The Adjustment Disorders
Prevalence
Course
Problems in Diagnosing Adjustment Disorders
Treatment
Individual and group counseling and psychotherapy
Pharmacotherapy
The adjustment disorders, a diagnostic category of the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV),[1] are defined as reactions to an identifiable psychosocial stressor
(e.g., cancer diagnosis) with a degree of psychopathology that is less severe
than diagnosable mental disorders such as major depressive disorder or
generalized anxiety disorder and yet are “in excess of what would be expected”
or result in “significant impairment in social or occupational functioning.”
Diagnostic Criteria for the Adjustment Disorders
-
Criterion A. The development of emotional or behavioral symptoms in response
to an identifiable stressor(s) occurring within 3 months of the
onset of the stressor(s).
-
Criterion B. These symptoms or behaviors are clinically significant as
evidenced by either of the following:
- Marked distress that is in excess of what would be expected
from exposure to the stressor.
- Significant impairment in social or occupational (academic)
functioning.
-
Criterion C. The stress-related disturbance does not meet the criteria for
another specific Axis I disorder and is not merely an
exacerbation of a preexisting Axis I or Axis II disorder.
-
Criterion D. The symptoms do not represent bereavement.
-
Criterion E. Once the stressor (or its consequences) has terminated, the
symptoms do not persist for more than an additional 6 months. Specify:
- Acute if the disturbance lasts less than 6 months.
- Chronic if the disturbance lasts for 6 months or longer.
- Specific subtypes represent the predominant symptoms and include:
- With depressed mood.
- With anxiety.
- With mixed anxiety and depressed mood.
- With disturbance of conduct.
- With mixed disturbance of emotions and conduct
unspecified.
[Note: Adapted from American Psychiatric Association, 2000.[1]]
Prevalence
In the general population, adjustment disorders are thought to be common,
though prevalence rates vary by population studied. In studies of community
samples of children, adolescents, and the elderly, prevalence estimates have
ranged from 2% to 8%. In outpatient mental health settings, prevalence rates
have been as high as 10% to 30%; while in general hospital inpatients,
prevalence rates have been as high as 12% of those referred for a mental health
consultation.[1]
Nearly every cancer patient experiences what could be considered an
identifiable stressor, whether that is diagnosis, treatment, recurrence, or
side effects. The presence of an adjustment disorder is determined more by the
patient’s response to the identifiable stressor, and whether that response is
considered in excess of what would be expected or results in significant
impairment, typically in social or occupational functioning.
One study [2] evaluated 215 randomly selected hospitalized and ambulatory
cancer patients in three different cancer centers and found that of this group,
slightly fewer than half (47% or 101 patients) met the diagnostic criteria for
any mental disorder (DSM-III criteria). From this group of 101, 68% (69
patients) met the diagnostic criteria for an adjustment disorder. Of the
entire 215 patients evaluated, approximately 32% were identified as meeting the
diagnostic criteria for an adjustment disorder—the highest prevalence of any
diagnostic category. Additional reviews [3] have continued to find adjustment disorders to be the most common mental disorder. In patients with advanced cancer, prevalence ranges from 14% to 34.7%; in terminally ill patients, rates range from 10.6% to 16.3%. These variable prevalence rates are influenced by stage of disease, type of cancer, diagnostic procedures used, and other patient variables. In a study of women with breast cancer undergoing adjuvant chemotherapy, a 36.1% prevalence rate was found.[4] In another study of terminally ill Japanese cancer patients referred to a palliative care unit, 16.3% were diagnosed with an adjustment disorder at the time of their initial referral, and 10.6% were diagnosed with an adjustment disorder at the time of their admission to the palliative care unit. Of patients diagnosed with adjustment disorder at initial referral, 42% had progressed to major depression at admission to the unit, and 42% had no diagnosis.[5] Thus, it seems safe to conclude that the adjustment disorders
are the most commonly diagnosed mental disorder in the oncology setting.
Course
As defined in the diagnostic criteria, an adjustment disorder begins within 3
months of the onset of an identifiable stressor and lasts no longer than 6
months after the stressor or its consequences have ceased. Two specifiers
exist to discriminate between an acute adjustment disorder (<6
months) and a chronic adjustment disorder (>6 months). The cancer
patient may experience a sequence of multiple, sequential stressors such as the
diagnosis, the start of treatment, side effects of treatment, conclusion of
treatment, and return to work. It is often difficult to determine when a
stressor has ceased. It is not unusual to see a chronic adjustment disorder
that persists because of the presence of multiple, sequential stressors. The
persistent adjustment disorder may also progress to become a more serious
mental disorder (e.g., major depressive disorder). Chronic adjustment
disorders that persist and progress to more severe mental disorders appear more
common in children and adolescents than in adults.[1] (Refer to the PDQ summary on Pediatric Supportive Care for more information.)
Problems in Diagnosing Adjustment Disorders
The adjustment disorders are an intermediate category between normal adjustment
and a specific diagnosable mental disorder. In terms of their location within
a hierarchy of increasingly severe mental disorders, the adjustment disorders
are an intermediate category as follows:
- Major mental disorders (e.g., major depressive disorder, panic disorder,
posttraumatic stress disorder, generalized anxiety disorder).
- Disorders not otherwise specified (NOS).
- Adjustment disorders.
- Problem-level diagnoses (e.g., partner relational problems, bereavement,
physical abuse of child).
- Fluctuations in mood that represent normal adaptation.[6]
Screening instruments for the identification of adjustment disorder have been difficult to identify.[7,8] This intermediate status and the lack of any specific list of symptoms raise a
number of problems with the adjustment disorder’s diagnostic category.[6] Most
of the problems stem from lack of specificity and resulting subjectivity. This
lack of specificity applies to both the identifiable stressor and the marked
distress/significant impairment.
No criteria or guidelines exist in DSM-IV to quantify the nature of the
psychosocial stressor(s). Given individual differences in coping abilities,
certain stressors are likely to be very stressful for one patient and not
stressful at all for another patient. With no quantifiable guidelines for
measuring stressors, a diagnosis is often determined by the nature of an
individual’s response. If a person responds with marked distress or
significant impairment in functioning, it is often assumed that the life event
was an identifiable stressor. However, the identification of a response that
evidences marked distress or significant impairment also lacks specificity and
is thus very subjective. Many of these diagnostic terms are too vague to be
valid or reliable; thus, there is considerable variation in the use of the
adjustment disorder category.
Despite these problems, the adjustment disorder category does provide a means
of identifying an emotional or behavioral response in need of further
treatment. Cancer patients are regularly confronted with a variety of
stressors and thus face the potential of experiencing an adjustment disorder.
Treatment
Individual and group counseling and psychotherapy
Although only one study has been targeted specifically at a population of cancer
patients diagnosed exclusively with adjustment disorder, a number of studies
have shown the benefits of psychosocial interventions with adult cancer
patients (e.g., meta-analysis).[9] These interventions have included both
individual [10] and group counseling [11-13] and have utilized a variety of
theoretical approaches.
In a randomized clinical trial for the treatment of adjustment disorders, 57 patients with mixed cancer types were randomly assigned to either an 8-week individual, problem-focused, cognitive-behavioral psychotherapy intervention or an 8-week individual, supportive counseling intervention.[14] Results showed that those receiving the problem-focused, cognitive-behavioral therapy exhibited a significant change in fighting spirit, coping with cancer, anxiety, and self-defined problems, both at the conclusion of the intervention and at the 4-month follow-up.
Cognitive-behavioral interventions have been widely studied. A
cognitive-behavioral approach is based on the idea that mental, emotional, and
even physical symptoms partly stem from one’s thoughts, feelings, and
behaviors, resulting in poor adaptation.[15] Interventions focus directly on a
patient’s thoughts, feelings, and behaviors with the goal of altering specific
coping strategies and alleviating emotional distress. Cognitive-behavioral
interventions include a variety of techniques such as:
- Relaxation training.
- Biofeedback.
- Contingency management.
- Problem-solving.[16]
- Cognitive
restructuring.
- Distraction.
- Thought stopping.
- Coping
self-statements.
- Mental imagery exercises.
Most studies have combined a
variety of these approaches into a multicomponent treatment strategy designed
to alleviate specific symptoms. Cognitive-behavioral approaches tend to be
relatively short-term, brief interventions, well-suited to the oncology
setting.[15,16] One study [17] randomly assigned 382 patients with different types of cancer to one of three groups: usual care, professionally led stress management, or self-administered stress management. The two intervention groups received stress management training that included abdominal breathing, progressive muscle relaxation training with guided imagery, and coping self-statements prior to the start of chemotherapy. The professionally led intervention group met with a mental health professional who taught them the stress management skills in one 60-minute session. The self-administered group received a packet of training materials that included a 15-minute videotape of instructions, a 12-page booklet on coping with chemotherapy, and a 35-minute audiotape of relaxation training instructions. Results showed enhanced quality of life over usual care in the self-administered group only. The professionally led group did not show any improvement in quality of life when compared with usual care.
A meta-analysis of 45 such studies investigating 62 treatment-control
comparisons found significant beneficial effects in emotional adjustment.[9]
Beneficial effect sizes for emotional adjustment ranged from .19 to .28,
indicating that the average cancer patient receiving treatment was better off
than 56.5% to 59.5% of those patients not receiving treatment. These
interventions have been administered in both individual [10] and group
formats,[18] indicating benefits in emotional adjustment from both formats at
the conclusion of the intervention and at 6-month and 12-month follow-up
assessments. One novel approach adapted a 6-week group format to a telephone conference call structure for breast cancer survivors; there was high acceptability and modest treatment effects immediately after the intervention but not at the 3-month follow-up.[19]
Another study found that a cognitive behavioral intervention to teach problem solving was effective in promoting better self-management of cancer-related symptoms, especially for patients aged 60 years or younger.[20]
Pharmacotherapy
No studies have specifically targeted a population of cancer patients diagnosed
exclusively with adjustment disorder, in which the primary intervention was some
form of pharmacotherapy. Given the nature of the adjustment disorders,
clinical experience suggests that, if available, an initial trial of short-term counseling or
psychotherapy designed to alter or eliminate the identified stressor (and thus
alleviate symptoms) should be tried before pharmacotherapy.[6] As mentioned
previously, sometimes the adjustment disorder may progress to a more severe
mental disorder (e.g., major depressive disorder) and thus warrant
consideration of pharmacotherapy. In addition, when the patient does not
benefit from short-term psychotherapy, adding an appropriate psychotropic
medication for a brief period of time (e.g., 2–3 weeks for antianxiety
medications, 12 months for antidepressants) may facilitate the psychotherapy,
allowing the patient to better employ available coping strategies. The
specific pattern of emotional or behavioral symptoms will determine which type
of psychotropic medication to consider. (Refer to the PDQ summaries on Depression and Anxiety Disorder for more information.)
References
-
American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.
-
Derogatis LR, Morrow GR, Fetting J, et al.: The prevalence of psychiatric disorders among cancer patients. JAMA 249 (6): 751-7, 1983.
[PUBMED Abstract]
-
Miovic M, Block S: Psychiatric disorders in advanced cancer. Cancer 110 (8): 1665-76, 2007.
[PUBMED Abstract]
-
Morasso G: Screening adjustment disorders related to mastectomy and its treatment. New Trends in Experimental and Clinical Psychiatry 13 (1): 90-3, 1997.
-
Akechi T, Okuyama T, Sugawara Y, et al.: Major depression, adjustment disorders, and post-traumatic stress disorder in terminally ill cancer patients: associated and predictive factors. J Clin Oncol 22 (10): 1957-65, 2004.
[PUBMED Abstract]
-
Strain JJ: Adjustment disorders. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 509-17.
-
Kirsh KL, McGrew JH, Dugan M, et al.: Difficulties in screening for adjustment disorder, Part I: Use of existing screening instruments in cancer patients undergoing bone marrow transplantation. Palliat Support Care 2 (1): 23-31, 2004.
[PUBMED Abstract]
-
Kirsh KL, McGrew JH, Passik SD: Difficulties in screening for adjustment disorder, Part II: An attempt to develop a novel self-report screening instrument in cancer patients undergoing bone marrow transplantation. Palliat Support Care 2 (1): 33-41, 2004.
[PUBMED Abstract]
-
Meyer TJ, Mark MM: Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 14 (2): 101-8, 1995.
[PUBMED Abstract]
-
Greer S, Moorey S, Baruch JD, et al.: Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. BMJ 304 (6828): 675-80, 1992.
[PUBMED Abstract]
-
Telch CF, Telch MJ: Group coping skills instruction and supportive group therapy for cancer patients: a comparison of strategies. J Consult Clin Psychol 54 (6): 802-8, 1986.
[PUBMED Abstract]
-
Penedo FJ, Dahn JR, Molton I, et al.: Cognitive-behavioral stress management improves stress-management skills and quality of life in men recovering from treatment of prostate carcinoma. Cancer 100 (1): 192-200, 2004.
[PUBMED Abstract]
-
Goodwin PJ, Leszcz M, Ennis M, et al.: The effect of group psychosocial support on survival in metastatic breast cancer. N Engl J Med 345 (24): 1719-26, 2001.
[PUBMED Abstract]
-
Moorey S, Greer S, Bliss J, et al.: A comparison of adjuvant psychological therapy and supportive counselling in patients with cancer. Psychooncology 7 (3): 218-28, 1998 May-Jun.
[PUBMED Abstract]
-
Jacobsen PB, Hann DM: Cognitive-behavioral interventions. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 717-29.
-
Allen SM, Shah AC, Nezu AM, et al.: A problem-solving approach to stress reduction among younger women with breast carcinoma: a randomized controlled trial. Cancer 94 (12): 3089-100, 2002.
[PUBMED Abstract]
-
Jacobsen PB, Meade CD, Stein KD, et al.: Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy. J Clin Oncol 20 (12): 2851-62, 2002.
[PUBMED Abstract]
-
Fawzy FI, Cousins N, Fawzy NW, et al.: A structured psychiatric intervention for cancer patients. I. Changes over time in methods of coping and affective disturbance. Arch Gen Psychiatry 47 (8): 720-5, 1990.
[PUBMED Abstract]
-
Heiney SP, McWayne J, Hurley TG, et al.: Efficacy of therapeutic group by telephone for women with breast cancer. Cancer Nurs 26 (6): 439-47, 2003.
[PUBMED Abstract]
-
Sherwood P, Given BA, Given CW, et al.: A cognitive behavioral intervention for symptom management in patients with advanced cancer. Oncol Nurs Forum 32 (6): 1190-8, 2005.
[PUBMED Abstract]
Back to Top
< Previous Section | Next Section > |