This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on changes made from the DSM-IV to the DSM-5.
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The Catch-All Nature of Adjustment Disorders by Micah Highfill
Stressors come in many forms. They can occur as a single event, such as a bad break-up, or as multiple events, such as marital difficulties. Stressors can also be recurrent, such as holiday seasons, or continuous, such as an impoverished living situation. Stressors can also affect a single individual, a family, or an entire community. Life events such as leaving for college, getting married, or having children are also common stressors (American Psychiatric Association, 2013). Not all stressful events lead to individual life impairment or dysfunction, but if impairment has resulted, a diagnosis of a specific mental disorder may be warranted. The behavioral and symptom presentation following the stressor is the defining feature that determines which disorder is appropriate to diagnose. Trauma- and stressor-related disorders include disorders that are due to stressful or traumatic events, and include several differentiated diagnoses that all share the quality of the stressor. Adjustment Disorder (AD) is one of the more prevalent disorders under this category. This may be due to the broad criteria of symptoms necessary to sufficiently diagnose. The diagnosis of adjustment disorder appears to be a ‘catch-all’ for individuals who do not meet criteria for one of the more specific trauma- and stressor-related disorders or for a mood or anxiety disorder.
According to the DSM-5, the diagnostic criteria required to qualify for a diagnosis of AD includes the development of emotional or behavioral symptoms in response to an identifiable stressor or stressors. Either evidence of marked distress that is out of proportion to the severity or the intensity of the stressor or a significant impairment in social, occupational, or other important areas of functioning must be present to identify symptoms or behaviors as clinically significant. The stressor cannot be better accounted for by another disorder, the symptoms are not related to normal bereavement, and the symptoms must be present within 3 months of the stressor and do not last more than 6 months once the stressor has concluded. Specifying whether the AD is presented with depressed mood, anxiety, both depressed mood and anxiety, disturbance of conduct, or mixed disturbance of emotions and conduct, or unspecified provides further information into the symptoms and behaviors present with the disorder.
Adjustment Disorders are common, appearing in the general population of around 5-20% of individuals receiving outpatient mental health treatment and up to 50% of individuals in hospital psychiatric consultation settings and are associated with an increased risk of suicide (American Psychiatric Association, 2013). AD was recently moved from a disorder categorized alone to the trauma- and stressor- related disorders in the DSM-5. This inclusion provides a more organized description of the relationship between AD and the other disorders included in the category.
Posttraumatic stress disorder and acute stress disorder are also found within the category of trauma- and stressor-related disorders. These disorders are distinct from AD by the stressor itself, which is commonly much more traumatic than the stressors associated with AD. Symptoms and behaviors also greatly differ. Individuals with posttraumatic stress disorder or acute stress disorder experience symptoms with more severity in mood, dissociative, avoidance, and arousal symptoms. Prevalence is much lower in these disorders, and in posttraumatic stress disorder the course can be much longer. It is important for practitioners to distinguish between these disorders, following the specific criteria provided in the DSM-5 to determine the appropriate diagnosis.
When criteria for posttraumatic stress disorder or acute stress disorder are not met, then a diagnosis of adjustment disorder can be considered. There are other disorders that have similar, but typically more severe symptomology to AD and must not be evident in order to diagnose an individual with adjustment disorder. These include and may not be limited to major depressive disorder, personality disorders, psychological factors affecting other medical conditions, and normative stress reaction.
Other specified trauma- and stressor-related disorder and unspecified trauma- and stressor-related disorder provide an even broader requirement of diagnostic criteria under the categorization of trauma- and stressor-related disorders. If an individual does not met criteria for a diagnosis of AD, a diagnosis of one of these disorders may offer a diagnostic solution. These classifications are new to the DSM-5, providing even more expansive diagnosis than before.
Whether such categories of diagnosis are necessary may be a matter of available treatments. Diagnosis can certainly lead to better treatment, but is treatment even necessary? According to Casey et al. (2001), the diagnosis of adjustment disorder in individuals leads to expensive and possibly unpredictable health interventions for symptoms and behaviors that are likely to resolve without treatment. Another likely benefit when symptoms are not severe enough to warrant a less prevalent but more controlled diagnosis is the ability for practitioners to record incidence of symptoms and behaviors in individuals that may provide documentation of vulnerability to other disorders in the future.
Some have called adjustment disorder useless and nothing more than a ‘wastebasket’ diagnosis (Fard et al., 1979), but more recent research has shown significance in difference of the stressors and symptoms of individuals diagnosed with adjustment disorder compared to individuals without diagnosis (Snyder et al, 1990; Despland et al, 1995). More research into differences of individuals diagnosed with adjustment disorder compared to individuals without diagnosis who have experienced comparable stressor events is needed to generate confidence in researchers and practitioners in the usefulness of the diagnosis.
Whether adjustment disorder is a valid diagnosis that promotes positive treatment results for the individuals diagnosed or is just a ‘catch-all’ diagnosis that allows practitioners to categorize symptoms unnecessarily is yet to be determined. A better organization of disorders may be present in the DSM-5, which may help practitioners recognize the utility of the diagnosis as compared to others within the category. However, the DSM-5 also seems to have created an environment of diagnoses of rather typical behavioral reactions to stress-related events. The changes in the most recent DSM may have created more confusion then solution to diagnosis, but hopefully the changes will provide an opportunity to further research in this area and provide more solid answers to these questions in the future.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Casey, P., Dowrick, C., & Wilkinson, G. (2001). Adjustment disorder: Fault line in the psychiatric glossary. The British Journal of Psychiatry, 179, pp. 479-481.
Despland, J.N., Monod, L., & Ferrero, F. (1995). Clinical relevance of adjustment disorder in DSM-III-R and DSM-IV. Comprehensive Psychiatry, 36,pp. 454-460.
Fard, F. Hudgens, R.W., & Welner, A. (1979). Undiagnosed psychiatric illness in adolescents. A perspective and seven year follow-up. Archives of General Psychiatry, 35, pp. 279-281.
Snyder, S., Strain, J.J., & Wolf, D. (1990). Differentiating major depression from adjustment disorder with depressed mood in the medical setting. General Hospital Psychiatry, 12, pp. 159-165.
