Life is full of stressful experiences – some expected and some unexpected. Stressful life events can precipitate a strong sense of uncertainty in even those who are normally resilient. However, instead of adapting and putting the experience behind them, some people become entrenched in the experience and displays what is known as a maladaptive response. At this time people may experience low mood or anxious feelings and find themselves unable to live their life as normal; changes in their emotions, mood or behaviors following the stressful event may be the sign of an adjustment disorder. Adjustment disorders are on the mild end of the continuum within the broad mental disorder spectrum – often known as sub-threshold disorders. They typically only last a few weeks or months, and the symptoms are much milder than would be seen in other disorders.
When such a stressor is experienced and provokes an excessively negative or lengthy reaction (known as adjustment disorder), they may also experience anxiety. Adjustment disorder is also associated with increased risks of suicidal behavior and substance abuse, as well as prolonging medical disorders or impacting upon medical treatment.
Adjustment disorders are believed to be common mental disorders; in fact, it is among the most often diagnosed mental disorders in clinical practice. Surprisingly, however, it is subject of relatively limited research. The prevalence seems to be higher in children and adolescents, in whom they are associated with significant morbidity and a poorer outcome than in adults. Suicidal behavior is common in both adolescents and adults with these disorders, and adjustment disorder is the diagnosis in up to one-third of young people who die by suicide.
The prevalence of adjustment disorder has been found to range from 10 to 20 percent in various outpatient settings. This, however, does not appear to be stable; it has been proposed that the current culture in psychiatry of prescribing may well be influencing the trends in diagnosis. For example, the diagnosis of adjustment disorder has gone from nearly 30 percent in 1988 to less than 15 percent in 1997; while the diagnosis of major depressive disorder has increased from six percent 15 percent over the same period.
The incidence of adjustment disorder may also be dependent upon the group under investigation and the method of assessment: in a 12-year-long survey of mental health admissions in military staff (who were currently in service), nearly forty percent of hospitalizations were believed to be due to adjustment disorder.
Adjustment disorder with anxiety
Symptoms associated with general adjustment disorder may include feeling overwhelmed, anxious, and stressed as well as reports of difficulties with concentration and memory. The category of adjustment disorder with anxiety lists anxiety as the primary symptom, where it manifests as continual or excessive worrying, restlessness or feeling nervous or “on edge”.
How is adjustment disorder diagnosed?
To be diagnosed with an adjustment disorder, the following criteria must be met:
The experiencing of psychological or behavioral issues following an identifiable stressor or stressor, that occurs within three months of its occurrence.
The stress experienced must be more than that which would be experienced normally or one which causes issues in a variety of psychosocial areas.
The symptoms improvement within six months after the stressor ceases.
The symptoms that aren’t as a result of another diagnosis.
Unfortunately, anxiety disorders and adjustment disorders are often confused. For people with a generalized anxiety disorder (GAD), for example, there is typically a chronic history of experiencing anxiety; whereas those with adjustment disorder will only experience symptoms in response to a stressor or change. People can have both disorders and GAD can be exacerbated by having to adjust to change. People with adjustment disorder should experience a significant reduction in their anxiety as an adaption to the life change takes place, whereas anxiety is perpetual for those with GAD.
Anxiety disorders and adjustment disorders: Diagnostic dilemmas
The first is the differentiation from typical reactions to stress but there is nothing to assist clinicians in making this distinction. It is argued that the distinction is the severity of response and impact upon daily functioning however there are wide cultural and individual differences in responses or reactions to stressors. Adjustment disorder is often viewed as a transient condition between the normal and the pathological however it has also been argued that classifying it as a disorder is tantamount to pathologizing normal reactions to stress.
Alternatively, some assert that it needs to be seen as a specific maladaptive stress-response reaction and condition following a clear stressor which needs acknowledging so that health care services can be provided so as to minimize association risks and mitigate against other mental disorders in the future.
It has also been argued that the definition itself is rather loose and that this results in misuse of the diagnosis in clinical practice. Because of the diagnostic challenges, findings about adjustment disorder prevalence are inconsistent when studies are examined. The second difficulty is the distinction between adjustment disorder and other conditions as, what for a matter of a couple of weeks, adjustment disorder could easily be re-labeled as another condition.
Structured interviews or self-report measures are usually regarded as “the gold standard” as they remove the subjective element of the diagnostic process; however, this is problematic for adjustment disorder as there are no specific measures for the condition. Some of the most commonly-used instruments, do not include the condition and others acknowledge it but regard it as sub-syndromal; ie. something that does not quite meet the criteria for a diagnostic label. This is thought to often lead to adjustment disorder being ignored or subsumed under another condition. Therefore when adjustment disorder dances with anxiety, a complicated routine is enacted.