adult adjustment disorder__a_review

Journal of Psychiatric Practice32 January 2001

Adjustment disorder is a diagnosis that is com-monly used, particularly in primary care and gen-eral medical settings. However, there has beenrelatively little research done on this disorder. Inthis article, the author reviews the informationthat is available on the epidemiology, clinical fea-tures, validity, measurement, and treatment ofadjustment disorder. She first reviews the histori-cal development of the diagnosis from transientsituational personality disorder in DSM-I to itscurrent definition in DSM-IV. The author also con-siders similarities and differences in how adjust-ment disorder is defined in the DSM and ICDsystems. The clinical features of the disorder thatdistinguish it from disorders such as major depres-sive disorder, generalized anxiety disorder, post-traumatic stress disorder, and acute stressdisorder are described. The author highlights anumber of the common controversies concerningadjustment disorder, especially criticisms that thediagnostic criteria are often poorly applied andthat the disorder itself involves the medicalizing ofproblems of living. Evidence in support of thevalidity of the adjustment disorder diagnosis isreviewed and the author concludes that the find-ings support the content and predictive validity ofthe diagnosis. The author then discusses the epi-demiology of adjustment disorders, their comor-bidity with other conditions, including personalitydisorders, substance abuse, and suicidal behavior,and their treatment and outcome. The article con-cludes with a discussion of the special problemsinvolved in evaluating for and measuring adjust-ment disorder. (Journal of Psychiatric Practice 2001;7:32–40)

KEY WORDS: adjustment disorder, DSM-IV, ICD-10, epi-demiology, prevalence, major depressive disorder, gener-alized anxiety disorder, substance abuse, posttraumaticstress disorder, acute stress disorder

djustment disorder is a common diagnosis, par-ticularly in primary care and general medicalsettings. However, surprisingly little has beenwritten to guide the clinician about adjustment

disorder, in part because this disorder has not been thesubject of much research. In this article, I collate theavailable information on the epidemiology, clinical fea-tures, validity, measurement, and treatment of adjust-ment disorder. I also outline the controversies concerningadjustment disorder and highlight the many lacunae thatexist in our understanding of this disorder.

DEFINITION AND HISTORY OF THEADJUSTMENT DISORDER DIAGNOSIS

Diagnostic and Statistical Manual

The concept of adjustment disorder has been some timein evolution. In DSM-I, it was characterized as transientsituational personality disorder, to be replaced in DSM-IIby transient situational disturbance, and then by theterm adjustment disorder in DSM-III.1 It has beenretained and refined in subsequent editions and is nowdefined in DSM-IV2 as follows:

Occurring within 3 months after the onset of a stressor.Marked by distress that is in excess of what would beexpected, given the nature of the stressor, or by signifi-cant impairment in social or occupational functioning.Should not be diagnosed if the disturbance meets thecriteria for another Axis I disorder or if it is an exacer-bation of a pre-existing Axis I or II condition.Should not be made when the symptoms representbereavement.The symptoms must resolve within 6 months of the ter-mination of the stressor but may persist for a prolongedperiod (longer than 6 months) if they occur in responseto a chronic stressor or to a stressor that has enduringconsequences.

If the stressor is an acute event, the onset of symptomsis usually immediate or within a few days and the dura-tion of symptoms is also brief. The DSM-IV text thataccompanies the diagnostic criteria states that there isan increased risk of suicide attempts and suicide associ-ated with adjustment disorder. It also states that anadjustment disorder may complicate the course of a gen-eral medical condition. DSM-IV lists several subtypes of

PATRICIA CASEY, FRCPSYCH, FRCPI, MD

Adult Adjustment Disorder: A Review ofIts Current Diagnostic Status

CASEY: Professor of Psychiatry, University College Dublin, and MaterHospital, Dublin, Ireland.

Copyright © Lippincott Williams & Wilkins Inc.

Please send correspondence and reprint requests to: Patricia Casey,FRCPsych, FRCPI, MD, Mater Hospital, Eccles St, Dublin 7, Ireland.

AA

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adjustment disorder: these include with depressed mood(309.0), with anxiety (309.34), with mixed anxiety anddepressed mood (309.28), with disturbance of conduct(309.3), with mixed disturbance of emotions and conduct(309.4), and unspecified (309.9). The acute specifier rep-resents symptoms that last less than 6 months, while thechronic specifier indicates those that persist for longer inresponse to a chronic stressor.

International Classification of Diseases

The history of the adjustment disorder diagnosis in theEuropean classification is similar, although the actualdiagnosis was introduced later. ICD-93 included transientsituational disturbances and divided them into two sub-groups: 1) acute reactions to stress and 2) adjustment dis-orders. This addition was in response to the confusiongenerated by the older concept of reactive depression—aterm that was much criticized4 as being an amalgam ofdepressive illness which had a life event precipitant oralternatively as an exaggerated but time-limitedresponse to stressful events. The new distinction betweenillness and reaction was very welcome. The current clas-sification, ICD-10,5 places adjustment disorder in a cate-gory of is own, separate from acute stress reactions anddefines it as:

Occurring within 1 month of a psychosocial stressorthat is not of an unusual or catastrophic type.The duration of symptoms does not usually exceed 6months except for prolonged depressive reaction (inresponse to prolonged exposure to a stressful situa-tion).The symptoms or behavior disturbances are of a typefound in any of the affective disorders but the criteriafor an individual disorder are not fulfilled.Symptoms vary in severity and form.

In the introduction to the diagnosis, ICD-10 states thatindividual predisposition or vulnerability plays a greaterrole in the etiology of adjustment disorder than in that ofother disorders in that section of ICD-10 (e.g., acutestress, posttraumatic stress disorder [PTSD]). The classi-fication of adjustment disorder in ICD-10 (F43.2) is verysimilar to that of DSM-IV and the categories include briefdepressive reaction (F43.20), prolonged depressive reac-tion (F43.21), mixed anxiety and depressive reaction(F43.22), predominant disturbance of other emotions(F43.23), predominant disturbance of conduct (F43.24),mixed disturbance of emotions and conduct (F43.25), andwith other specified predominant symptoms (F43.28). Asin DSM-IV, ICD-10 states that none of the symptoms is ofsufficient severity or prominence to warrant a more spe-cific diagnosis. However, since ICD-10 allows for clinicaljudgement, stating “a degree of flexibility is retained fordiagnostic decisions in clinical work,” the threshold forduration or number of symptoms is not applied as rigidly

as in DSM-IV. This suggests that there may not be con-cordance between the classifications—a view that hasbeen confirmed6 for PTSD among others. It is thereforepossible that the more rigid application of the durationand symptom thresholds in DSM-IV would also affect theconcordance between the related diagnoses of adjustmentdisorder.

Clinical Features

The core feature of adjustment disorder is that the symp-toms can present in individuals of any age without anypre-existing mental disorder and occur in close temporalrelationship to stressful events. The symptoms are time-limited and last only a few months. Although subtypes ofadjustment disorder are enumerated in both DSM-IV andICD-10, there is no research demonstrating their individ-ual validity or clinical merit.

The algorithm for the diagnosis of adjustment disorderin DSM-IV is a mix of stressor, symptom threshold, andduration. Thus, a period with severe symptoms lastingjust a week following a stressor would be classified asadjustment disorder; similarly, a patient who had hadfewer than five symptoms of major depressive disorder(MDD) for several weeks following a life event would bediagnosed with adjustment disorder. However, once fivesymptoms of major depression have been present forlonger than 2 weeks, even if they were precipitated by alife event, the diagnosis would change to MDD using theDSM-IV system. In the ICD-10 system, in contrast, apatient with these features would still continue to bediagnosed with adjustment disorder.

Case History 1

Mrs. A, a 58-year-old lady, referred herself to the out-patient clinic. Her 30-year-old son had told her 1month earlier that he was leaving his wife to live withanother women. He had moved abroad and was notpaying maintenance to his wife and child, and Mrs. A.had to provide financial and emotional support to herdaughter-in-law and her grandchild, who had devel-oped enuresis. Mrs. A was tearful and sad about this.

ADULT ADJUSTMENT DISORDER

Journal of Psychiatric Practice January 2001 33

The core feature of adjustment disorder isthat the symptoms can present in individu-als of any age without any pre-existingmental disorder and occur in close tempo-ral relationship to stressful events.

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She and her son were both deeply religious and shecould not understand why this had happened. Shehad initial insomnia but her concentration remainedgood, especially for reading religious material. Shehad difficulty meeting friends and did not enjoy fam-ily gatherings and avoided both. She continued toexpress her belief that everything would work out. Shewas seen once every 2 weeks at the clinic and dis-cussed strategies for dealing with problems as theyarose. After 2 months, Mrs. A was feeling much betterand felt she had the resources to continue to supporther daughter-in-law. She had also begun socializingagain.

Commentary. This patient’s history illustrates the closetemporal relationship between mood changes and a lifestressor. It also shows the ongoing association betweenmood and an event whose consequences are enduring—in this case, the effect of the separation on her daughter-in-law and grandchild. Of note is the functional incapaci-ty this patient experienced, in that she avoided socialgatherings. However, at no point did Mrs. A meet the cri-teria for MDD and, as time passed, her symptomsimproved with basic support and she was dischargedfrom treatment.

Case History 2

Mr. B, a 48-year-old man, was brought to the emer-gency department by his wife. She had found himwriting a suicide note and he admitted forming a sui-cide plan after receiving the news 2 days before thathis 18-year-old son had been remanded into custodyon a serious criminal charge. He was distraughtabout this since his son had no prior problems andwas due to begin university. He had not slept for theprevious 24 hours and paced constantly. He had eatennothing and could speak about nothing else. He feltthe future was bleak and had decided the shame wastoo much to bear, refusing to speak with friends orfamily about it and unable to go to work. Mr. B wasadmitted to the psychiatric unit and, over the follow-ing 5 days, his agitation lessened; he began to speakabout the problem, and his hopelessness and suicidalideation decreased. Upon discharge 1 week later, Mr.B was eating and his mood and concentration hadimproved to the point that he was able to return towork. At follow-up, Mr. B reported that he continuedto worry about his son’s future and to be sad aboutwhat had occurred, but that this did not impingeupon his ability to work.

Commentary. Mr. B man is typical of many patients whoare given a diagnosis of adjustment disorder. The symp-toms showed a very close temporal relationship to amajor family crisis. The symptoms were severe at the

time of presentation, but rapidly resolved. Although somesymptoms were present following discharge, there was nofunctional incapacity.

Overlap with Other Disorders

Clearly there is symptom overlap with other disorders.MDD is the most obvious, but the threshold and durationspecifier should assist in distinguishing one from theother. Similarly, generalized anxiety disorder can be dis-tinguished from adjustment disorder by the requirementthat three of six symptoms of anxiety be present moredays than not for a period of 6 months. Both acute stressdisorder and PTSD also require a stressor, however thestressor must be extreme as distinct from the more com-monplace stressor associated with adjustment disorder.Acute stress disorder is associated with characteristicsymptoms such as depersonalization, numbing, and dis-sociation, and resolves within 4 weeks. If symptoms lastlonger than this, the diagnosis changes to PTSD.

CONTROVERSIESSince first included in modern classifications, adjustmentdisorder has been the subject of controversy. Two themesdominate the criticisms—the poor application of the diag-nostic criteria and the medicalizing of problems of living.The first type of criticism was expressed by an investiga-tor who examined the use of the adjustment disorderdiagnosis among adolescents and described it as a “waste-basket diagnosis” that was all encompassing and vague.7

The second approach has been to challenge adjustmentdisorder as “ontologically unsound and outside the field ofmedicine, lacking the elements that enable a clinician todecide whether a person is ill or not ill, with any clarity.”8

In their provocative essay, Fabrega and Mezzich arguethat the inclusion of adjustment disorder in modern clas-sification represents a shunting away “from a spiritual,moral and socially inevitable human adjustment prob-lem” into what is largely a biological discipline, in whichadjustment disorders are designated as “cryptic forms ofdisease entities.”8 They argue that adjustment disorderdoes not conform to the criteria for “traditional disor-ders,” such as having a specific symptom profile or bio-logical correlates; they also raise the issue of theinteraction between personal vulnerability and the stres-sor necessary for the development of adjustment disor-der—i.e., are individuals with adjustment disorder highlyvulnerable to ordinary stressors or are ordinary individu-als vulnerable to high stressor levels?

There has been no criticism of the inclusion of a cate-gory defined by etiology rather than symptom profile, norhas anyone questioned the failure to provide any criteriafor evaluating the “significant impairment in social andoccupational (academic) functioning” that is essential tothe distinction between normal and abnormal reactionsto stress.



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It is clear from the paucity of research on adjustmentdisorder, with fewer than 30 papers in English on thesubject published since the introduction of the diagnosis,that some of these questions cannot be answered.

VALIDITY: CAN ADJUSTMENT DISORDERSBE DISTINGUISHED FROM OTHER AXIS IDISORDERS?There is little point in devising diagnostic labels unlessthe validity of the symptom cluster/syndrome they repre-sent has been demonstrated. This means showing not onlythat the clinical features of the syndrome differ from thoseof other disorders but also that the course, sociodemo-graphic background, response to treatment, etiology, andlaboratory markers are distinguishable from those foundin other disorders. Validity studies of adjustment disorderhave thus far focused almost exclusively on the course ofthe disorder, which is not surprising, since there is tacitacknowledgment in DSM-IV that there are similaritiesbetween adjustment disorder and depressive episodes.The instructions state that, if the criteria for any otherdisorder are fulfilled, then that diagnosis must be maderather than adjustment disorder. In other words, adjust-ment disorder is subordinate to other diagnoses, so thatsymptom distinctions between adjustment disorder andMDD will not be relevant to the validity debate unless thesymptom threshold is altered in future editions.

Content Validity

One approach to dealing with the criticisms of the adjust-ment disorder diagnosis discussed above was to comparethose who met the criteria for adjustment disorder, thosewho were diagnosed with depressive disorders, and thosewho were given no diagnosis in a psychiatric outpatientsetting. If adjustment disorder constituted a valid clinicalcategory as distinct from a normal reaction, then the

adjustment disorder group should more closely resemblethe depressive disorder group than the “no diagnosis”group on a number of parameters.9 The results of thiscomparison showed that the adjustment disorder groupwas much closer to the heterogeneous depressive disordergroup than to the no diagnosis group: the sex ratio wassimilar, the comorbidity of substance abuse was compa-rable, and there was a similarly high frequency of stres-sors. However, there were differences in the type ofstressor, with patients with adjustment disorder havingmore stressors related to marital problems and fewerrelated to family matters and occupation when comparedto those with other diagnoses. However, length of treat-ment was much shorter in the adjustment disordergroup, although it did extend beyond the 6-month periodspecified in DSM. A study of medical inpatients10 foundthat adjustment disorder and major depression were dis-tinguishable on a number of features. Those with adjust-ment disorder were likely to be older, widowed, and livingalone and adjustment disorder was associated with lesssevere symptoms than major depression. Rapid sympto-matic improvement was the norm. Among psychiatricoutpatients who were evaluated using the SF-36,11 ameasure of social functioning, quality of life, and healthstatus, those with a diagnosis of adjustment disorder hadsignificantly less impairment on all scales at the time ofinitial assessment when compared to groups with depres-sive disorders.12 At follow-up, the patients with adjust-ment disorder also manifested further improvement inscores, equivalent to that seen in major depression anddysthymia when the variance in baselines scores waseliminated.

Temporal Reliability and Predictive Validity

The stability of the adjustment disorder diagnosis isanother issue that has been raised by investigators,because variations in diagnosis over time among thosewith an index diagnosis of adjustment disorder wouldcall into question its validity. One of the earliest investi-gations into adjustment disorder (termed transient situ-ational disturbance at the time) examined indexadmission and readmission diagnoses over a 3-year fol-low-up period and found that the diagnosis was changedto personality disorder in 47% of cases.13 The authorssuggested that the failure to record the presence of a per-sonality disorder at the index admission may have beendue to choosing the less stigmatizing label of adjustmentdisorder. They correctly argued that “it seems unlikelythat it would be in the patient’s interest to…substitute amore benign diagnosis for a more serious one.” They alsopointed to the lack of precision in the criteria and advo-cated grater clarity.

Despite the introduction of more specific criteria, arecent study demonstrated that the diagnosis remainedunstable:14 of 59 adolescents admitted with with a diag-



The adjustment disorder group was muchcloser to the heterogeneous depressivedisorder group than to the no diagnosisgroup: the sex ratio was similar, thecomorbidity of substance abuse was com-parable, and there was a similarly highfrequency of stressors.

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nosis of adjustment disorder, 21 were discharged with adifferent diagnosis, most commonly conduct disorder; of102 adults admitted with a diagnosis of adjustment dis-order, 41 were discharged with a different diagnosis,mainly substance use disorder. Of 29 adults who werereadmitted, only 18% received the same diagnosis.However, this was a study with significant methodologi-cal weaknesses, not least the fact that adjustment disor-der may have been diagnosed pending furtherinformation. More recently, other researchers have sup-ported the temporal stability of the adjustment disorderdiagnosis and confirmed the good prognosis associatedwith the diagnosis in a 5-year follow-up study of patientsadmitted to a crisis intervention unit, which showed thatonly 17% developed a chronic course15 (see also the dis-cussions of “Comorbidity” and “Outcome” below).

Taken together, these studies support the content andpredictive validity of the adjustment disorder diagnosis.

EPIDEMIOLOGYAdjustment disorders are said to be common, particular-ly in the general population and in primary care.However, most large-scale studies of psychiatric disordersconducted in the general population, including theEpidemiological Catchment Area (ECA) study,16 the U.S.National Comorbidity survey (NCS),17 and the NationalPsychiatric Morbidity Survey of Great Britain,18 have notexamined the prevalence of adjustment disorder. The onlylarge study that included adjustment disorder was theOutcome of Depression International Network (ODIN)project.19 The goal of the ODIN project was to identifythose with depressive disorders (including adjustmentdisorder with depressed mood, persistent bipolar mooddisorder, and single and recurrent depressive episodesclassified according to ICD-10) in both urban and ruralsites in five European countries. Using a two-stagescreening method, the researchers found that adjustmentdisorder was the diagnosis in fewer than 1% of those withdepressive disorders (Casey et al., unpublished data).This was a surprisingly low figure and might give comfortto the critics of the diagnosis. However, there may beexplanations for this low prevalence that are related toproblems inherent in commonly used diagnostic tools andare extraneous to the adjustment disorder diagnosisitself. This will be discussed below (see “Measurement”).

DSM-IV acknowledges that adjustment disorders are“apparently common although epidemiological figuresvary widely as a function of the population studied.” Itstates that, among psychiatric outpatients, 5%–20% havea principal diagnosis of adjustment disorder and thatthose from disadvantaged backgrounds may be atincreased risk for the disorder. The basis for this figure isunclear; although adjustment disorder is a common diag-nosis in some settings, figures such as those cited abovehave not been described among psychiatric outpatients.

Studies have suggested that adjustment disorders areparticularly common in primary care settings. A Britishtwo-stage screening study20 found that patients withadjustment disorder constituted 17.9% of those with AxisI disorders in this setting. A somewhat lower figure wasobtained in another study,21 although this difference maybe explained by the methods used, since in this study itwas the general practitioner who screened for psychiatricdisorders. However, in both of these studies, the diagnosiswas a clinical one, based on ICD-9 following detailed per-sonality, social, and symptomatic assessments by aresearch psychiatrist. Among patients being treated in anoutpatient clinic and diagnosed by a psychiatrist accord-ing to strict DSM-III-R22 criteria, adjustment disorderwas the most frequent diagnosis, being made in 23% ofpatients, and was more common than “disorders linked topsychoactive substances” (19.8%) or “thymic disorders”(19.6%).9 In a retrospective evaluation of case notes ofemergency admissions, adjustment disorder was the clin-ical diagnosis in 7.1% of adults and 34.4% of adolescentsadmitted as emergencies, although it is not clear whomade the diagnosis or how rigidly the DSM criteria wereapplied.14

Adjustment disorder is a diagnosis that is made mostfrequently in general medical settings. In a recent studyof over 1,000 consultation-liaison referrals,23 an adjust-ment disorder diagnosis was made in 12% of patients,adjustment disorder was comorbid with personality dis-order or organic disorder in an additional 4.2% ofpatients, and was a rule-out diagnosis in 10.6% ofpatients. A smaller study24 of 313 consecutively admittedmedical inpatients found that adjustment disorder waspresent in 13.7% of patients and was the most commondiagnosis.

COMORBIDITY WITH OTHER BEHAVIORSAND DISORDERS

Personality Disorder

There is a view, stated specifically in ICD-10, that per-sonal vulnerability plays a particularly prominent role inthe etiology of adjustment disorders, and statements con-cerning personal vulnerability are common in the majorpostgraduate textbooks,25 although evidence for theseassertions is lacking. There is no literature on the natureof this vulnerability or the mechanism by which it oper-ates; however, at least one British postgraduate textbooklinks it to personality disorder.26 Although there is anextensive literature on personal and personality vulnera-bility to depressive illness,27 this type of investigation hasnot been extended to adjustment disorder.

The comorbidity of personality disorder and adjust-ment disorder has been the subject of some studies. Oneinvestigator28 examined 116 male outpatients and foundthat the prevalence of personality disorder increased



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progressively across the three categories of adjustmentdisorder, major depression, and dysthymic disorder,reaching a prevalence of 15%, 22%, and 43%, respective-ly. These findings replicated the pattern found in otheroutpatient populations, with personality disorder foundin 66% of patients with adjustment disorder, 85% ofthose with major depression, and 88% of those with dys-thymia.29 In other treatment settings, such as primarycare settings, patients with adjustment disorders havebeen found to have a lower prevalence of associated per-sonality disorder than those with depressive illness.30

In non-clinical populations (e.g., the general popula-tion), the relationship between Axis I and Axis II hasreceived little attention; however, the one study thatexplored this relationship replicated the patterndescribed in clinical populations. The ODIN19 projectfound that 11.8% of those with adjustment disorder withdepressive features, 22.2% of those with a depressiveepisode, 19.4% of those with recurrent depression, and32.6% of those with dysthymia had a comorbid personal-ity disorder (Casey et al., unpublished data).

In view of the paucity of studies and the conflation ofpersonal vulnerability with personality disorder, there isan argument in favor of clarifying the associationbetween personality disorder and adjustment disorder infuture classifications.

Other Diagnoses

The issue of comorbidity is not limited to personality dis-order but extends to other conditions such as substanceabuse. One study found that, among those admitted witha diagnosis of adjustment disorder, 59% had a new pri-mary diagnosis of substance use disorder at dischargeand that, overall, 76% had either a primary or secondarydiagnosis of substance abuse at discharge.14

Suicidal Behavior

Studies among psychiatric patients have found that sui-cidal behavior varies according to diagnosis. In one studyof Axis I disorders, suicidal behavior was found to behighest in major depression (27%), followed by dysthymicdisorder (17%) and adjustment disorder (4%).31 Thisstudy also confirmed that major depression and dys-thymia were associated with a longer period from theonset of the disorder until the episode of self-harm andinvolved more planned acts than the adjustment disordergroup. Another investigation demonstrated the oppositeand found that suicidal behavior was a presenting fea-ture in adults (78%) and adolescents (89%) with adjust-ment disorder significantly more often than in patientswith other psychiatric diagnoses (21%).14 However, thisdid not present a barrier to early discharge and thepatients with adjustment disorder who presented withsuicidal behavior had somewhat shorter admissions thannonsuicidal patients, suggesting that the suicidality in

adjustment disorder is short-lived and therefore mostlikely to arise in the context of personal crises. Moreover,a 5-year follow-up of patients with a diagnosis of adjust-ment disorder15 showed that 2% committed suicide. Thus,although DSM-IV is correct in stating that there is anincreased risk of completed suicide, the risk would seemto be substantially lower than in other Axis I disorders.

Finally, how often is adjustment disorder a diagnosisamong those who completed suicide? Most studies usingthe psychological autopsy method suggest that MDD isthe most common diagnosis made in this group. However,this is at variance with clinical impressions, particularlyconcerning youth suicide, where the suicide often followssome stressful event that occurred in the preceding daysor weeks in an otherwise mentally healthy young person.One of the few studies to examine this question specifi-cally found that adjustment disorder was the diagnosis in28% of young men who died by suicide,32 while majordepression was more common among women. Althoughsome investigators have found that suicide in young peo-ple is linked to major depressive disorder and alcoholabuse,33 others have found an association with adjust-ment disorder, as described above, a finding that if repli-cated in other studies has implications for suicideprevention that differ from the usual guidelines relatingto recognition of “depression” and antidepressant pre-scribing.

In summary, although adjustment disorder and MDDbear a superficial resemblance to each other, when con-sidered in the context of the comorbid conditions and sui-cidal behavior associated with each of them, it is clearthat a distinction exists between the two, thus lendingfurther weight to the validity of the adjustment disorderdiagnosis.

TREATMENT ISSUES By definition, adjustment disorders are short-lived andresolve with the passage of time: for this reason it isunlikely that any specific intervention is required, unless



By definition, adjustment disorders areshort-lived and resolve with the passageof time: for this reason it is unlikely thatany specific intervention is required,unless the individual is acutely suicidal.

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the individual is acutely suicidal, in which case appropri-ate intervention should be taken. This may explain thepaucity of research concerning this disorder. However onestudy of antidepressant prescribing patterns in psychi-atric outpatients between 1985 and 1993/94 found thatthere was an increase in antidepressant prescribing in anumber of groups, including those with adjustment disor-der.34 Another study reported that, in a general medicalsetting, antidepressants were prescribed for adjustmentdisorder in a manner similar to that in other Axis I dis-orders.23 These studies suggest that there is a failure tograsp the concept of adjustment disorder as time-limitedand point to a lack of clarity in distinguishing symptom,syndrome, and illness. It is likely that antidepressantswere being prescribed on the basis of depression as asymptom rather than as an illness, thus conflating twosuperficially similar, but prognostically different, condi-tions.

The only trial that has evaluated psychological andpharmacological interventions in adjustment disorder35

found that, after 4 weeks, four different treatments—sup-portive psychotherapy, an antidepressant, a benzodi-azepine, and a methyl donor— all produced a significantimprovement. A study that compared placebo with plantextract36 in adjustment disorder demonstrated the supe-riority of plant over placebo. A study comparing tra-zodone and a benzodiazepine in cancer patients withadjustment disorder (which did not include a placebogroup) found no statistically significant differencebetween treatments.37 These studies all suffer from thelimitations of small sample size. Clearly, further studiesare required to ascertain if interventions, particularlypsychological and social, shorten the duration or severityof adjustment disorder symptoms.

OUTCOMEFew follow-up studies of adjustment disorder have beendone. By definition, there is an expectation of good out-come in adjustment disorder, with symptoms remittingonce the stressor is removed. Such outcomes were demon-strated in a seminal study, which showed that, at 5-yearfollow-up, 71% of patients diagnosed with adjustmentdisorder did not meet Research Diagnostic Criteria(RDC) criteria for any diagnosis, only 13% had a diagno-sis of major depression and/or alcoholism, and 8% met thecriteria for antisocial personality disorder.38

A 5-year follow-up study15 of 76 patients from a crisisintervention ward who were given an ICD-9 diagnosis ofadjustment disorder confirmed the good prognosis associ-ated with this condition, with only 17% developing achronic or severe course and the number who committedsuicide also low (2%). Moreover, utilization of outpatientservices during the follow-up period was low, a finding con-firmed by a 2-year follow-up study14 showing that adultswith an admission diagnosis of adjustment disorder had

significantly fewer psychiatric readmissions and fewertotal days in hospital.

MEASUREMENTOne of the problems with the diagnosis of adjustment dis-order is that it is difficult to measure using diagnosticalgorithms based on symptom thresholds. On the surface,the symptoms resemble those of MDD or generalized anx-iety disorder and are distinguished only by the promptremission of symptoms when the stressor is removed or anew level of adaptation is reached. Since many depres-sive episodes also are precipitated by life events, the dis-tinction based on the stressor criterion is problematic. Ingeneral, adjustment disorders are less severe thandepressive illness; however, in a clinical setting, thisseverity construct is unlikely to be helpful since thepatient is likely to have been referred because of a levelof symptoms or incapacity that appears to warrant psy-chiatric evaluation and treatment rather than manage-ment in a primary care setting.

It is striking that the main diagnostic tools used in cur-rent epidemiological research either pay little attentionto adjustment disorder or do not incorporate it at all. Forexample, the Structured Clinical Interview for DSM-IV(SCID)39 says, “In most cases this section is skipped dur-ing the administration of SCID-IV because another morespecific diagnosis has been made.” It goes on to state:“The border between adjustment disorder and ordinaryproblems of life may be clarified by the notion thatadjustment disorder implies that the severity of the dis-turbance is sufficient to justify clinical attention or treat-ment.” It is surprising that the application of a diagnosticlabel should be determined by treatment-seeking behav-ior and not by objective criteria such as dysfunction. Thistheoretical approach, if generally applied, would raisehuge philosophical and diagnostic problems, not least forthe concept of hidden psychiatric morbidity.40

Problems also exist with the other diagnostic sched-ules. Although the Schedules for Clinical Assessment inNeuropsychiatry (SCAN)41 incorporates adjustment dis-order, it does so at the end of the interview in Section 13,dealing with Inferences and Attribution, after all othersections have been completed. Placing this section at theend sends a clear message that this section is not asimportant as others. The effect of this on the diagnosis ofadjustment disorder in epidemiological studies that usethe SCAN is obvious. Confirmation of this comes from theODIN study,19 in which adjustment disorder was exam-ined for but in which a prevalence of less than 1% wasfound, with some sites failing to find any cases, notwith-standing the fact that the study was conducted in thegeneral population in whom this condition is said to becommon.

Two other prestigious schedules, the Clinical InterviewSchedule-Revised (CIS-R)42 which was used in the British



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National Psychiatric Morbidity Survey18 and theComposite International Diagnostic Interview43 whichwas used in the U.S. National Comorbidity Study,17 failedto incorporate adjustment disorder in their assessments.

WHERE HAVE ALL THE ADJUSTMENTDISORDERS GONE?The investigation of adjustment disorders is of more thantheoretical importance. It is possible that the failure toincorporate adjustment disorders into recent studies mayhave caused the prevalence of depressive disorders to bemisrepresented, an issue that was highlighted by Regieret al.44 when he pointed out the very different prevalencerates in the first and second wave ECA studies and thefirst and second wave NCS studies. For example, in thesefour studies, the 12-month prevalence rates for a majordepressive episode were calculated at 4.2%, 6.4%, 10.6%,and 10.7%, respectively. Regier pointed out the implica-tions of this, suggesting that variations in prevalencemay be explained by the mislabeling of short-lived home-ostatic responses that are “not in need of treatment” as“mental syndromes.” If it is correct that adjustment dis-order has been incorporated into major depression in epi-demiological studies, then the development and inclusionof scientifically sound algorithms for distinguishing theseshort-term responses (adjustment disorders) from illness-es (major depression) is imperative. The implications arenot just theoretical but also clinical since they may havean impact on funding for mental health care.

Undoubtedly, another problem with the adjustmentdisorder diagnosis is linguistic. Although language is acrude descriptor for the range of emotions that we feel, itis the only one available to all but the few individualswho use other modes of expression such as art or music.Interestingly, in clinical settings, patients are frequentlyable to distinguish between the emotion that is depres-sive illness and emotions that are responses to life stres-sors, notwithstanding the use of identical adjectives toilluminate both feeling states. The overinclusive use ofthe term “depression” was pointed out by one observer45

in his critique of “mild depression,” in which he says:“Here are the states of grief at loss, frustration of failed

aspirations, the gloom of despair, , the accidie of disillu-sion, the demoralization of the long suffering and thecynical outlook of the pessimist.” Including in this mix ofemotions are the emotions associated with depressive ill-ness, those biological states that require pharmacologicaltreatments, among other interventions. As psychiatryhas increasingly allied itself with the biological sciences,it is predictable but deeply regrettable that all moodstates described as depression will be seen as a singleentity requiring “treatment.” The subtlety of languagehas no current biological marker. This conflation ofunhappiness with illness is not the fault of the pharma-ceutical industry so much as of the lack of descriptiverigor in which there is confusion between symptoms, syn-drome, and illness.

SUMMARY AND IMPLICATIONSWhat is known about adjustment disorder is limited butincludes its clinical utility, brief duration, and good prog-nosis. Although the suicide risk associated with adjust-ment disorder is higher than in the general population, itis lower than in most other psychiatric disorders, and,when suicidal ideation is present in adjustment disorder,it resolves rapidly. On the basis of the studies outlined inthis review, there is now enough evidence to confirm thedescriptive and prognostic validity of adjustment disor-der, but little or no evaluation of the merits of its sub-types. Some of the details outlined in both DSM-IV andICD-10 related to personal vulnerability require modifi-cation in light of the absence of further research on theseissues. Moreover, the failure to give clear guidance for dis-tinguishing adjustment disorder from problems of livingis a shortcoming that needs to be addressed.

The potential for viewing major depression and adjust-ment disorder as a single unit on the basis of superficial-ly similar symptoms and the treatment habits that flowfrom this perspective has provided fodder for criticismfrom the vocal anti-psychiatry lobby. In a powerful essay,Snaith45 ponders these matters and arrives at the nub ofthe challenge when he opines: “Considering the vastnessof the sea of human unhappiness and the huge number ofpeople attempting to fish souls out of it, the definition (ofbiological depression) is perhaps the most urgent prob-lem demanding solution by psychiatrists.”

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