lowest readmission rates. Initial psychological recovery from an AD may be attributable to removal of the stressor or recovery from the effects of the stressor. This was the case in prisoners who developed AD after being placed in solitary confinement and whose symptoms resolved shortly after their release (Andersen et al. 2000).
17.3.6 Suicide and Adjustment Disorder
As an example of the clinical significance of AD, Runeson et al. (1996) found that a lesser interval (1 month) between the diagnosis of AD and suicidal behavior than for depression (3 months), borderline personality disorder (30 months), and schizophrenia (47 months). Portzky et al. (2005) conducted psychological autopsies on adolescents with AD who had committed suicide and found that suicidal thinking in these patients was brief and evolved rapidly and without warning, complicating an attempt at timely intervention. Suicide—a most serious behavioral symptom—has been associated with the diagnosis of AD which may be the only indicator of this life threatening behavior.
A slightly different profile was found in two other studies that looked at suicide attempters with a diagnosis of AD. These patients were more likely to have poor overall psychosocial functioning, prior psychiatric treatment, comorbid personality disorders, substance abuse histories, and a current “mixed” symptom profile of depressed mood and behavioral disturbances (Kryzhanovskaya and Canterbury 2001; Pelkonen et al 2005).
A study of the neurochemical variables of AD patients of all ages who had attempted suicide revealed biological correlates consistent with the more major psychiatric disorders. Attempters exhibited lower platelet monoamine oxidase activity, higher 3-methoxy-4-hydroxyphenylglycol (MHPG) activity, and higher cortisol levels than control subjects. Although these findings differ from the lower MHPG and cortisol levels found in patients with major depression and suicidality, they are similar to the observations in other major stress-related conditions.
Despland et al. (1997) observed 52 patients with AD at the end of or after 3 years of treatment: Results showed the occurrence of psychiatric comorbidity (31 %), suicide attempts (14 %), development of a more serious psychiatric disorder (29 %), and an unfavorable clinical state (23 %). Spalletta et al. (1996) stated that suicidal behavior and deliberate self-harm are important predictors in the diagnosis of AD. Suicide attempts and self mutilation may be included in psychiatric diagnosis as an F code (other conditions that may be a focus of clinical attention). Thus, with self-harm, there would be two psychiatric diagnoses: the primary disorder and the suicide attempt.
17.3.7 Treatment
17.3.7.1 Psychotherapy
Treatment of AD relies primarily on psychotherapeutic measures that enable reduction of the stressor or its consequences, enhanced coping with stressors that cannot be reduced or removed, and establishment of a support system to maximize adaptation.
The first goal is to note significant dysfunction secondary to a stressor and to help the patient moderate this imbalance. Many stressors may be avoided or minimized (e.g., taking on more responsibility than can be managed by the individual or putting oneself at risk by having unprotected sex with an unknown partner). Other stressors may elicit an overreaction (e.g., abandonment by a lover): The patient may attempt suicide or become reclusive, or damage the source of income. The therapist assists the patient to minimize distress and other feelings by placing them into words rather than into destructive actions; more optimal adaptation and mastery of the trauma or stressor are sought.
The role of verbalization cannot be overestimated as an effective approach for reducing the impact of the stressor and enhance coping—in essence conflict resolution. The therapist needs to clarify and interpret the meaning of the stressor for the patient. For example, a mastectomy may have devastated a patient’s feelings about her body and herself. It is necessary to clarify that the patient is still a woman, capable of having a fulfilling relationship, including a sexual one, and that the patient can have the cancer removed or treated and not necessarily have a recurrence. Otherwise, the patient’s pernicious fantasies—“all is lost”—may take over in response to the stressor (i.e., the mastectomy) and make her dysfunctional in work and/or sex, in relationships, and precipitate a painful disturbance of mood that is incapacitating.
A 48 year old enterprising executive has experienced his first myocardial infarction. He is now in the Coronary Care Unit on bed rest and without a telephone. He is anxious, worried what is happening at his office and with all his accounts that are currently being reviewed for renewal. He wonders if he will be the man he was, running three times a week, sex a couple of times a week and sometimes more, playing ball with his teen age son, and being able to pull the “all nighters” upon occasion when the demands are brisk. “Will I be the man I was. Can you give me something for my anxiety so I can manage the stress I am under? I have never felt so lost or incompetent before. I was always the guy who could and was expected to get through.”
The CL psychiatrist reassured the patient, that it took quite a man to stay in bed when he had been so active, and that the most manly thing he could do was to stay in bed, stay off the phone and let his heart have a chance to heal. It may be one of the most difficult things he ever had to do since he was always so active. And then the psychiatrist said: “I know you can be passive and give up all those activities for a few days to let your heart have a chance to recover.” This supported the concept that passivity and following directions was one of the most manly things he could do.
17.3.7.1.1 Counseling, Cognitive Behavioral Therapy (CBT), Supportive Group Treatment, Family Therapy
Counseling, cognitive behavioral therapy (CBT), interpersonal therapy, medical crisis counseling, crisis intervention, family therapy, and supportive group treatment may be employed to encourage the verbalization of fears, anxiety, rage, helplessness, and hopelessness related to the stressors imposed (or self imposed) on a patient. The goals of treatment in each case are to expose the concerns and conflicts that the patient is experiencing, identify strategies to reduce the stressors, enhance the patient’s coping skills, help the patient gain perspective on the adversity and establish relationships (e.g., a support network) to assist in the management of the stressors and the self. CBT was successfully used in young military recruits (Nardi et al. 1994).
17.3.7.1.2 Brief Psychotherapy
AD diagnosed by DSM III-R criteria has been reported to profit most from brief psychotherapy (Sifneos 1989). The psychotherapy should attempt to reframe the meaning of the stressor(s). Although brief therapeutic interventions are often sufficient, ongoing stressors or enduring character pathology that may make a patient vulnerable to stress intolerance may signal the need for lengthier treatments.
Many types of therapeutic modalities have a place in the treatment of AD. Wise (1988), drawing from military psychiatry, emphasized the treatment variables of Brevity, Immediacy, Centrality, Expectance, Proximity, and Simplicity (BICEPS principles) (Wise 1988). The treatment approach is brief, usually no more than 72 h and focuses on the immediate stressors (True and Benway 1992).
17.3.7.1.3 Interpersonal Psychotherapy
Interpersonal psychotherapy was applied to depressed HIV-positive outpatients and found to be effective (Markowitz et al. 1992).The mechanisms of interpersonal psychotherapy are important in understanding psychotherapeutic approaches to the AD: (1) psychoeducation about the sick role, (2) a here-and-now framework, (3) formulation of the problems from an interpersonal perspective, (4) exploration of options for changing dysfunctional behavior patterns, (5) identification of focused interpersonal problem areas, and (6) the confidence that therapists gain from a systematic approach to problem formulation and treatment.
Related posts:
The Why and How of Psychiatric Consultation
Interviewing in Consultation-Liaison Psychiatry
Systems and Ethical Issues in CL Psychiatry: Hospital as a Social System, Sick Role and Doctor Role, Ethical and Legal Issues
Dissociative Disorders
The Renal Dialysis and Kidney Transplant Patient
Obstetrics and Gynecology Patients: Menstrual Cycle, Pregnancy, and Postpartum-Related Psychiatric Disorders
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