Individuals who have adjustment disorder will often appear relatively healthy compared to others with psychiatric disorders, sometimes deceptively so. Although successful treatment rates are greater than 70% in adjustment disorders, about one third of patients do not fare well. Timely intervention can prevent later, more serious problems and point to an underlying weaknesses that can be a focus of treatment. As with patients with almost any psychiatric diagnosis, and possibly especially so for adjustment disorders, effective referral for follow-up care has a greater impact on frequency of ER visits than the diagnosis itself.
According to the patient's capacities, different therapeutic techniques can be chosen that may challenge erroneous beliefs and help the patient develop a psychological understanding of the problem. Adjustment difficulties worsen in the face of novel stressors when strong emotions are harbored but are poorly recognized or awkwardly expressed. Early intervention is probably more important than a particular therapeutic approach. As in other disorders, the building of an alliance in the course of diagnostic interviewing is critical to the success of future therapy. The prudent interviewer will patiently avoid judgmental inflection and allow the individual wide latitude for emotional expression. An expeditious identification of the stressor in a permissive environment, allowing open expression of the fears and perceived helplessness, helps build an alliance focused on management of emotions resulting from the stressor. Table 29–3 summarizes psychotherapeutic and pharmacologic approaches to the treatment of adjustment disorders.
Psychoanalytic & Psychodynamic Approaches
There are numerous viewpoints from which psychological disturbances can be modeled in the effort to create treatment approaches. Historically, psychoanalytic and psychodynamic approaches have taken a leading role in the interpretation of behavior and emotion. In this view, individuals with adjustment disorder struggle unsuccessfully with effects of a stressor that most would manage more adaptively. Different forms of stress, difficult as they are to quantify, affect individuals in markedly different ways. Each individual has coping skills and mechanisms, some of which are used out of habit. Patients accommodate more easily to currently unmanageable stress when a history of similar difficulties is brought to light. Such a history can be examined in the transference, where perceptions of the relationship between the patient and the therapist are contaminated by attributes from prior relationships despite therapeutic neutrality. As therapy unfolds, the therapist becomes a target for misdirected anger and resentment, which is pointed out and examined as a means of exploring the problem. The work of therapy is to help the patient recognize and understand the unconscious struggle that arises when the pursuit of pleasure and relief from irritants (the pleasure principle) stands in the way of grasping reality (the reality principle), as pursued within the transference relationship.
Trauma or loss may be perceived as an assault on a strongly developed self-perception, too noxious to be accessible to grief-coping mechanisms. Inflated perceptions of the self and unreasonable expectations of others are usually strongly guarded secrets. In analytic treatment, transference may contain the perception that the therapist is a harbinger of these demands. The overburdening super-ego (internal conscience) can then be revealed as the true aggressor, alleviating the exaggerated sense of the loss. Although the loss remains a reality, its importance then diminishes to a more acceptable level. Being able to project the cause of discomfort away from inappropriate self-blame onto a realistic outside agent will relieve the patient's sense of responsibility for the loss. For example, irrational guilt can arise over having been away on a trivial errand when a parent dies of cancer. The patient, after expressing a feeling that even the therapist blames him or her, is able to examine the need to accept cancer as the cause of loss.
Other, briefer types of therapies are encouraged in the current managed care environment. Although good comparison studies are lacking, certain individuals will probably do as well with briefer approaches. Psychodynamic, crisis-focused, time-limited psychotherapies require careful patient selection based on strong past interpersonal relationships, good premorbid functioning, and the absence of personality disorder. Some authors limit the use of these more confrontational techniques to situations in which there is a circumscribed focus, high motivation and capacity for insight, and a powerful degree of involvement in the interview. The time-structure of this technique is set out clearly at the beginning, with planned termination emphasized and treated as a new stressor to be managed throughout. Goals must be defined clearly. For example, self-deprecating patients may perceive parents as simultaneously irreproachable yet harsh and over-demanding. Such patients may have recurrent, severe (but brief) emotional disturbances after any confrontation with their bosses. They may benefit from a better understanding of emotional similarities to maladaptive but customary rules of relationships from childhood. Such therapy allows recognition of relationship patterns without focusing primarily on the transference. Brief dynamic therapy has been shown to be effective compared to other therapies.
Cognitive–behavioral therapy provides the patient with tools for the recognition and modification of maladaptive beliefs regarding the stressor and the patient's ability to cope with it. Adjustment disorders can be addressed in this way because the importance of the stressor is often unrealistically overestimated in the patient's perception. In a cognitive–behavioral therapy the patient learns to recognize connections between emotions and maladaptive perceptions or beliefs, and then learns to challenge those beliefs. Cognitive–behavioral therapy has demonstrated utility in occupational health. It has been successfully used in telepsychiatry for adjustment disorders in patients with cancer.
Some clinicians prefer interpersonal therapy, especially for patients who have chronic medical illness or HIV infection. Many patients with severe medical illness shun intrapsychic introspection and benefit more from a psychoeducational approach. This is true for many adolescents. Discussion remains in a here-and-now about the sick role, which is a complicated balance of needs, independence, and becoming a more or less willing target for the caring of other individuals. Open discussions ensue about who does what for whom in which way, and about how the illness and its consequences will affect the self and others. The modeling of coping mechanisms can be helpful. Humor can be effective, if introduced carefully. Death and dying become more approachable. These individuals often benefit from a reframing of problems from an interpersonal perspective and welcome discussions of ways to change dysfunctional behavior. The therapist may be able to address issues inaccessible to a medical–surgical team. The patient may be reluctant to seem ungrateful to, and fearful of losing a relationship with, the primary care physician. Such a patient may regard the medical caregiver's purpose as one that provides medical treatment alone.
Supportive therapy is sometimes erroneously written off as hand-holding and comforting, whereas “real therapy” involves confrontation, analysis, and intellectualization. Supportive therapy should involve specific strategies and careful planning. Interventions have the goal of shoring up inadequate defense mechanisms. Intervention gently guides the individual to a verbalization of emotions regarding the stress. Communication, relaxation, and anger control (e.g., “counting to 10”) are emphasized. In an acute crisis involving loss, or in medical settings where new information brings acute distress, a skilled supportive intervention can be eminently appropriate and effective.
Family therapy is often recommended. It can be among the most effective approaches to alleviating adjustment disorder by identifying the role the family plays in promoting a maladaptive coping response. However, some families are ill-prepared to participate in treatment for the “identified” patient. In family sessions, lines of support can be examined and reestablished by skillful work to minimize distortions, blame, and isolation.
Pharmacotherapy is often used to treat adjustment disorders. It may be useful when specific symptoms merit a medication trial. Drug selection is based on symptoms; for example, a short course of a benzodiazepine for adjustment disorder with anxious mood. The treatment goal is rapid symptom relief and prevention of a chronic problem, such as generalized anxiety disorder. Antidepressants are used frequently, even more frequently now with the advent of direct-to-consumer marketing (Samuelian, 1994). Selective serotonin reuptake inhibitors are generally well-tolerated and appear to be beneficial for some patients, but double-blind, placebo-controlled studies are lacking. They are probably under-prescribed for adolescents, males, those on welfare, and those in rural areas. Short-term trials of benzodiazepines and alprazolam are often prescribed, for example, for adjustment disorder involving anticipatory anxiety prior to chemotherapy. Hypnotics, such as zolpidem, should be considered for short-term use. The use of herbal preparations, such as St. John's Wort, merits further study.
In association with other treatments, nontraditional approaches can provide added benefit. Relaxation techniques, yoga, massage, and progressive muscle relaxation have been reported as helpful. Guided exposure or guided imagery can help with anticipatory stressors. Acupuncture has been used to treat adjustment disorders; but the results are unclear. Sleep deprivation, effective in treating endogenous and reactive depressions, may be useful in treating adjustment disorders.
The financing of treatment for adjustment disorders will depend increasingly on the recognition that treatment improves outcome and quality of life, prevents more serious reactions from developing, and reduces the risk of recurrences. There is little to be gained by waiting for the advent of disorders that are difficult to treat. Adjustment disorder should be treated actively, assuring restored premorbid functioning. Even so, brief therapies will need to be used. To justify treatment, third-party payers typically require information about symptoms that indicate risk, treatment goals, therapeutic methods, and outcome monitoring.