THERAPY IN PRACTICECNS Drugs 2CX»; 23 (11): 927-936

1172-7047/09/0011 -0927/S49.95/0

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Adjustment DisorderEpidemiology, Diagnosis and Treatment

Patricia Casey

University Department of Psychiatry, Mater Misericordiae University Hospital, Dublin, Ireland

ContentsAbstract 9271. Diagnostic Criteria 9282. Epidemiology in Various Popuiations 929

2.1 Gênerai Popuiation and Primary Care Studies 9292.2 Psychiatric Out- and Inpatient Clinics 9292.3 Consuitation Liaison Psyciiiatry 9292.4 Deiiberate Seif-Harm 929

3. Issues in tiie Ciassificatian of Adjustment Disorder 9304. Diagnosis 931

4.1 Diagnosis Using Structured interviews 9314.2 Diagnosis in Ciinicai Practice 931

4.2.1 Stressars 9314.2.2 Symptoms 931

4.3 Differentiai Diagnosis . . . 9324.3.1 Distinction from Narmai Responses 9324.3.2 Distinction fram Otiier Psyciiiatric Disorders 932

5. Ca-iVlorbidity 9336. Treatment 933

6.1 Psyciiaiogicai interventions 9336.1.1 Enabiing Reduction or Removal of tiie Stressor 9346.1.2 iVIeasures to Faciiitate Adaptation 9346.1.3 Aitering the Response to the Stressor - Symptom Reductian/Behaviourai Change 934

6.2 Pharmacologicai interventions 9346.3 Treatment Setting 936

7. Conciusians 936

Abstract Adjustment disorder was introduced into the psychiatric classificationsystems almost 30 years ago, although the concept was recognized for manyyears before that. In DSM-IV, six subtypes are described based on the pre-dominant symptoms, but no further diagnostic criteria are offered to assistthe clinician. These are common conditions, especially in primary care and inconsultation liaison psychiatry, where the prevalence ranges from 11 % to18% and from 10% to 35%, respectively. Yet they are under-researched,possibly due to the failure of some of the common diagnostic tools to allowfor the diagnosis of adjustment disorder. Among the tools that incorporateadjustment disorder, the concordance between the clinical and interview

928 Casey

diagnosis is very poor, with the diagnosis being made more commonly inclinical practice than the diagnostic tools allow for. Adjustment disorder isfound in all cultures and in all age groups.

The presence of a causal Stressor is essential before a diagnosis of adjust-ment disorder can be made, while the symptoms vary and include those thatare found in other common psychiatric disorders. It is also important todistinguish adjustment disorder from normal reactions to stressful events.

Adjustment disorders are difficult to distinguish from normal responses tolife's Stressors, while the distinction from major depression also poses a classi-ficatory conundrum since both are conceptually different. Adjustment disorderis a diagnosis based on the longitudinal course of symptoms in the context of aStressor, while a diagnosis of major depression is a cross-sectional one based onsymptom numbers. Treatments consist mainly of brief interventions, whilepharmacotherapy is limited to the symptomatic management of anxiety or in-somnia. There are no robust studies demonstrating benefits from antidepressants.However, the number of studies of either type of intervention is very limited.

This article examines the diagnostic criteria foradjustment disorder and outlines the diagnosticprocess, both clinically and using structured in-terviews. It also discusses the differential andco-morbid diagnoses, while the controversy sur-rounding the diagnosis itself is briefly considered.Various approaches to management conclude thearticle. Throughout, the lacunae in our knowledgeregarding adjustment disorder are highlighted.

1. Diagnostic Criteria

Adjustment disorder has been recognized sincethe DSM-Il'l was introduced in 1952, although atthis time it was called transient situational per-sonality disorder, finally changing to adjustmentdisorder in DSM-III (1980).[2] Adjustment dis-order has been incorporated into the Interna-tional Classification of Diseases (ICD) since theninth revision in 1978.1 '

Despite its long history, the criteria for adjust-ment disorder in DSM-IV-TR^ continue to bevague and largely unhelpful. The core criterion isthat the person must not meet the criteria for anyother psychiatric condition, a bar that is set verylow indeed, especially for major depression, whichrequires only five symptoms to be present for2 weeks. Notwithstanding this criticism, DSM-IV-TR does specify that adjustment disorder occurs:

• In response to a stressful event.• When the onset of symptoms is within 3 months

of exposure to the Stressor.• When the symptoms are distressing and in

excess of what would be expected by exposureto the Stressor.

• When there is significant impairment in socialor occupational functioning.

• When the symptoms are not due to anotheraxis I disorder or bereavement.

• When, once the Stressor or its consequences isremoved, the symptoms resolve within 6 months.Moreover, DSM-FV-TR recognizes that adjust-

ment disorder may be acute, if lasting less than6 months, or chronic, if lasting longer. Six subtypesare described based on the predominant symptompattern and these include: with depressed mood;with anxiety; with mixed depression and anxiety;with disturbance of conduct; with mixed disturbanceof emotions and conduct; and unspecified. The cri-teria for these are not spœified in greater detail.

The ICD-10 has similar criteria'^' but specifiesthat the onset is within 1 month of exposure tothe Stressor and it specifically excludes psycho-social Stressors of an unusual or catastrophicnature. Seven subtypes broadly similar to thosein DSM-IV-TR are identified in ICD-10 butthe depressive reactions are divided into brief(<1 month) and prolonged (<2 years).

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Adjustment Disorder 929

2. Epidemiology in Various Popuiations

DSM-IV-TR states that adjustment disorder isa common diagnosis yet the evidence for this isunclear since it is seldom measured in epidemio-logical studies.

2.1 General Population and Primary CareStudies

None of the major international studies suchas the ECA (Epidemiological Catchment Area)study,t l the National Co-morbidity Survey' ' orthe National Psychiatric Morbidity Surveyt ' in-cluded adjustment disorder among the conditionsexamined. An exception to this was the ODIN(European Outcome of Depression InternationalNetwork) study of depressive disorders in fivecountries in Europe. l Using a two-stage screen-ing method that included the Schedules for Clin-ical Assessment in Neuropsychiatry (SCAN)''"'only 1 % of those with depressive disorders weregiven the diagnosis of adjustment disorder.However, a recent study of elderly people selectedfrom the general population identified adjust-ment disorders as occurring with a prevalence of2.3%, similar to that of major depression.[••'

Adjustment disorders are said to be very com-mon in primary care, where family practitionersdeal with the long-term impact of physical illnessas well as the consequences of social and inter-personal problems, all of which are associatedwith adjustment disorder. Prevalence rates from11% to 18%t' ''-'i have been described amongconsulters with mental health problems, althoughthese studies were conducted over 20 years ago,and more recent studies are conspicuously absent.

2.2 Psychiatric Out- and inpatient Ciinics

There are few studies of adjustment disorderamong psychiatric in- or outpatients. One studyt'"*'of nonpsychotic patients presenting at rural andurban clinics found that adjustment disorder wasthe most common clinical diagnosis, made in 36%of patients, but this dropped to just over 11%using the Structured Clinical Interview for DSM-IV (SCID). Concordance between clinical andSCID diagnoses was lower for adjustment dis-

order than for any other diagnosis. Among ado-lescents attending an outpatient clinic, ' ' almost30% were diagnosed with adjustment disorder.As a diagnosis among inpatients, one study''^'identified adjustment disorder in 9% of conse-cutive admissions to an acute public sector unit.

Among those presenting to a psychiatricemergency care team,!'^' adjustment disorder wasdiagnosed in 19.2% of women (second only tomood disorders) and in 14.5% of men (fourthafter 'other disorders', psychoactive substanceabuse and mood disorders).

In summary, these studies show that even inthe secondary care psychiatric services, adjust-ment disorders are commonly diagnosed.

2.3 Consuitation Liaison Psychiatry

A diagnosis of adjustment disorder is mostlikely to be made in liaison psychiatry. Up to 12%of referrals to the consultation liaison psychiatryservice in several university hospitals''^' weregiven a diagnosis of adjustment disorder and itwas considered a rule-out diagnosis in a further10.6%, figures that resemble those of a largeEuropean study, which identified adjustmentdisorder as the primary diagnosis from 56 centresacross 11 European countries.''^' However, thefrequency with which adjustment disorder isdiagnosed in this setting seems to be declining intandem with an increase in the diagnosis of majordepression.' ^l This may not so much reflect achange in the prevalence of these disorders as achange in the 'culture of diagnosis''^'' with theavailability of newer antidepressants.

Among specific medical groups, studies havedemonstrated that adjustment disorder was al-most 3-fold more common than major depression(13.7% vs 5.1%) in acutely ill, medical in-patients'^^' and was diagnosed in 35% of cancerpatients experiencing a recurrence.f ' In obstetric/gynaecology consultation liaison psychiatry,' '*'adjustment disorders predominated over mooddisorders.

2.4 Deiiberate Self-Harm

Turning to those who engage in deliberate self-harm, a clinical diagnosis of adjustment disorder

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930 Casey

is commonly made, and this was confirmed in anemergency department study where adjustmentdisorder was diagnosed in 31.8% of those inter-viewed, while major depression was less commonat 19.5%.[ 1 These proportions changed to 7.8%and 36.4%, respectively, when a structured inter-view (SCID) was used. One explanation for thisdiscrepancy is that structured interviews may beoverly rigid, having been designed for use by layinterviewers who might apply the criteria in acook-book fashion. This is especially pertinentfor a diagnosis such as adjustment disorder,which relies heavily on clinical judgement, con-text and a longitudinal course.

What about patients with a diagnosis of ad-justment disorder - is there an association withself-harm? The studies to date suggest that thereis. A study of adolescents and young adults with adiagnosis of adjustment disorder who were at-tending an outpatient clinict'^' found that 25%had engaged in a suicide attempt and, comparedwith the non-suicidal adjustment disorder pa-tients, the suicidal patients had a significantlygreater history of prior psychiatric treatment,poorer psychosocial functioning, dysphoricmood, suicide in a significant other and psycho-motor restlessness. A history of self-harm is evenmore common in adults with a diagnosis of ad-justment disorder,[ ^1 with over 60% having sucha history and over two-thirds having a diagnosisof either antisocial or borderline personality dis-order, both associated with self-harm repetition.In short, adjustment disorder carries with it thesame risk factors for self-harm as do other psy-chiatric diagnoses, so the belief that it is lessserious than other axis I diagnoses is belied bythese findings.

The profile of suicide attempters among thosewith adjustment disorder as compared with thosewith major depression includes a greater like-lihood of childhood deprivation, orphanhoodand parental instability. The act is more likely tobe carried out under the influence of alcohol andto be unplanned, and the interval from the onsetof the disorder until the attempt is significantlyshorter in the adjustment disorder group.' ^lTherefore, this is a group with long-standingvulnerability and a tendency to impulsivity that is

even greater than in those with major depression.These studies all point to the role of personalitydisorder as a prominent feature of those withadjustment disorder who engage in self-harm.

3. Issues in the Classification ofAdjustment Disorder

There are a number of debates taking placewith regard to the classification of adjust-ment disorder. These are complex and beyondthe scope of this review, which is focused onthe clinical aspects of adjustment disorder, butfor completeness they will be briefiy outlinedhere.

Adjustment disorder is a diagnostic categorythat is ring-fenced in a particular way. On oneside is the differentiation from other psychiatricdisorders such as major depression, ^ ' somatiza-tiont^'l or minor depression, although there havebeen no studies comparing the latter with ad-justment disorder. The terms minor depressionand adjustment disorder may be used inter-changeably since both are characterized bycognitive and mood-related symptoms^^"' ratherthan vegetative symptoms, and both are alsoviewed as sub-syndromes on the trajectory toother disorders.

A debate within the broader debate relates toadjustment disorder as a sub-syndrome since thisexcludes the possibility of it being diagnosedwhen the criteria for another disorder are met;hence, major depression will always trump adiagnosis of adjustment disorder, notwithstand-ing the low threshold for arriving at a diagnosis ofmajor depression. Some argue that the currentsub-syndromal position should continue,'^'^while others contend that it should be accordedfull syndromal status with its own diagnosticcriteria, a position that is supported by thisauthor. [ '1

With regard to distinguishing adjustment dis-order from major depression, somatization dis-order and others, there are conceptual difficultiessince a diagnosis of adjustment disorder is basedon the longitudinal pattern of symptoms trig-gered by a Stressor that ultimately resolves, whilea diagnosis of major depression or somatization

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Adjustment Disorder 931

disorder is made cross-sectionally based on symp-tom numbers and severity. So different dimen-sions, one longitudinal and one cross-sectional,exert themselves in the diagnostic process. This islikely to render attempts at comparison problem-atic, although to date no differences in symp-toms between adjustment disorder and majordepression have been identified.

On the other side of the adjustment disorderfence lie the adaptive homeostatic reactions tostressful events from which adjustment disordermust also be distinguished. A system of diagnosisbased simply on the presence of symptoms aloneis likely to be over-inclusive, capturing in its neta variety of appropriate responses to Stressors.A warning note was sounded in a recent edito-j.ja].[32] "[X]here may well be a latent genius inthese labels, for professionals, for laypersons andfor society, because they represent psychiatry'srecognition of the existential limits and un-certainties of living. Beware a Trojan horse,however; these categories, if widely used, couldmédicalise most of life." Surmounting thisrequires clinical skills that consider various do-mains within the symptom complex such ascontext, cultural norms, etc. These will be consi-dered further below (see differential diagnosis insection 4.3).

4. Diagnosis

4.1 Diagnosis Using Structured interviews

Few of the structured diagnostic interviewsincorporate adjustment disorder. Neither theClinical Interview Schedule (CIS)'"' nor theComposite International Diagnostic Interview

t^l include adjustment disorder. Thedoes include adjustment disorder in

section 13, which deals with inferences and attri-butions. This comes after the criteria for all otherdisorders have been completed and there are nospecific questions to assist the interviewer inmaking the diagnosis. The SCID^ l also includesa section dealing with adjustment disorder butthe instructions to interviewers specify that thisdiagnosis is not made if the criteria for any otherpsychiatric disorders are met. The Mini Interna-

tional Neuropsychiatrie Interview (M.I.Nalso incorporates a section on adjustment dis-order but, as in SCID, it is trumped when anotherdiagnosis is made.

4.2 Diagnosis in Ciinicai Practice

Diagnosing adjustment disorder in clinicalpractice can be difficult since there is symptomoverlap between the various subcategories ofadjustment disorder and other psychiatric syn-dromes such as generalized anxiety, major de-pression, etc. Most research in distinguishingadjustment disorder subtypes from other dis-orders has focused on adjustment disorder withdepressed mood and major depression.t^^l

4.2.1 StressorsThe essential requirement for diagnosing ad-

justment disorder is that the symptoms must betriggered by a stressful event and the maximumtime lag specified in ICD-10 is 1 month and inDSM-IV-TR is 3 months. In this regard it issimilar to post-traumatic stress disorder. For allother psychiatric disorders, a Stressor is not a re-quirement, although there is evidence'^^' that over80% of those with major depression have experi-enced a recent life event.

Concerning the type of events, there is little toassist the clinician in distinguishing adjustmentdisorder from other diagnoses and even events ofthe magnitude that are typically associated with adiagnosis of post-traumatic stress disorder canalso trigger adjustment disorder. A study com-paring those with major depression to those withadjustment disorder identified a higher propor-tion of events related to marital problems andfewer to occupational or family Stressors in theadjustment disorder group.t^^' Although statis-tically significant, these differences are unlikely tobe helpful in making the diagnosis since they arenot specific to either diagnosis.

4.2.2 Symptoms

In both ICD-10 and DSM-IV-TR, the criteriafor diagnosing adjustment disorder are silentwith respect to specific symptoms. Nevertheless,there are some symptoms that may be of diag-nostic assistance. The loss of mood reactivity, the

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932 Casey

presence of diurnal mood change, a distinctquality to the mood change and a family historyof depression might suggest a depressive episoderather than adjustment disorder. This was par-tially supported in a study' ' comparing patientswith major depression, with and without physicalco-morbidity. Using an instrument designed todistinguish typical melancholic features fromother symptoms of depression,!^ ' those withphysical illness were less likely to experience theformer, raising the possibility that the greater theenvironmental triggers the less likely that typicalmelancholic symptoms of depression will bepresent. Since adjustment disorder represents,par excellence, a disorder in which environmentalfactors are prominent, it is possible that thesesymptoms will distinguish those with adjustmentdisorder from those with more biologically deter-mined depression. Only further studies willdemonstrate if these symptoms have sufficientspecificity.

With regard to the symptom of low mooditself, the mood state of those with adjustmentdisorder often depends more on the cognitivepresence of the Stressor, so that immediate im-pairment of mood is observed when the Stressor ismentioned, followed by a more pronouncedmood recovery when the patient is distracted.

Ultimately, due to the limitations in the cri-teria for diagnosing adjustment disorder, the di-agnosis is based on the presence of a precipitatingStressor and on a clinical evaluation of the like-lihood of symptom resolution on removal of theStressor.

4.3 Differential Diagnosis

4.3.1 Distinction from Normai Responses

Adjustment disorder is different from otherpsychiatric disorders since one element of thediagnosis is whether the response to the Stressor isa manifestation of appropriate distress.

The failure to differentiate appropriate, non-pathological reactions to stressful events fromthose that are pathological could lead to normalsadness being misdiagnosed as adjustment dis-order or depression,''*"' simply by the presence ofsymptoms. In the absence of criteria distinguish-

Table I. Variables to consider in distinguishing adjustment disorderfronn normai responses to Stressors

Personal circumstances and context of the Stressor

Proportionality between symptom severity and triggering event

Persistence beyond expected duration

Cuitural norms for emotionai response/expression

Duration and severity of functionai impairment

ing normal from abnormal responses, clinicaljudgement will play a prominent part in decidingwhether the responses are proportionate orexcessive (table I).

This will have to take into account the perso-nal circumstances of the individual and the ex-pression of symptoms within the person's culture.For example, the loss of a job might be acceptablefor one person while for another it could heappoverty on a family. Cultural differences inthe expression of emotion will also need to beconsidered since some individuals are more ex-pressive than others; a knowledge of 'normal'coping with illness and other stressful events isessential and the diagnostic process will be guidedby the extent to which an individual's symptomsare in excess of this, both in terms of severity andduration. For instance, failure to appreciate thatsome cultures grant compassionate leave fromwork following bereavement might lead to such aperson being identified as disordered in anotherculture. Finally, the presence of functional im-pairment is also an indicator of a pathologicalresponse.

With regard to symptoms and functioning, it isrecommended that these should only be regarded asexcessive if they are 'clinically significant', '*'' al-though this has not been defined and has been criti-cized as being inadequate'''^' and tautological.'" '

4.3.2 Distinction from Otiier Psychiatric Disorders

Because of the symptom overlap between ad-justment disorder and a number of axis I dis-orders such as major depression and generalizedanxiety, the possibility that these diagnoses mightbe present rather than adjustment disorder mustbe considered. The failure to diagnose major de-pression, for instance, could have serious treat-ment and prognostic implications. Alternatively,

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Adjustment Disorder 933.

diagnosing such disorders as major depressionwhen a diagnosis of adjustment disorder is moreappropriate could reinforce the 'culture of pre-scribing' even when spontaneous recovery islikely. A problem arises if the DSM-IV-TR diag-nostic criteria are rigidly applied since, once thecriteria (symptom numbers and duration) for anyother disorder are reached, the diagnosis of ad-justment disorder cannot be made. In practice itis more likely that major depression will be over-diagnosed at the expense of adjustment disorderthan the converse, due to the low thresholdapplied to major depression.

Post-traumatic stress disorder and acute stressdisorder require the presence of a Stressor of amagnitude that would be traumatic for almosteverybody and a specific symptom constellation,although these have recently been challenged.t'* !However, not everybody exposed to such trauma-tic events develops post-traumatic stress disorderand the possibility that other disorders, such as ad-justment disorder, can occur needs to be considered.

Finally, what may appear to be an adjustmentdisorder, because of the sub-threshold level of thesymptoms or the lack of functional impairment,might be an axis I disorder in evolution that onlyemerges as a recognisable syndrome after a peri-od of watchful waiting, especially if symptomspersist despite termination of the Stressor.

For those experiencing long-standing Stressors,the persistently low mood that is the responseto these may be misdiagnosed as dysthymia, asenduring personality change after psychiatric ill-ness (ICD-10 only) or as depressive personalitydisorder (DSM-IV-TR only).

5. Co-Morbidity

The preamble to the section on adjustmentdisorder in ICD-10 points to the greater promi-nence of personal vulnerability in the aetiology ofthis disorder as compared with others. While thisis suggestive of co-morbidity with personalitydisorder, the research base for this is limited.Some studiest'* ^ identify cognitive style as a pos-sible contributing feature. In particular, trauma-tic childhood experiences are hypothesized asstimulating the perception of events as outside of

one's control, thus leading to distress and de-pressive symptoms. Other studies have identifiedthe trait of neuroticism as being associated withadjustment disorder when compared with thosewho are symptom free.t'* ^ Few studies have ex-amined the disorders that are co-morbid withadjustment disorder, an exercise that is hamperedby the fact that the criteria for adjustment disorderpreclude its diagnosis if the criteria for anothercondition are met. Yet a recent study'"! foundthat 46.1 % of patients exhibited co-morbidity andthis was highest for major depression (relativerisk [RR] 26.8) and post-traumatic stress disorder(RR 5.1). This should not be surprising sinceco-morbidity is commonly associated with allpsychiatric disorders and the finding may repre-sent the co-occurrence with another disorder ofdifferent aetiology.

The relationship between substance abuse andadjustment disorder is also deserving of mentionsince it may explain the seeming instability of theadjustment disorder diagnosis. Substances maybe misused for relief of symptoms such as anxietyand depression, which are prominent in adjust-ment disorder. Alternatively, substances such asalcohol are themselves depressants and abuse ofthese agents may present with mood-relatedsymptoms, leading to misdiagnosis. There issome evidence for the latter from a study''* ' thatfound that 59% of patients diagnosed with ad-justment disorder were relabelled on discharge ashaving a primary diagnosis of substance misuse.

6. Treatment

There are few trials of treatment, whetherpsychological or pharmacological, for adjust-ment disorder, but in clinical practice the focushas been mainly on psychological interventions.

6.1 Psychological Interventions

In general, brief therapies are considered themost appropriate''*^] as adjustment disorders tendto be short lived, although lengthier therapiesmay be required when Stressors are chronic orwhen there is an underlying personality patho-logy that increases vulnerability to such Stressors.

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934 Casey

There are three broad componentsl * ' tothe psychological interventions for adjustmentdisorder.

Ó. 1.1 Enabling Reduction or Removal oithe Stressor

These measures consist of practical assistancein removing the Stressor from the person or theperson from the Stressor. For example, when anindividual is in a violent relationship, encoura-ging the person to obtain protection or to leave islikely to reduce the levels of distress. Moreover,many Stressors can be minimized or avoided,such as when a person takes on too much work.Problem-solving techniques may assist the pa-tient in making these decisions.

6.1.2 Measures to Facilitate Adaptation

When a Stressor cannot be removed, such as aperson caring for a sick relative, measures such aspsycho-education, problem-solving techniques orcognitive restructuring may help reframe it.

Putting support systems in place can help adistressed person deal with problematic situa-tions especially when it results in practical assis-tance, such as someone being available when acarer needs time off. This may involve harnessingthe input of family members or encouraging in-volvement in a support or self-help group.

6.1.3 Altering the Response to ttie Stressor-Symptom Reduction/Behavioural Change

Relaxation techniques can reduce symptomsof anxiety, and more general measures that in-clude facilitating the verbalization of fears andemotions and exploring the meaning that theStressor has for the individual might also ame-liorate symptoms. Many who are confronted bylife's problems will engage in deliberate self-harm, either due to hopelessness, anger or someother emotion. Assisting the person in findingalternative responses that do not involve self-destruction will be of obvious benefit and, to date,dialectical behaviour therapy has the best evi-dence base.I l

Interventions may be delivered individually orin groups, and family or interpersonal therapymay be of value in some contexts.t ^^ In general,the psychological therapies span the range in-cluding supportive, psycho-educational, cogni-

tive and psychodyhamic approaches. Althoughnot yet tested in relation to adjustment disorder,resilience-enhancing techniques might also havea role.t l

Unfortunately, the evidence base for theseapproaches is limited. A few studies have fo-cussed on the elderly, who are particularlyvulnerable to adjustment disorders. One studyutilized ego-enhancing therapy during periods oftransition,t^°l while another used 'mirror therapy'in those with adjustment disorder secondary tomyocardial infarction,t^'' both with benefit.

In a younger population, cognitive therapywas helpful when administered to those with ad-justment disorder who experienced work-relatedstress,' - ' while among army conscripts it wasbeneficial to those with adjustment disorder.'^^'In a study of terminally ill cancer patients, '*'similar improvements were found in those withadjustment disorder and other psychiatric diag-noses when they were treated with cognitivetherapy.

A grey literature study of nine patients withadjustment disorder^^ ' found benefits from eyemovement desensitization.

Some of these psychological interventionshave been tested in specific medically ill groupssuch as cancer patients, those with heart disease,HIV and so on. While improvements in copinghave been demonstrated, it is unclear if patientshad adjustment disorder, some were open-labelpilot studies' ^1 and survival and quality of liferather than symptoms were the outcome mea-sures in others.[ ' 1 Another study confirmed thebenefits of brief dynamic and supportive therapyfor minor depressive disorders'^^' that includedadjustment disorders, but the sample sizet l wassmall and diagnostically diverse.

6.2 Pharmacoiogicai interventions

The pharmacological management of adjust-ment disorder consists of the symptomatic treat-ment of insomnia, anxiety and panic attacksand the use of benzodiazepines is common.I 'While antidepressants are advocated by some,' **'especially if there has been no benefit frompsychotherapy, there is little solid evidence to

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Adjustment Disorder 935

support their having an effect on depressivesymptoms in those with adjustment disorders.Nevertheless, antidepressants with sedative pro-perties targeting sleep and anxiety may have arole when benzodiazepines are contraindicated,^ ']such as in those with a history of substancedependence.

There are few trials specifically directed at thepharmacological treatment of adjustment dis-orders and these are mainly of patients with ad-justment disorder with anxiety. Some of thesestudies are summarized in table II.

A recent double-blind, controlled studyt ^comparing a benzodiazepine (lorazepam) with anon-benzodiazepine anxiolytic (etifoxine) foundthat the anxiolytic effects of each were similar,although more patients responded to the non-benzodiazepine medication.

Two randomized, placebo-controlled studiesexamined herbal remedies including extracts fromkavain (kava-kava)' ' and valerian plus other ex-tractst^^ among outpatients with adjustment dis-order (with anxiety) and demonstrated a positive

effect on symptoms. A further study in patientsdiagnosed with adjustment disorder with anxietyfound that anxiolytics and antidepressants wereequally effective,' ! while a pilot study of cancerpatients with anxious and depressed mood showeda benefit from trazodone in comparison with abenzodiazepine, although the results were notstatistically significant.'^'

One study in primary care' ' examined theresponse of patients with major depression andthose with adjustment disorder to antidepres-sants using reported changes to functional dis-ability based on case note information. Overall,the adjustment disorder group was twice as likelyto respond to antidepressants. However, being aretrospective case note study, the relevance of theresults is questionable.

One of the few studies to compare pharmacolo-gical with psychological interventions' *' randomlyassigned 85 patients diagnosed with adjustmentdisorders to supportive psychotherapy, an anti-depressant, a benzodiazepine, ademetionine orplacebo. All improved significantly.

Table II. Summary of medication trials in the treatment of adjustment disorder (AD)

Study (year)

Nguyen et al.'^^l(2006)

Volz andKieserl°3I(1997)

Bourin et al.'^^l(1994)

Ansseau et a l . '^ '(1996)

Razavi et al.'^^i(1999)

Hameed et al.i^i(2005)

De Leol«81(1989)

Design

r, db, pg

r, db, pc

db, pc

db, pg

r, db

Retrospectivecase review

r

a Dosage not specified.

db=double-blind;

Treatment, dosage and duration

Etifoxine 50 mg tId vs lorazepam0.5-1 mg/day for 28 days

Kavain (kava-kava) extract WS 1490°vs placebo for 25 weeks

Valerian and other extracts(Euphtose'^) 2 tablets tId vs placebo for28 days

Tianeptlne 37.5 mg/day vs alprazolam1.5 mg/day vs mianserin 60 mg/day for6 weeks

Trazodone mean dosage 111.5 mg/dayvs clorazepate mean dosage17.5 mg/day for 28 days

Antidepressants in major depressionvs AD

Vlloxazine vs lormetazepam vsademetionine (S-adenosylmethlonine)°vs psychotherapy vs placebo for4 weeks

GPs = general practitioners; HAM-A = Hamilton Rating Scaler == randomized; tid = three times daily.

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Population

191 outpatientsattending GPs

101 outpatients

182 outpatients

152 patients

18 cancerpatients

96 primary-carepatients

85 outpatients

Outcome

HAM-A score decreased by 54.6%vs 52.3% (p=0.0006)

Kavain decreased HAM-A scoresignificantly more than placebo fromweek 8

Extracts decreased HAM-A scoresignificantly more than placebo fromday 7 to day 28

Similar improvement with all threetreatments

Successful response to treatment In10/11 patients receiving trazodonevs 4/7 patients receivingclorazepate (p=0.1373)

Response rates better In patientswith AD than in patients withdepression

All treatments produced similarImprovements on the Zung Self-Rating Depression Scale

for Anxiety; pc = placebo-controlled; pg = parallel-group;

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936 Casey

Overall, these studies lend little support for thesuperiority of antidepressants, and arguably forany specific treatment, in the management ofadjustment disorders but further studies areclearly required.

6.3 Treatment Setting

Finally, the question of the setting in whichthese interventions should be delivered is im-portant and, while it might be tempting to re-direct those with adjustment disorders from thespecialist services back to their primary carephysicians, the demands in terms of time'^'' andskills might make this impractical. Managementin a community setting in which large numbers ofpatients are offered an intervention delivered byclinical psychologists is another possibility. Thishas been tested in individuals self-diagnosed as'stressed', by providing a 1-day free workshopcomprising psycho-education using a cognitiveapproach. ™! At 3 month's follow-up the inter-vention group was significantly less symptomaticthan the waiting list control groups. This ap-proach needs to be tested in patients diagnosedwith adjustment disorder since it may have beenreaching only those in the throes of normaladaptation to Stressors. For the moment, patientsdiagnosed with adjustment disorder by psychia-trists are best treated by members of the psy-chiatric multidisciplinary team who have theappropriate skills.

7. Conclusions

Adjustment disorders are common, yet thisdiagnosis is made in the absence of specific diag-nostic criteria, an issue that has been the subjectof criticism. This lacuna has made research intothe epidemiology and treatment of these condi-tions difficult. The diagnosis is currently one thatis based on clinical judgement concerning theappropriate response to a stressful event or itsconsequences. It also demands a judgement thatresolution will occur when the Stressor is re-moved. Treatments are mainly psychological butsome brief pharmacological interventions havealso been examined, although overall data are

sparse. The fact that, despite the conceptual anddiagnostic difficulties, the diagnosis continues tobe made is indicative of its utility. Much work isstill needed to develop evidence-based interven-tions for adjustment disorders. Meanwhile, thebest evidence is for psychological treatments.

Acknowledgements

No sources of funding were used to assist with the pre-paration of this review. The author has no conflicts of interestthat are directly relevant to the content of this review.

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Correspondence: Prof. Patricia Casey, Consultant Psychia-trist and Professor of Psychiatry, University Department ofPsychiatry, Mater Misericordiae University Hospital, EcclesStreet, Dublin 7, Ireland.E-mail: apsych@mater.ie

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