Special Topic Report



Special Topic Report

ADJUSTMENT DISORDER

I. Definition

• type of mental disorder resulting from maladaptive, or unhealthy, responses to stressful or psychologically distressing life events. 

• clinically significant emotional or behavioral symptoms that develop in response to an identifiable psychosocial stressor, stressors.

• often called situational depression, is a relatively common short- term condition that occurs when a person has abnormal and excessive reaction to a particular stressor

• short – term maladaptive reactions to what a layperson would call a personal calamity but in psychiatric terms would be reffered to as a psychosocial stressor.

• does not imply that the patient has an underlying brain disease.

II. Epidemiology

• Women are diagnosed with adjustment disorder twice as often as men (2:1).

• Single women are generally overly represented as being most at risk.

• In clinical samples of children and adolescents, boys and girls were equally likely to be diagnosed with an adjustment disorder. 

• Nolen-Hoeksema, a researcher who has conducted numerous studies on gender differences in depression, has argued that women over the age of 15 exhibit a more depressive temperament than men.

o She theorizes that women are more likely to respond to depression in ways that make the disorder worse and prolong it.

• There are no current studies of differences in the frequency of adjustment disorder in different racial or ethnic groups.

III. Etiology

• An adjustment disorder is precipitated by one or more stressors. Stressors are adjustive demands made on the individual. The severity of the stressor or stressors is not always predictive of the severity of the disorder.

• Stressors may be:

o Single, such as a divorce or the loss of a job, or multiple, such as a divorce or loss of a job OR

o Multiple, such as the death of a person important to a patient which coincides with the patient’s physical illness and loss of a job.

o Recurrent, such as seasonal business difficulties OR

o Continuous, such as chronic illness or poverty.

- A discordant intrafamilial relationship may produce an adjustment disorder that affects the entire family system, or the disorder may be limited to a patient who was perhaps the victim of a crime or who has a physical illness.

- Sometimes adjustment disorders occur in a group or community setting and the stressors affect several people, as in natural disaster, or in racial, social, or religious persecution.

- Specific developmental ages - such as beginning school, leaving home, getting married, becoming a parent, failing to achieve occupational goals, having the last child leave home and retiring are often associated with adjustment disorders.

• 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.

Psychoanalytic Factors:

Several psychoanalytic researchers have pointed out that the same stress can produce a range of responses in various normal human beings. Psychoananalytic research has emphasized the role of the mother and the rearing environment in a person’s late capacity to respond to stress. Particularly important was Donald Wonicott’s concept of a good- enough support to enable the growing child to tolerate the frustrations in life.

Psychodynamic Factors:

Pivotal to the understanding of adjustment disordes is an understanding of three factors:

• The Nature of the Stressor

• The Conscious and Unconscious Meanings of the Stressor

• The Patient’s Preexisting Vulnerability

A concurrent personality disorder or organic impairment may make a person vulnerable to adjustment disorders. Vulnerability is also associated with the loss of a parent during infancy. Actual perceived support from key relationships may affect behavioral and emotional responses to stressors.

IV. Pathophysiology

• The most seriously disruptive reaction to stress is decompensation. When the stressor situation is extremely demanding or prolonged any adaptive capacities of the individual may be overwhelmed.

• Efficiency is lost, vulnerability to other stressors is increased, somatic disorders develop, and complete exhaustion makes any self- sustaining effort impossible.

V. Signs and 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. This type must be distinguished from major depressive disorder and uncomplicated bereavement.

• 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. Must be differentiated from anxiety disorders.

• With mixed anxiety and depressed mood: The patient has a combination of symptoms from the previous two subtypes. Do not meet the criteria for an already established anxiety or depressive disorder.

• 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 predominant manifestation involves conduct in which the rights of others are violated or age- appropriate societal norms and rules are disregarded. 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.

According to ICD- 10, adjustment disorders are more affected by individual variability than are the reactions to severe stress. Nevertheless, the stressor is a necessary feature of the condition, as is the emotional disturbance caused by the stressor or life change; to be classified as an adjustment disorder, the emotional disturbance must be severe enough to interfere with social performance.

Differential Diagnosis:

Although uncomplicated bereavement can often produce temporarily impaired social and occupational functioning, the person’s dysfunctioning remains within the expectable bounds of a reaction to the loss of a loved one and, thus, is not considered adjustment disorder.

Other disorders from which adjustment disorder must be differentiated include: major depressive disorder, brief psychotic disorder, generalized anxiety disorder, somatization disorder, various substance- related disorders, identity problems and posttraumatic stress disorder. These diagnoses should be given precedence in all cases thtat meet their criteria, even in the presence of a stressor or group of stressors that served as a precipitant.

Patients with Adjustment Disorder, unlike those other conditions, are impaired in social or occupational functioning and show symptoms beyond the normal and expectable reaction to the stressor. Because no absolute criteria help to distinguish an adjustment disorder from another condition, clinical judgment is necessary.

Posttraumatic Stress Disorder:

Symptoms develop after a psychologically traumatazing event or events outside the range of normal human experience; the stressors producing this syndrome are expected to cause such a reaction in average human beings.

People may experience the stressors alone, as in rape or assault, or in groups, as in military combat or death camps, mass catastrophes. These stressors contain a psychological component and frequently a concomitant physical component that may directly damage peoples nervous systems.

In Adjustment Disorders, the precipitating stress need not be severe or unusual.

VI. Course and Prognosis

• Symptoms of an adjustment disorder must appear within three months of a stressor. The symptoms usually resolve within 6 months, although they may last longer if produced by a chronic stressor or one with long- lasting consequences.

• With appropriate treatment, the overall prognosis of an adjustment disorder is generally favorable. Most patients return to their previous level of functioning within 3 months. Adolescents usually require a longer time to recover than do adults.

• For most people, an adjustment disorder is temporary and will either resolve by itself or respond to treatment. For some, however, the stressor will remain chronic and the symptoms may worsen. Still other patients may develop a major depressive disorder even in the absence of an additional stressor.

VII. Medical Management

The judicious use of medications can help patients with adjustment disorders, but they should be prescribed for brief periods. Depending on the type of adjustment disorder a patient may respond to anti-anxiety agent or to an antidepressant.

VIII. OT application

A. FOR -

• Cognitive – Behavioral FOR

▪ The cognitive behavioral approach assumes that a person's cognitive function and beliefs influence their behavior, and that by helping a person dispute their irrational thoughts, they will be empowered to change their behavior.

• Role Acquisition Frame of Reference

▪ In this frame of reference, human life is understood as a series of social roles, some held or experienced concurrently. Humans learn their roles from other people and their role behavior is influenced by their environment. Illness or dysfunction occurs when role patterns are disrupted. When traumatic or environmental factors keep people from performing an expected role such as parent, worker or friend, they are considered to be dysfunctional.

▪ The goal of therapy becomes assisting the individual to relearn a more functional role or in the case of chronic terminal illness, to adapt the role so that function is maintained.

B. Evaluation and assessment

• Psychotherapy remains the treatment of choice for adjustment disorder.

- Psychotherapy is a process focused on helping you heal and learn more constructive ways to deal with the problems or issues within your life. Generally psychotherapy is recommended whenever a person is grappling with a life, relationship or work issue or a specific mental health concern, and these issues or concerns are causing the individual a great deal of pain or upset for longer than a few days. It can also be a supportive process when going through a difficult period or under increased stress.

- Psychotherapy can help people adapt to stressors if they are not reversible or time limited and can serve as a preventive intervention if the stressor does remit.

o Group therapy can be particularly useful for patients who have undergone similar stresses.

o Individual psychotherapy offers the opportunity to explore the meaning of the stressor to the patient.

C. OT Management

Goodman Battery

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