When it’s an Adjustment Disorder
What is an Adjustment Disorder (AD)?
According to Soreff, MD (2016) it is: “a short-term, non-psychotic, emotional or behavioural response to an identifiable stressful event or change in a person’s life.” The emphasis here is ‘short-term’.
For an adult, a stressful event (or stressor) is something that causes a change in behaviour. It could be for example, relationship problems, experiencing financial difficulties or a job-related matter. For children it could be moving house and settling into a new school; parents’ divorce or perhaps managing the arrival of a new baby into the family.
All too often a person can be diagnosed with Depression when it is in fact, an Adjustment Disorder. Timing is critical i.e. looking at the dates of the stressful even and the onset of the behaviour. Have the symptoms occurred within three months of the identified stressor?
When we go to see our GP, current standard NHS guidelines allocate ten minutes per patient to diagnose a ‘single’ medical problem. Our GP’s do a fantastic job in that time. However, it can be easy to miss what might be an Adjustment Disorder (AD) for Depression. According to the Bible of Psychological diagnosis (the Diagnostic Statistical Manual (DSM) IV-TR), depression includes: experiencing daily depressed mood / reduced ability to concentrate or think throughout the day among other symptoms. Patricia Casey, (who has written many academic journal articles about AD) affirms that like any diagnosis it requires treatment. However, she emphasises the important role of the GP in being able to view the symptoms within their cultural context relative to the persons life.
Good stress bad stress
What is really important to avoid is ‘pathologising’ regular levels of stress which occur as a response to everyday stressful events. We all have difficult days right? And sometimes stressful events get us up and moving, changing, working towards personal or collaborative goals; or representing others less fortunate who don’t have a voice.
We all know people who seem to deal more effectively with difficult times than others. We can probably identify in the workplace those who are regularly off sick, and those who seem to just get through and manage. There is no right or wrong or any definitive way to be. What I’m doing here is sowing the seed for a future article on levels of consciousness and stress and how you can be in charge of your response to any stressful event(s).
To medicate or not to medicate?
When AD is mistaken for Depression, anti-depressants can be prescribed. I have clients who have been prescribed Citalopram (an SSRI) for what might well be an Adjustment Disorder. The NHS guidelines for Citalopram indicate that it takes between four and six weeks for the drug to take effect, so by the time the ‘drug’ starts to work, the person could well be on their way to coming to terms with the stressful event in a regular, drug-fee way. Because Citalopram ‘depresses’ the system – any regular, natural, bio-responses can be suppressed, including feelings joy or happiness. Equally, the impulse to cry or feel anger can be muted. If Adjustment Disorder is diagnosed it has clinical relevance and consequently requires treatment. However Casey purports that “antidepressants are not necessary, nor do they work.
And this is the crux of the debate to medicate or not?
The critical point is to take each individual case as just that. It’s about the person; their specific situation, the cause of the events which have led to their particular situation and the meaning of those events in a person’s life.
Whilst a diagnosis of an Adjustment Disorder might reduce the stigma of a mental disorder, it is imperative that physicians are not lulled into ‘therapeutic inactivity’ either.
I carried out some research using a specific Cast Study on Adjustment Disordera couple of years ago, where the emphasis for treatment was Cognitive Behavioural Therapy (CBT). Please get in touch if you would like a full copy of it. (I have some excerpts from it below in blue text).
I have found equally positive results applying Biodynamic Psychotherapy and Massage as an intervention. This works particularly well in AD when the client is experiencing an acute symptoms. So when they are finished speaking about their experience, they can receive specific Biodynamic body work. Sometimes words are insufficient, and the applied body work can facilitate resolution and peace when a client is full of ‘feeling’ and there are no words to express them. The massage methods can bring relief from existing physical symptoms, bring awareness to the breath and can put a person in touch with the healthy aspects of themselves and their life situation. I also share mindful techniques with people where appropriate.
In terms of scientific classification, Adjustment Disorders are ‘controversial’ and suffer from academic and scientific neglect. Casey’s central argument is that ADs are under-researched and without a stable diagnosis in the DSM-IV or International Classification of Diseases (ICD)-10. The latter diagnosis incorporates symptoms and impaired function, and the former argues for impairment or symptoms for an AD diagnosis.
I have highlighted areas of the text in the Case Study for my own emphasis. No doubt you will find your own if it’s relevant to your own experience or that of someone you love. (Do email me [email protected] if you would like a copy of the full case study).
“… the important role of the clinician in being able to view the symptoms within their cultural context, relative to the patient’s life. It is also crucial to avoid ‘pathologizing’ (Casey: 2008, p.1203) regular levels of stress which occur as a response to everyday stressful events.
“… is that ‘the symptoms must be triggered by a stressful event’, but critically must not be misdiagnosed as Post Traumatic Stress Disorder (NICE: 2005, p.12).”
“… diagnosis was reached by acknowledging specific timing of the onset of K’s excessive emotions and behaviours in response to the event or ‘stressor’ (Rhoads: 2011, p.146).”
“ADs are not uncommon both in primary and secondary care, with prevalence ranging from 11 to 18% of the population and from 10 to 35% respectively”
“Despite NICE guidelines, Casey (2008) argues that AD has clinical relevance because treatment is required, however, antidepressants are not necessary, nor do they work.”
“… this leads on to the political, economic argument put forward by Casey et al (2001) who pose that AD, as a clinical concept, has been obscured by policy makers and researchers and categorised as a mood disorder.”
I’d be delighted to hear from you if you have any comments / responses / additions / different experiences, or realise that you have manged through an Adjustment Disorder(s) with different tools. Contact me [email protected].