Top

CNS Drugs

Published in:

01-11-2009 | Therapy in Practice

Adjustment Disorder

Epidemiology, Diagnosis and Treatment

Author: Prof. Patricia Casey

Published in: CNS Drugs | Issue 11/2009

Abstract

Adjustment disorder was introduced into the psychiatric classification systems almost 30 years ago, although the concept was recognized for many years before that. In DSM-IV, six subtypes are described based on the predominant symptoms, but no further diagnostic criteria are offered to assist the clinician. These are common conditions, especially in primary care and in consultation liaison psychiatry, where the prevalence ranges from 11% to 18% and from 10% to 35%, respectively. Yet they are under-researched, possibly due to the failure of some of the common diagnostic tools to allow for the diagnosis of adjustment disorder. Among the tools that incorporate adjustment disorder, the concordance between the clinical and interview diagnosis is very poor, with the diagnosis being made more commonly in clinical practice than the diagnostic tools allow for. Adjustment disorder is found in all cultures and in all age groups.

The presence of a causal stressor is essential before a diagnosis of adjustment disorder can be made, while the symptoms vary and include those that are found in other common psychiatric disorders. It is also important to distinguish adjustment disorder from normal reactions to stressful events.

Adjustment disorders are difficult to distinguish from normal responses to life’s stressors, while the distinction from major depression also poses a classificatory conundrum since both are conceptually different. Adjustment disorder is a diagnosis based on the longitudinal course of symptoms in the context of a stressor, while a diagnosis of major depression is a cross-sectional one based on symptom numbers. Treatments consist mainly of brief interventions, while pharmacotherapy is limited to the symptomatic management of anxiety or insomnia. There are no robust studies demonstrating benefits from antidepressants. However, the number of studies of either type of intervention is very limited.

American Psychiatric Association. The diagnostic and statistical manual of mental disorders. 1st ed. Washington, DC: American Psychiatric Association, 1952

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980

World Health Organization. Mental disorders: glossary and guide to their classification in accordance with the ninth revision of the International Classification of Diseases. Albany (NY): World Health Organization, 1978

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association, 2000

World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical description and diagnostic guidelines (ICD-10). Geneva: World Health Organization, 1992

Myers JK, Weissman MM, Dischler GL, et al. Six-month prevalence of psychiatric disorders in three communities 1980 to 1982. Arch Gen Psychiatry 1984; 41: 959–67PubMedCrossRef

Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 617–27PubMedCrossRef

Jenkins R, Lewis G, Bebbington P, et al. The National Psychiatric Morbidity surveys of Great Britain: initial findings from the household survey. Psychol Med 1997; 27: 775–89PubMedCrossRef

Ayuso-Mateos JL, Vazquez-Barquero JL, Dowrick C, et al. Depressive disorders in Europe: prevalence figures from the ODIN study. Br J Psychiatry 2001; 179: 308–16PubMedCrossRef

10.

Wing JK, Babor T, Brugha T, et al. SCAN: Schedules for Clinical Assessment in Neuropsychiatry. Arch Gen Psychiatry 1990; 47: 589–93PubMedCrossRef

11.

Maercker A, Forstmeier S, Enzler A, et al. Adjustment disorder, post-traumatic stress disorder, and depressive disorders in old age: findings from a community survey. Compr Psychiatry 2008; 49(2): 113–20PubMedCrossRef

12.

Casey PR, Dillon S, Tyrer P. The diagnostic status of patients with conspicuous psychiatric morbidity in primary care. Psychol Med 1984; 14: 673–81PubMedCrossRef

13.

Blacker CV, Clare AW. The prevalence and treatment of depression in general practice. Psychopharmacology 1988; 95 Suppl.: S14–7PubMed

14.

Shear KM, Greeno C, Kang J, et al. Diagnosis of nonpsychotic patients in community clinics. Am J Psychiatry 2000; 157: 581–7PubMedCrossRef

15.

Pelkonen M, Marttunen M, Henriksson M, et al. Suicidality in adjustment disorder, clinical characteristics of adolescent outpatients. Eur Child Adolesc Psychiatry 2005; 14: 174–80PubMedCrossRef

16.

Koran LM, Sheline Y, Imai K, et al. Medical disorders among patients admitted to a public sector psychiatric inpatient unit. Psychiatr Serv 2003; 53(12): 1623–5CrossRef

17.

Bruffaerts M, Sabbe M, Demyttenaere K. Attenders of a university hospital psychiatric emergency service in Belgium: general characteristics and gender differences. Soc Psychiatry Psychiatr Epidemiol 2004; 39: 146–53PubMedCrossRef

18.

Strain JJ, Smith GC, Hammer JS. Adjustment disorder: a multisite study of its utilisation and interventions in the consultation-liaison psychiatry setting. Gen Hosp Psychiatry 1998; 20(3): 139–49PubMedCrossRef

19.

Huyse F, Herzog T, Lobo A, et al. Consultation-liaison psychiatric service delivery: results from a European study. Gen Hosp Psychiatry 2001; 23: 124–32PubMedCrossRef

20.

Diefenbacher A, Strain JJ. Consultation-liaison psychiatry: stability and change over a 10-year period. Gen Hosp Psychiatry 2002; 24(4): 249–56PubMedCrossRef

21.

Strain J, Diefenbacher A. The adjustments disorders: the conundrums of the diagnoses. Compr Psychiatry 2008; 49: 121–30PubMedCrossRef

22.

Silverstone PH. Prevalence of psychiatric disorders in medical in-patients. J Nerv Ment Dis 1996; 184(1): 43–51PubMedCrossRef

23.

Okamura H, Watanabe T, Narabayashi M, et al. Psychological distress following first recurrence of disease in patients with breast cancer: prevalence and risk factors. Breast Cancer Res Treat 2002; 61(2): 131–7CrossRef

24.

Rigatelli M, Galeazzi GM, Palmieri G. Consultation-liaison psychiatry in obstetrics and gynaecology. J Psychosom Obstet Gyhaecol 2002; 23(3): 165–72CrossRef

25.

Taggart C, O’Grady J, Stevenson M, et al. Accuracy of diagnosis and routine psychiatric assessment in patients presenting to an accident and emergency department. Gen Hosp Psychiatry 2006; 8: 330–5CrossRef

26.

Kryzhanovskaya L, Canterbury R. Suicidal behaviours in-patients with adjustment disorders. Crisis 2001; 22(3): 125–31PubMed

27.

Polyakova I, Knobler HY, Ambrumova A, et al. Characteristics of suicide attempts in major depression versus adjustment disorder. J Affect Disord 1998; 47(1–3): 159–67PubMedCrossRef

28.

Casey P, Maracy M, Kelly BD, et al. Can adjustment disorder and depressive episode be distinguished? Results from ODIN. J Affect Disord 2006; 92(2–3): 291–7PubMedCrossRef

29.

Grassi L, Mangelli L, Fava L, et al. Psychosomatic characterisation of adjustment disorders in a medical setting: some suggestions for DSM-V. J Affect Disord 2007; 101: 251–4PubMedCrossRef

30.

Howland RH, Schettler PJ, Rapaport MH, et al. Clinical features and functioning of patients with minor depression. Psychother Psychosom 2008; 77: 384–9PubMedCrossRef

31.

Baumeister H, Maercker A, Casey P. Adjustment disorders with depressed mood: a critique of its DSM-IV and ICD-10 conceptualization and recommendations for the future. Psychopathology 2009; 42: 139–47PubMedCrossRef

32.

Kleinmna A. The normal, the pathological and the existential. Compr Psychiatry 2008; 48: 111–2CrossRef

33.

Lewis G, Pelosi AJ, Araya R, et al. Measuring psychiatric disorders in the community: a standardised assessment for use by lay interviewers. Psychol Med 1992; 22: 465–86PubMedCrossRef

34.

Kessler RC, Ustun TB. The World Mental Health (WMH) survey initiative version of the World Health Organisation (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res 2004; 13: 93–121PubMedCrossRef

35.

First MB, Spitzer RL, Williams JW, et al. Structured Clinical Interview for DSM-IV (SCID 1). New York: New York Biometric Research Department, 1995

36.

Sheehan D, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59Suppl. 20: 22–33PubMed

37.

Despland JN, Monod L, Ferrero F. Clinical relevance of adjustment disorder in DSM-III-R and DSM-IV. Compr Psychiatry 1995; 36: 454–60PubMedCrossRef

38.

Yates WR, Mitchell J, Rush AD, et al. Clinical features of depressed out-patients with and without co-occurring medical conditions in STAR*D. Gen Hosp Psychiatry 2004; 26(6): 421–9PubMedCrossRef

39.

Trivedi MH, Rush AJ, Ibrahim HM, et al. The Inventory of Depressive Symptomatology, Clinician Rating (IDS-C) and Self-Report (IDS-SR), and the Quick Inventory of Depressive Symptomatology, Clinician Rating (QIDS-C) and Self-Report (QIDS-SR) in public sector patients with mood disorders: a psychometric evaluation. Psychol Med 2004; 34: 73–82PubMedCrossRef

40.

Horwitz AV, Wakefield JC. The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder. New York: Oxford University Press, 2007

41.

Maj M. Are we able to differentiate between true mental disorders and homeostatic reactions to adverse life events. Psychother Psychosom 2007; 76: 257–9PubMedCrossRef

42.

Spitzer RL, Wakefield JC. DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem? Am J Psychiatry 1999; 156: 1856–64PubMed

43.

Rosen GM, Spitzer RL, McHugh PR. Problems with the post-traumatic stress disorder diagnosis and its future in DSM-V. Br J Psychiatry 2008; 192: 3–4PubMedCrossRef

44.

Giotakos O, Konstantakopoulos G. Parenting received in childhood and early separation anxiety in male conscripts with adjustment disorder. Mil Med 2002; 167(1): 28–33PubMed

45.

For-Wey L, Fei-Yin L, Bih-Ching S. The relationship between life adjustment and parental bonding in military personnel with adjustment disorder in Taiwan. Mil Med 2002; 167(8): 678–82PubMed

46.

Greenberg WM, Rosenfeld DN, Ortega EA. Adjustment disorder as an admission diagnosis. Am J Psychiatry 1995; 152(3): 459–61PubMed

47.

Sifneos PE. Brief dynamic and crisis therapy. In: Kaplan HI, Sadock BJ, editors. Comprehensive textbook of psychiatry IV. 5th ed. Vol. 2. Baltimore (MD): Williams and Wilkins, 1989: 1562–7

48.

Linehan MM, Comtois MA, Murray AM, et al. Two year randomised controlled trial and follow-up of dialectical behaviour therapy vs therapy by experts for suicidal behaviour and borderline personality disorder. Arch Gen Psychiatry 2006 Jul; 63(7): 557–66CrossRef

49.

Steinhardt M, Dolbier C. Evaluation of a resilience intervention to enhance coping strategies and protective factors and decrease symptomatology. J Am Coll Health 2008; 56(4): 445–53PubMedCrossRef

50.

Frankel M. Ego enhancing treatment of adjustment disorders of later life. J Geriatr Psychiatry 2001; 34: 221–3

51.

Gonzalez-Jaimes EI, Tirnball-Plaza B. Selection of psychotherapeutic treatment for adjustment disorder with depressive mood due to acute myocardial infarction. Arch Med Res 2003; 34: 298–304PubMedCrossRef

52.

Van der Klink JJL, Blonk RW, Schene AH, et al. Reducing long term sickness absence by an activating intervention in adjustment disorders: a cluster randomised design. Occup Environ Med 2003; 60: 429–37PubMedCrossRef

53.

Nardi C, Lichtenberg P, Kaplan Z. Adjustment disorder of conscripts as a military phobia. Mil Med 1994; 159: 612–6PubMed

54.

Akechi T, Okuyama T, Surawara Y, et al. Major depression, adjustment disorders and post-traumatic stress disorder in terminally ill cancer patients: associated and predictive factors. J Clin Oncol 2004 May 15; 22(10): 1957–65PubMedCrossRef

55.

Mihelich ML. Eye movement desensitization and reprocessing treatment of adjustment disorder. Dissert Abstr Int 2000; 61: 1091

56.

Markowitz JC, Klerman GL, Perry SW. Interpersonal psychotherapy of depressed HIV-positive outpatients. Hosp Community Psychiatry 1992; 43: 885–90PubMed

57.

Fawzy FL, Canada AL, Fawzy NW. Malignant melanoma: effects of a brief structured psychiatric intervention on survival and recurrence at 10-year follow-up. Arch Gen Psychiatry 2003; 60: 100–3PubMedCrossRef

58.

Maina G, Forner F, Bogetto F, et al. Randomised controlled trial comparing brief dynamic and supportive therapy with waiting list condition in minor depressive disorders. Psychother Pychosom 2005; 74: 43–50CrossRef

59.

Shaner R. Benzodiazepines in psychiatric emergency settings. Psychiatr Ann 2000; 30: 268–75

60.

Stewart JW, Quitkin FM, Klein DF. The pharmacotherapy of minor depression. Am J Psychother 1992; 46: 23–36PubMed

61.

Uhlenhuth EH, Balter MB, Ban TA, et al. International study of expert judgement on therapeutic use of benzodiazepines and other psychotherapeutic medications: III. Clinical features affecting experts’ therapeutic recommendations in anxiety disorders. Psychopharmacol Bull 1995; 31: 289–96

62.

Nguyen N, Fakra E, Pradel V, et al. Efficacy of etifoxine compared to lorazepam monotherapy in the treatment of patients with adjustment disorder with anxiety: a double blind controlled study in general practice. Hum Psychopharmacol 2006; 2(3): 139–49CrossRef

63.

Volz HP, Kieser M. Kava-kava extract WS 1490 versus placebo in anxiety disorders: a randomised placebo-controlled 25 week outpatient trial. Pharmacopsychiatry 1997; 30: 1–5PubMedCrossRef

64.

Bourin M, Bougerol T, Guitton B, et al. A combination of plant extracts in the treatment of outpatients with adjustment disorder and anxious mood: controlled study versus placebo. Fundam Clin Pharmacol 1994; 11: 127–32CrossRef

65.

Ansseau M, Bataille M, Briole G, et al. Controlled comparison of tianeptine, alprazolam and moanserin in the treatment of adjustment disorders with anxiety and depression. Hum Psychopharmacol 1996; 11: 293–8CrossRef

66.

Razavi D, Kormoss N, Collard A, et al. Comparative study of the efficacy and safety of trazadone versus clorazepate in the treatment of adjustment disorders in cancer patients: a pilot study. J Int Med Res 1999; 27: 264–72PubMed

67.

Hameed U, Schwartz TL, Malhotra K, et al. Antidepressant treatment in the primary care office: outcomes for adjustment disorder versus major depression. Ann Clin Psychiatry 2005; 17(2): 77–81PubMedCrossRef

68.

De Leo D. Treatment of adjustment disorders: a comparative evaluation. Psychol Rep 1989; 64: 51–4PubMedCrossRef

69.

Strain JJ, Smith GC, Hammer JS, et al. Adjustment disorder: a multisite study of its utilisation and interventions in the consultation-liaison psychiatry setting. Gen Hosp Psychiatry 1998; 20(3): 139–49PubMedCrossRef

70.

Brown JSL, Cochrane R, Hancox T. Large scale stress management workshops for the general public: a controlled evaluation. Behav Cogn Psychother 2000; 28: 139–51

Title: Adjustment Disorder
Epidemiology, Diagnosis and Treatment
Author: Prof. Patricia Casey
Publication date: 01-11-2009
Publisher: Springer International Publishing
Published in: CNS Drugs / Issue 11/2009
Print ISSN: 1172-7047
Electronic ISSN: 1179-1934
DOI: https://doi.org/10.2165/11311000-000000000-00000

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Adjustment Disorder

Epidemiology, Diagnosis and Treatment

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 11/2009

Visual Field Loss in Patients with Refractory Partial Epilepsy Treated with Vigabatrin

Epidemiology and Management of Anxiety in Patients with Bipolar Disorder

Cholinergic Functioning in Stimulant Addiction

Aggressive Behaviour in Adults with Intellectual Disability

Of Mice and Men

Experience with Intravenous Levetiracetam in Status Epilepticus