Adjustment disorder Health Article

Definition

An adjustment disorder is a type of mental disorder resulting from maladaptive, or unhealthy, responses to stressful or psychologically distressing life events. This low level of adaptation then leads to the development of emotional or behavioral symptoms.

Description

Often, a person experiences a stressful event as one that changes his or her world in some fundamental way. An adjustment disorder represents significant difficulty in adjusting to the new reality.

The stressful events that precipitate an adjustment disorder vary widely. They may include the loss of a job; the end of a romantic relationship; a life transition such as a career change or retirement; or a serious accident or sickness. Some are acute "one-time" stressors, such as relocating to a new area, while others are chronic, such as caring for a child with mental retardation.

Psychiatrists have disagreed about the validity of the diagnosis of adjustment disorder, largely because of its lack of specificity. What qualifies as a stressful event, and what is an abnormal response to it? While adjustment disorders are more difficult to quantify than other mental disorders, many researchers consider the category a useful one for two reasons: 1) an adjustment disorder may be an early sign of a major mental disorder and allow for early treatment and intervention; 2) adjustment disorders are "situational" or "reactive"; they do not imply that the patient has an underlying brain disease.

Causes

The Diagnostic and Statistical Manual of Mental Disorders, which is the basic reference work consulted by mental health professionals, included an important change in its most recent version, the DSM-IV-TR, with regard to the criteria for adjustment disorder. In the previous edition, the identifiable stressor was described as being "psychosocial," a category that excludes physical illnesses and natural disasters. In the DSM-IV-TR, the word "psychosocial" was deleted in order to make the point that any stressful event can lead to an adjustment disorder. It is important to recognize, however, that while adjustment disorders are triggered by external stressors, the symptoms result from the person's interpretation of and adaptation to the stressful event or circumstances. Beliefs, perceptions, fears, and expectations influence the development of an adjustment disorder.

People with chronic physical illnesses appear to have an increased risk of developing adjustment disorders, particularly one with depressed mood. This connection has been demonstrated among cancer patients. The relationship between chronic pain (as is commonly experienced by cancer patients) and depressive symptoms is still being studied.

Symptoms

DSM-IV-TR states that the symptoms of an adjustment disorder must appear within three months of a stressor; and that they must meet at least one of the following criteria: 1) the distress is greater than what would be expected in response to that particular stressor; 2) the patient experiences significant impairment in social relationships or in occupational or academic settings. Moreover, the symptoms cannot represent bereavement, as normally experienced after the death of a loved one.

DSM-IV-TR specifies six subtypes of adjustment disorder, each with its own predominant symptoms:

• With depressed mood: The chief manifestations are feelings of sadness and depression, with a sense of accompanying hopelessness. The patient may be tearful and have uncontrollable bouts of crying.
• With anxiety: The patient is troubled by feelings of apprehension, nervousness, and worry. He or she may also feel jittery and unable to control his or her thoughts of doom. Children with this subtype may express fears of separation from parents or other significant people, and refuse to go to sleep alone or attend school.
• With mixed anxiety and depressed mood: The patient has a combination of symptoms from the previous two subtypes.
• With disturbance of conduct: This subtype involves such noticeable behavioral changes as shoplifting, truancy, reckless driving, aggressive outbursts, or sexual promiscuity. The patient disregards the rights of others or previously followed rules of conduct with little concern, guilt or remorse.
• With mixed disturbance of emotions and conduct: The patient exhibits sudden changes in behavior combined with feelings of depression or anxiety. He or she may feel or express guilt about the behavior, but then repeat it shortly thereafter.
• Unspecified: This subtype covers patients who are adjusting poorly to stress but who do not fit into the other categories. These patients may complain of physical illness and pull away from social contact.

Adjustment disorders may lead to suicide or suicidal thinking. They may also complicate the treatment of other diseases when, for instance, a sufferer loses interest in taking medication as prescribed or adhering to diets or exercise regimens.

An adjustment disorder can occur at any stage of life.