Adjustment Disorder

Introduction and Clinical Features of ASD

an individual suffering from acute-stress-disorder
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Adjustment disorder—according to DSM-IV Opens in new window—is defined as the appearance of clinically significant emotional and/or behavioral symptoms in response to an identifiable stressor(s) that occur within three months of the onset of the stressor(s); and the emotional/behavioral response is not merely an exacerbation of an existing Axis I or Axis II disorder.

Further, the individual’s response appears to be in excess of what one would normally expect, given the nature of the stressor(s), and is characterized by substantial impairment in social or academic/occupational functioning.

Importantly, symptoms are expected to dissipate with the termination of the stressor(s) and/or its consequences. Although there is no typical clinical presentation of adjustment disorder in children and adolescents, recent advances in formal diagnostic schemes (e.g., DSM-IV) have contributed to a more comprehensive picture of the disorder.

Subtypes of Adjustment Disorder

Adjustment disorder is categorized into six subtypes that allow clinicians to more precisely classify the disorder according to predominant symptom clusters:

  1. Adjustment Disorder with Depressed Mood

Adjustment disorder with depressed mood subtype is analogous to what used to be known as “reactive depression,” in that depressed mood is the primary presenting problem and a specific stressor can be identified as the precipitant.

  1. Adjustment Disorder with Anxiety

Adjustment disorder with anxiety subtype is characterized by major symptoms of worry and nervousness. It should not be confused with Axis I Anxiety Disorders, which involves panic, generalized anxiety, and motor tension in the absence of an identifiable antecedent stressor.

  1. Adjustment Disorder with Mixed Anxiety and Depression

Adjustment disorder with mixed anxiety and depression subtype is used when it is difficult to discern the primary emotional disturbance associated with the disorder and/or when individuals present with a combination of both anxiety and depression.

  1. Adjustment Disorder with Disturbance of Conduct

Adjustment disorder with disturbance of conduct subtype is commonly seen in adolescence Opens in new window and involves behavior which violates the rights of others or age-appropriate social norms and rules (e.g., truancy, fighting, vandalism, reckless driving).

The key distinction between this subtype and Axis I Conduct Disorder is that Adjustment Disorder with Disturbance of Conduct is much shorter in duration and can be linked to identifiable environmental stressors.

  1. Adjustment Disorder with Mixed Disturbance of Emotions and Conduct

Adjustment disorder with mixed disturbance of emotions and conduct subtype is used when the predominant symptoms represent a combination of both emotional difficulties (i.e., anxiety Opens in new window and depression Opens in new window) and conduct problems.

  1. Adjustment Disorder, Unspecified

Adjustment disorder, unspecified subtype is infrequently used, but is applied to classify maladaptive responses that do not fit into one of the specific subtypes (e.g., physical complaints, social withdrawal). The most common presentation of adjustment disorder in children and adolescents is one of the mixed subtypes.

As a rule, females are more likely to be classified in the adjustment disorder with depressed mood subtype, whereas males are more likely to be seen in the adjustment disorder with mixed disturbance of emotions and conduct subtype.

Despite refinement in diagnostic taxonomy, adjustment disorder remains a controversial diagnostic category largely because of the perceived lack of specificity in its parameters and its seemingly all-encompassing nature. Furthermore, there is little evidence to suggest that subtyping according to predominant symptom complex has predictive validity in terms of treatment.

Nevertheless, many clinicians consider adjustment disorder’ to be a distinct, albeit transitional diagnostic label, in that the degree of symptomatology in adjustment disorder exists somewhere between the less severe problem-level diagnoses (i.e., V Codes) and the more severe major mental disorders (e.g., Axis I Major Depressive Disorder). Still others suggest that adjustment disorder is retained in diagnostic nomenclature because it represents a less pathological and less stigmatizing label for children.

Incidence

Adjustment disorder is one of the most frequently diagnosed conditions in children and adolescents. Indeed, some have suggested that the high rate of adjustment disorder diagnosis in this population may be due in part to the inclusive nature of the disorder.

Trends in incidence rates of adjustment disorder diagnosis accurately reflect these concerns. To illustrate, early estimates of the disorder from the 1970s and 1980s that utilized less refined diagnostic criteria indicted incidence rates ranging from 16 to 42 percent, depending on the population studied (e.g., general population, inpatient, etc.). More current estimates place incidence rates around 2–8 percent for the general rates as high as 34 percent have been observed in special populations, such as psychiatric emergency service admissions.

Correlates

Even though adjustment disorder is considered largely a subthreshold diagnosis, it can be accompanied by significant morbidity.

Suicidal behavior is one of the more serious sequelae associated with adjustment disorder. Estimates vary, but evidence indicates that suicide attempts are observed in approximately 25 percent of adolescents with adjustment disorder, particularly when impulsivity is part of the clinical presentation.

It should be noted that significant life stressors, such as hospitalization, bereavement following loss of a family member, chronic illness, and divorce often precede adjustment disorder. However, there is ample evidence to suggest that adjustment disorder and suicidal behavior frequently occur subsequent to events of lesser magnitude.

The most common precipitants associated with the manifestation of adjustment disorder (and even suicidal behavior) include school problems, problems with parents, peer rejection, substance use, and problems with boyfriends/girlfriends.

Furthermore, data indicate that a significant minority of adolescents with adjustment disorder later develop more severe diagnoses, such as antisocial personality disorder Opens in new window, bipolar disorder Opens in new window, and drug abuse Opens in new window. Chronicity of behavioral symptoms accompanying adjustment disorder diagnosis has been identified as a reliable indicator of more severe complications later on in life.

Assessment

Adjustment disorders are typically diagnosed through clinical interviews and/or by use of interview checklists that follow DSM-IV Opens in new window diagnostic taxonomy. For research purposes, others have implemented a variety of structured and semistructured interview schedules designed for use with children and adolescents.

The key differential diagnostic consideration in clinical assessment hinges on the identification of a perceived proximal stressor in the environment that precipitates the manifestation of behavioral or emotion symptoms. Importantly, the utilization of different assessment methods serves as an additional factor impeding the establishment of more reliable diagnostic parameters and accurate incidence estimates of adjustment disorder.

Prognosis

As with most aspects of adjustment disorder, prognostic estimates vary greatly. As a general rule, children and adolescents with adjustment disorder fair more poorly than adults with the disorder. This may be due to the sheer number of stressful events that youth must navigate in the process of growing up.

Alternatively, it could suggest that youth simply have developed fewer adequate coping mechanisms to handle the significant stressors in their ever-changing environment. In either case, recovery rates of adjustment disorders vary from 30 to 97 percent, depending on the nature of the stressor(s) encountered (severity, chronicity) and on the population examined. There is some suggestion that children and adolescents who are older with predominantly the depressed subtype demonstrate faster recovery time and have fewer hospital readmissions.

As noted previously, the chronicity of behavioral symptoms, not the number and types of symptoms, is the best prognostic indicator of future outcome. A number of authors have indicated that although recovery rates from adjustment disorders are encouraging, recovery often takes more than 6 months, which exceeds the 6-month duration parameter established in the diagnostic criteria.

Treatment

Not unlike psychotherapeutic treatments for other stress-related reactions, treatment of adjustment disorder is best approached from a therapeutic stance that attempts to first remove or minimize the precipitant stressors.

If this is not possible, cognitive behavioral approaches should be utilized that assist children and adolescents in identifying and modifying the precipitant stressor(s) in an attempt to reinterpret and/or neutralize the impact of the stressor on the child’s life. Often encouraging children to simply verbalize their fears or apprehensions surrounding the stressors can substantially minimize their impact.

Systematic relaxation and guided imagery techniques have also proven to be effective in minimizing fear and anxiety reactions to stressors. Attempts should also be made to engage parents in treatment so that a supportive home environment is established.

In the case of older adolescents, writing assignments that provide the opportunity for expression of emotions about the immediate stressor can prove to beneficial in a matter of weeks. In the case of adjustment disorders that involve high degrees of both emotional impairment (i.e., depression) and impulsivity, medication (antidepressants/anxiolytics), and/or hospitalization may be indicated to protect against suicidal behavior.

    Adapted from: Encyclopedia of Clinical Child and Pediatric Psychology, edited by Thomas H. Ollendick, Carolyn S. Schroeder. References as cited include:
  1. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
  2. Despland, J., Monod, L., & Ferrero, F. (1995). Clinical relevance of adjustment disorder in DSM-III-R and DSM-IV. Comprehensive Psychiatry, 46, 454-460.
  3. Kovacs, M., Gatsonis, C., Pollock, M., & Parrone, P. (1994). A controlled prospective study of DSM-III adjustment disorder in childhood. Archives of General Psychiatry, 51, 535-541.
  4. Newcorn, J., & Strain, J. (1992). Adjustment disorder in children and adolescents. Journal of the American Academy of Child and Adolescents Psychiatry, 31, 318-327.
  5. Strain, J., Smith, G., Hammer, J., McKenzie, D., Blumenfield, M., Muskin, P., Newstadt, G., Wallack, J., Wilner, A., & Schleifer, S. (1998). Adjustment disorder: A multi-site study of its utilization and intervention in the consultation-liason psychiatry setting. General Hospital Psychiatry, 20, 139-149.