Chapter 29. Adjustment Disorders

The diagnosis of adjustment disorder would seem relatively straightforward, provided the clinician considers a wide range of stressors and other Axis I diagnoses, but it can present a number of pitfalls. Challenging diagnostic situations can arise when the stressor is subtle, for example, in a change of a previously stable life situation without any obvious stressor. The clinician should exclude any specified symptom complex that meets diagnostic criteria for another Axis I disorder even if it may be related to a specific stressor. Only the other Axis I diagnoses should be recorded if its criteria are met. However, if a discrete recent stressor has been identified, an adjustment disorder diagnosis may be more appropriate than, for example, anxiety disorder not otherwise specified or depressive disorder not otherwise specified.

The normal challenges of a life cycle are usually taken in stride with socially and culturally prescribed ranges of expected responses. However, commonly encountered events can disrupt an unusually crucial part of an individual's self-view (Table 29–1), and provoke symptoms outside of expected norms. Stressors leading to adjustment disorders are often termed “problems in coping.” Among adolescents, adjustment disorders frequently emerge following disappointment(s) in relationships with family members or friends. Especially complex difficulties may be encountered among homosexual teens. In adult crime victims, early detection of adverse responses was shown to improve outcome.

Individuals of all ages may encounter adjustment disorders following psychiatric hospitalization, or after treatment for another, otherwise unrelated, psychiatric disorder. For example, after being hospitalized for severe obsessive–compulsive disorder (OCD), a patient may express a conduct disturbance that is otherwise atypical for OCD. It may then be appropriate to add the diagnosis of adjustment disorder. Exceptionally severe or extreme stressors may precipitate maladaptive responses. Retirement and aging can bring feelings of loss, depleted health and vigor, and fear of the future. If the symptoms and gravity of the stressor are less than those required for acute stress disorder, the diagnosis of adjustment disorder may be appropriate.

Lacking clear behavioral or emotional symptom criteria, the validity of the diagnostic label of adjustment disorder is sometimes questioned. Diagnostic recording allows communication with patients, insurers, and other clinicians. It assists in disease control by focusing research and guiding therapeutic selection. Contemporary knowledge of differential diagnosis, prognosis, course, and future risks may be illuminated by naming a disorder. Even though more studies are needed, the adjustment disorder diagnosis fulfills these expectations. The therapist will find criteria easily met, defensible, and practical. However, the adjustment disorder diagnosis must not become a conciliatory label aimed to avoid controversies. A diagnostic label cannot reconcile societal and individual standards of response to a stressor. Examples include the societal acceptance of requests for death, euthanasia, or “rational suicide;” the differentiation between biological and functional (purely psychological) disorders; or other similar contemporary issues. They must remain foci of controversy rather than indications of underlying psychopathology. When used with poor specificity or to evade controversy, the application of a diagnosis of adjustment disorder effectively undermines psychological and organic pathological correlates and diminishes the credibility of psychiatric nosology.

Clinical use of the diagnosis of adjustment disorder diagnosis may be less prevalent in other countries, even though the true prevalence is similar. The description of these symptoms in International Classification of Diseases, 10th edition, (ICD-10) largely overlaps with Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision (DSM-IV-TR). In ICD-9, the term “adjustment reaction” was used for disturbances lasting weeks to months, and symptoms lasting hours to days were labeled “acute reaction to stress.” This system required a retrospective view because duration cannot be established at the onset of symptoms. There are other possible reasons for intercultural differences in the use of the diagnosis of adjustment disorder. In some European countries, reimbursement for treatment does not cover extensive care for minor conditions. Culture-specific syndromes, such as the Latino ataque de nervios, apply to a variety of symptom presentations, many of which do not come to psychiatric attention. Appendix I of DSM-IV-TR is devoted to cultural syndromes. In addition, substance abuse and alcoholism are often comorbid in patients with adjustment disorders. Because thresholds for the diagnosis of substance abuse are interpreted differently from one country to the next, an international standardization of the diagnosis may be difficult to achieve.

DSM-IV-TR Diagnostic Criteria

1. 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).

2. These symptoms or behaviors are clinically significant as evidenced by either of the following:

   1. marked distress that is in excess of what would be expected from exposure to the stressor

   2. significant impairment in social or occupational (academic) functioning

3. 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.

4. The symptoms do not represent bereavement.

5. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington DC: American Psychiatric Association, 2000.)

Epidemiology

In the United States, adjustment disorder diagnoses are quite common. Among psychiatric admissions, one estimate suggests that 7.1% of adults and 34.4% of adolescents had adjustment disorders. Among adults in France seen in general practice settings, a similar rate of 13.7% of those with psychological problems was observed. This was 1% of all patients consecutively seen with or without psychological problems. Many of these individuals merit substance abuse and conduct disorder diagnoses. Among university students receiving psychiatric assessments, a very high proportion was diagnosed as having adjustment disorders. Large population studies such as the Epidemiologic Catchment Area study have not assessed adjustment disorders because of a lack of sensitivity in the instrument used, that is, the Diagnostic Interview Schedule. Further studies are needed to better understand cultural, reimbursement, and records-confidentiality influences on true population rates and clinician utilization rates for the adjustment disorder diagnosis.

Etiology

Adjustment disorders appear to occur more often in individuals who are at risk for other psychiatric disorders, implying that etiologic factors may be shared. As in posttraumatic stress disorder (PTSD), neurobiological characteristics (e.g., elevated corticosteroid blood levels in response to stress) have been associated with the development of adjustment disorders.

A commonplace stressor may not be immediately clear, or it may be paradoxical. Adaptation difficulties in marriage, pregnancy, or childbirth can provoke feelings of guilt because the experience “should” be welcomed, not shunned. Natural preferences for lifestyle stability may be difficult to reconcile with goals requiring change. For example, a stably married individual unexpectedly confronted by parenthood faces role change, increased responsibility, and loss of freedom. Improved coping may result if the individual develops insight into a long-standing fear of being thrust into the role of single parent, as may have happened in his or her own family.

Risk Factors for the General Population

Major early risk factors include prior stress exposure, stressful early childhood experiences, and a history of mood or eating disorder. Family unity disruptions or frequent family relocations predispose children to adjustment disorders. The incidence of adjustment disorders is greater in children of divorced families following a subsequent, independent stressor. The death of a parent predisposes children to adjustment disorders. A high-suicide risk has been reported, especially after the loss of the father. Adjustments to living with the extended family (e.g., in-laws, step-parents) are additional predisposing factors. The outlet of symptom expression—be it depressed mood, conduct disturbance, or anxiety—may be determined by prior experience or biological constitution. Prior exposure to war, without meeting criteria for PTSD; (see Chapter 20), is a risk factor.

Factors that increase susceptibility in one situation can decrease it in another. For example, a high educational level can protect an individual who faces one stressor, but it can pose a risk factor for adjustment disorders in another context. Small-town life can predispose by providing too much shelter from stress yet limited support networks.

Risk Factors in Special Populations

Immigrant populations are at risk for adjustment disorder. It is simplistic to regard the entire immigration process as a precipitant; rather, precipitant stressors should be identified separately. For example, among new immigrants to Israel, stress responses to missile attacks during the Gulf War could be predicted by the immigrants’ adaptation prior to the attacks. Laotian Hmong immigrants in Minnesota were the focus of highly informative investigations that showed the need for studies of preventive intervention. Acculturation may be similar to other novel situations in many ways, but it also presents a large number of unique difficulties, all at the same time (Table 29–2). Any or all of these factors may require attention in treatment.

Among prison populations, adjustment disorder contributes heavily to suicide, which is frequently preceded by inmate-to-inmate conflict, disciplinary action, fear, physical illness, and the receipt of bad news. For a substantial number, the provision of mental health services within 3 days of the event was not sufficient to prevent suicide.

Chronic illness increases the need for medical contact and may constitute a major challenge to usual coping. Illness appears to be a precipitant rather than a predisposing factor. Adjustment disorders are not more prevalent among those with medical illnesses. On the other hand, should an adjustment disorder occur, it will often affect the clinical course of a somatic illness. The detection of adjustment disorder is remarkably poor, even on oncology services. It might improve with universal screening on admission. Early psychiatric consultation is associated with shorter length of stay. The course of asthma, chronic obstructive pulmonary disease, diabetes mellitus, end-stage renal disease, systemic lupus erythematosus, stroke, coronary artery disease, HIV/AIDS, chronic pain or headache, or cancer can be affected by the individual adjustment. Illness behavior, the give and take between patient and caregiver, and secondary gain all affect assessments of adjustment. The distinction between lifestyle versus coping style and then the setting of expectations for treatment compliance require skilled clinical judgment. For example, the asthmatic adolescent who rebels by skipping a scheduled inhaler dose does not need as rigid a guideline as one with “brittle” diabetes who skips insulin shots.

Also observed in the medical setting, complaints or lawsuits against physicians frequently result in adjustment disorder.

Genetics

Other than a global suggestion that a family history of psychiatric disorder is a risk factor for adjustment disorder, little is known about genetic inheritance or determinants of this condition, not surprising given the potential heterogeneity of a disorder defined by stressor rather than symptom.

Signs & Symptoms

In the primary care setting, distress reported by individuals, friends, or family members must be carefully assessed. Individual distress is variably reported and interpreted. Adjustment disorder diagnoses derive solely from expressed emotional and behavioral symptoms that may not be expressed clearly or may be minimized, masking distress. Symptoms themselves may contribute further to the individual's loss of confidence and disrupted sense of safety and well-being. Maladaptive behavior, fear, and uncertainty arise from losing control as customary defenses fail. The gravity of the stressor is interpreted in a context of past encounters with similar events and cannot be evaluated solely by the therapist's or society's standards. Stress must be evaluated in terms of the individual's subjective perception, giving perceptions a degree of validity. Adjustment will be facilitated when the therapist shows flexibility and accepts the individual's needs and distress. Careful listening and sensitivity are required because, with its paucity of somatic symptoms, individuals with adjustment disorder can masquerade as fairly stable, hiding high fragility and even suicidal risk. Clinicians may not appreciate the importance of a seemingly minor stressor, but they must give utmost respect to the individual, scheduling an interview that is long enough to understand the patient's subjective perceptions.

The distress experienced with adjustment disorder may include dissimilar emotions and behaviors. Such distress is beyond the expected response to the identified stressor (as can be identified on Axis IV). Suspicion of heightened severity, intensity (e.g., suicidal risk), or duration beyond that manageable by the primary care clinician indicates a need for professional psychiatric assessment and treatment, as does the failure of supportive intervention. Symptoms can be delayed, especially in women, and may change over time. Chronic stress can elicit chronic adjustment disorders. Clinical observation of the course of adjustment disorder reveals a strong association with suicidality, personality disorder, and drug use. A lack of suicide attempt in a first episode does not protect from future attempts. Completed suicide appears to be more frequent after an earlier attempt, or in the presence of personality disorder. The severity and lethality of suicide attempts often increase over time. Individuals with adjustment disorder are no less a suicide risk than those with major depressive disorder.

Psychological Testing

Psychological testing (e.g., using the Minnesota Multiphasic Personality Inventory) has documented adjustment disorder risk factors (see “General Considerations” section earlier in this chapter) and comorbidity with type A personality style and other personality disorders (especially cluster B). Psychological testing can help the clinician to identify suicidal individuals, the degree of depression, and the level of hopelessness. Testing suggests that adjustment disorders are more likely in individuals with socially prescribed perfectionism—a tendency toward the exaggerated perception that others have inordinately high expectations of them. On neuropsychological testing, no impairment is observed in patients with adjustment disorders; impairments are found in patients with depression and other disorders.

Laboratory Findings

Pathophysiologic studies of adjustment disorders show little evidence of somatic involvement, although different mechanisms may be involved among different symptom groups. Patients with adjustment disorders resemble normal control subjects in most physiologic studies, with the nonspecific exception of elevated cortisol response to stress, decreased sensitivity to pain and decrease in delta sleep (e.g., following marital separation or soon after divorce). In comparison to patients with adjustment disorder and controls, individuals with major depressive episodes exhibit more physiologic markers of change (e.g., event-related potentials, decreased heart rate, and cortisol and ACTH suppression following dexamethasone).

Neuroimaging

Treatment-refractory adjustment disorder may be an indication for imaging with a goal of differential diagnosis. One study, for example, revealed temporal lobe epilepsy after the patient had had 2 years of failed psychotherapy for misdiagnosed adjustment disorder. In another case, Hallervorden–Spatz disease was revealed by MRI in a presentation initially presumed to be a severe adjustment disorder.

The symptoms of adjustment disorder usually resolve quickly, with or without resolution of the stressors. Generally, inpatient stays are shorter for adjustment disorders than for depression, and improvement takes place during the first 3 weeks of admission. Long-term outcome surveys suggest cautious optimism in the prognosis for treated children and adults. Adjustment disorders may reoccur in children and adolescents with greater frequency than in adults. Clearly adolescence is fraught with many somatic changes and social adjustment requirements. For a first-time diagnosis, the majority of adults will fare very well after suicide risks abate. Adjustment disorders in children and adolescents predict future episodes of adjustment disorder but do not predict future affective episodes. Recovery is not greatly affected by comorbidity; the prognosis of an adjustment disorder alone is the same as for an adjustment disorder with comorbid diagnoses.

Relationship to Other Entities

When symptoms do not resolve quickly and therapy reveals other psychopathology or personality disorder, the initial diagnosis of adjustment disorder is often revised. When the diagnosis is uncertain, a provisional diagnosis accommodates individuals who may otherwise resist treatment because of preconceived expectations or fears of psychiatric labeling. Patients may accept more readily a temporary and minimal diagnosis, one that permits further assessment. It is often appealing to view a new patient as healthy, with a milder diagnosis. The temporary and relatively vague nature of “adjustment disorder” allows for changes in the primary admission diagnosis. Emergency room diagnoses of adjustment disorder are often changed to conduct disorder or substance abuse. This broadly inclusive diagnosis allows symptoms to be addressed while relatively mild, before a major syndrome develops, such as a major depressive episode. Given these properties, some vagueness and ambiguity are unavoidable.

Reactions to Stress

Normal grief reactions or bereavement may show cultural variability and be difficult to differentiate from adjustment disorders. Suicide risks may be present following bereavement, no matter which diagnosis is ultimately given. If the reaction to the stressor is within expectable and culturally acceptable norms, a nonpathologic reaction to stress should be recorded.

The diagnoses of Acute Stress Disorder and PTSD differ from adjustment disorder in accordance with the extreme severity of the stressor. Acute stress disorder follows an extreme stressor, more severe than stressors in adjustment disorder, and is associated with severe, specific symptoms (see Chapter 20). Acute stress disorder differs from PTSD in that the former remits after 1 month. The adjustment disorder diagnosis differs from both stress disorder diagnosis in that it is applicable to a wider range of presentations than these very specific and severe disorders. Furthermore, the emotional and behavioral responses in adjustment disorder are out of proportion to the stressor. In PTSD, the stressor leads to symptoms that are specific, severe, enduring, and handicapping (see Chapter 20).

In the impulse-control disorders, particularly intermittent explosive disorder, the precipitant stressor is minute in significance.

In Medical Settings

Adjustment disorder diagnoses may be applicable when the psychological stress of a physical illness causes psychiatric symptoms. For example, recently introduced implantable cardioverter defibrillators, have been associated with considerable psychological stress. In a way, adjustment disorder is the converse of the diagnosis of psychological factors affecting physical illness, in which a defensive coping style (e.g., repression) might worsen a systemic problem (e.g., peptic ulcer). It may be appropriate to give both diagnoses.

General medical conditions can cause psychiatric symptoms physiologically (and not psychologically as in adjustment disorder) and should be reported as such (e.g., mood disorder due to general medical condition). Individuals with chronic medical conditions may merit a second diagnosis of psychological factors affecting physical condition, reflecting both directions of the mind–body interaction.

Comorbidity

The symptoms of cluster B personality disorders often overlap with those of adjustment disorder, so that an adjustment disorder diagnosis is redundant in most cases. By definition, behavioral and emotional disturbances are excessive in personality disorders; these individuals would almost all be diagnosed as having adjustment disorder. However, according to DSM-IV-TR, adjustment disorder should be specified under circumstances in which the observed adjustment disorder is atypical for that personality disorder type.

Other, often comorbid, diagnoses that need to be assessed include substance or alcohol abuse or dependence, somatoform and factitious disorders, and psychosexual disorder.

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.

Psychotherapeutic Interventions

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 Approaches

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.

Interpersonal Psychotherapy

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

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

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.

Psychopharmacologic Interventions

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.

Nontraditional Approaches

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.

Recovery from adjustment disorders can be complicated by a variety of poor outcomes. It is all too easy to overlook risk factors in the clinical setting. For example, persistent denial of the importance of a stressor may result in masked or displaced anger with a strong risk of suicidality. In the patient's distorted view, denial will sometimes justify deceit in order to conceal issues such as physical safety and suicidality. Highly ambivalent, mixed emotional struggles (e.g., terminal illness in an unfaithful spouse, relationship problems among adolescents) require the clinician to be extra attentive and cautious. Among adolescents with adjustment disorder, suicidal ideation, threat, or attempt are associated with previous psychiatric treatment, poor psychosocial functioning, suicide as a stressor, dysphoric mood, and psychomotor restlessness. Notably, the suicidal process—evolution of ideation to completion—is short and rapid in adjustment disorder, and often comes with little warning in the form of prior emotional or behavioral problems. Adolescents in urban areas who were diagnosed as having adjustment disorder made more serious suicidal attempts than those with other disorders. Assessing suicide risk in the presence of adjustment disorder is extremely important.

In the presence of a comorbid personality disorder, adjustment disorder episodes frequently reoccur, to the point where diagnosing them separately is not necessary. However, it is still necessary to treat adjustment disorder in this common context. According to one study, 15% of individuals with adjustment disorder also meet criteria for one of the cluster B personality disorders (antisocial, histrionic, borderline, or narcissistic personality disorders). A personality disorder diagnosis predicts poor acute outcome and the likelihood of chronic impairment in social support among individuals with an adjustment disorder.

Comorbid substance abuse is common in individuals with a primary diagnosis of adjustment disorder. Although, alcoholism may “protect” people from stress (see discussion on cultural norms, earlier in this chapter), it clearly diminishes coping skills, promotes social isolation, and adds a suicide risk factor.

Some adverse outcomes are iatrogenic. Although helpful for some patients, the risks of somatic treatment must be explained carefully. Medications carry side effects and other risks (e.g., suicide by overdose of tricyclic antidepressants), and for these disorders the potential for benefit has not been demonstrated against placebo. Hypomanic or manic switches occur occasionally even with modern antidepressants, and individual risk for this response cannot be predicted reliably. Movement disorder has been reported after single doses of neuroleptics. Benzodiazepines may impair judgment and pose risks of abuse and dependence.

Although short-term prognosis is quite good in adjustment disorder, there may be an increased frequency of Axis I or Axis II diagnoses in the longer term. Further research is needed to identify individual prognostic factors and appropriate treatments.