Differentiating Adjustment Disorder with Depressed Mood

Differentiating Adjustment Disorder with Depressed Mood

Bernadette L. Treece

Liberty University Online

Abstract This paper looks at the etiological concepts of adjustment disorder (AD) with depressed mood in individuals and the signs and symptoms that distinguish this diagnosis.  The content gives insight into the investigative procedures and analysis used in diagnosing the differences of adjustment disorder with depressed mood.  The effects of gender and age differences are explored.  Stressors are examined by event, single or multiple, length, and recurrence.  Treatments are looked at through the process of natural recovery, psychological therapy, and/or medication.  The research is evaluated through the author’s biblical world-view perspective inclusive of a holistic approach addressing the biopsychosocial dynamics of an individual as well as the spiritual aspect of treatment. Keywords: adjustment disorder (AD), depressed mood, signs, symptoms, diagnosis, treatment

Differentiating Adjustment Disorder with Depressed Mood

Etiological concept of Adjustment Disorder (AD) with depressed mood is understood through the examination of the context and variable/s that influence and precipitate its onset.  It is from this understanding that the stressor/s that trigger an episode helps to differentiate the diagnoses and a possible treatment plan.  AD is outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR)  as a stress related mental disturbance occurring within 3 months of a stressor/s onset; symptoms are in excess of expected normal response and/or individual may show considerable interference of social or job related performance (APA, 2000, p. 679).  The disturbance cannot meet other Axis disorders, it should not be representative of bereavement, and not lasting more than 6 months once stressor/s are ended. AD in earlier DSM (2nd edition) manual was known as adjustment reaction defined as “a transient mental disturbance provoked by overwhelming stress” (Bisson & Sakhuja, 2006).  The definition has developed over time taking into consideration the stressor/s its recurrence, continuality, specific development, and effect on individual, family or community (APA, 2000). This leads to subtypes based on characteristics of predominant symptoms presenting with an AD diagnosis; such as with depressed mood.  The addition of depressed mood and other subthreshold categories to the diagnosis of AD was added in DSM-III (1980) to allow classification of prodromal symptoms that are vague but may signal an abnormal excessive reaction (Strain & Diefenbacher, 2008).  Research by Despland, Monod, and Ferrero (1995) compared AD with depressed mood and other mood disorders, and found AD with depressed mood influenced by the stressor/s that caused an emotional flux indicative of a moderate form of depression. Clinical depression is defined as “depression so severe as to be considered abnormal, either because of no obvious environmental causes, or because the reaction to unfortunate life circumstances is more intense or prolonged than would generally be expected.”  The combination of AD and a form of clinical depression (depressed mood) has become a common diagnosis distinguished by its etiological context that helps distinguish the association of normality and pathology (Strain et al., 2008).  Even with this data there is still debate about the distinguishing criteria, causing many to believe AD is a wastebasket due to the lack of “gravity of symptoms, psychosocial adaption and number and intensity of stressors” (Despland et al.).

Investigative Research & Analysis

From the DSM-III to the DSM-V TR continued observation of an increase of the diagnosis of AD with depressed mood has required valid and reliable research to substantiate the validity and reliability of this diagnosis.  Research by Snyder, Strain, and Wolf (1990) found that from 1981-1987 that 130 patients out of 944 (14%) seen for consult were diagnosed as AD with depressed mood compared to 59 patients (6%) diagnosed with major depression (MD). This finding made from the general hospital setting gave theory to the distinguishably of the two disorders meriting further investigation.  Snyder et al., (1990) reviewed 944 cases of AD with depressed mood and MD defined by DSM-III; based on data from inventory assessment, demographics, presenting problem, mental status examination, treatment proposal, with two or more admissions, and were reviewed by the supervisor and his assistant.  The results suggested distinguishable qualities; AD patients have higher stress ratings on Axis IV, however they showed marked improvement in psychiatric condition at discharge, and MD tends to manifest in older, more isolated patients, showing little improvement in psychiatric condition when released (Snyder et al.). Comparative research in Lausanne, Switzerland at the University Psychiatric Outpatient Clinic compared patients with forms of AD, other disorders, and no diagnoses.  Despland, Monod, & Ferrero (1992) found AD with depressed mood to resemble depression in the severity of symptoms and psychosocial adjustment of the diagnosis; reflected by the stressor/s severity in younger patients and instability of emotional control in more mature adults. The research supported earlier findings that AD with depressed mood has a higher remission rate with shorter hospital stay, and better cognitive recovery than MD.  AD is understood to be a specific type of psychopathology made evident by depressive symptoms brought on by stressors of marital, family, job related, interpersonal, and intrapersonal problems (Despland, et al).  Because the characteristics of this disorder relates to a large clinical diagnosis, the researchers concluded that “…depressed mood in adjustment disorder should allow this symptom to be used as the clinical core of the disorder” (Despland et al.). The problem of clinical validity has made it difficult to establish adequate specific symptoms, behavioral parameters or environmental influences predicated by the stressor/s.  Research by Jones, Yates, Williams, Zhou, and Hardman (1999) studied data in hopes of establishing clinical validity for diagnostic categories by focusing on depressive diagnoses and treatment results.  Data was collected from adult participants from 1995 to 1997 from an outpatient clinic in Oklahoma.  Participants were given a 36-item Short-Form Health Status Survey (SF-36) and a follow up SF-36 six months later; 8 subscales comprise 2 summary scores evaluating a Physical Component Summary (PCS) and Mental Component Summary (MCS). Jones et al., (1999) used demographic variables of gender, age, marital status, employment status, and scores from PCS and MCS to detect differences between volunteers.  They were divided into 5 groups: MD (single), recurrent episodes, dysthymia, depression NOS, and AD with depressed mood or mixed anxiety and depressed mood.  Differences in AD and MD mean scores showed that MD scored lower on all 8 scales while AD with depression scored higher , with females showing higher baseline scores. Results showed that females suffered a higher rate of AD and depression, but showed significant improvement after six months of treatment that was individualized; either psychotherapy, medication, or both. Barrow, Linden, Lucht, &Freyberger (2002) hypothesized that men and women are impacted by the severity of depression concerning social factors, and the presences of acute and chronic life stress. The authors cited several studies that support the importance of the impact of psychosocial stressors and depressing life events on the relentlessness of depressive syndromes. A study by Hautzinger (1984) listed depressive episodes as death in immediate social circle, providing care for family, unemployment, or financial crises; an increase in these events were manifested prior to depressive episode (as cited in Barrow et al., 2002).  These psychosocial stressors are necessary in determining the diagnostic criterion for AD.  Other factors of gender differences related to marital status, children in the home, education, and increase of responsibility were noted for the increase in depressive symptoms in females more than males (Barrow et al.)  By collecting data from 662 inpatients from the Department of Psychiatry at the Free University of Berlin, they used the AMDP system that covers 100 psychopathological and 31 somatic symptoms; 7 categories including depressive, psycho-organic, and autonomic and apathy, using 4 point Likert scale.  The authors found that the experience of psychosocial stress was enhanced by sociodemographic factors (education, marital status, children in home have higher significant affect on women) and the severity of the depressive condition (Barrow et al,).   This research supports the further need for research regarding diagnostic criteria of sociodemographic influences distinctive of AD and depressed mood, and the possibility of a new diagnostic model to align the scientific conundrum of criteria for AD related diagnoses. Using a new diagnostic model for adjustment disorder (AJD) based upon the hypothesis “that AJD is a stress response syndrome,” and differentiated by “…psychosocial stressor of a different magnitude or quality (non-threatening) than in PTSD” (Maercker, Forstmeier, Ensler, Krüsi, Hörler, Maier, & Ehlert, 2008).  Non-life threatening stressors are qualified as, “…divorce or separation, severe illness, family or work related problems, or moving home, as well as 3 central symptoms groups of intrusion, avoidance, and failure to adapt” (Maercker et al., 2008).  One major change allows for a diagnosis of AJD even in the presences of other Axis I disorders (Maercker et al.).  The authors attempt to support the hypothesis that AJD is distinct from other disorders by estimating the occurrence of AJD. They surveyed 570 elderly adults ranging in age from 65-96, by phone and then by either face to face interview, or mailed surveys. They were separated by sex, age ranges (65-69, 70-74, etc), living alone, with partner or family, and institution. Using the AJD-New Model diagnoses were based on symptoms appearing within 3 months after stress event and still present, and presence of 3 to 4 symptoms from symptom group; intrusive 3 of 4, avoidance 4 of 6, and failure to adapt 3 of 4.  Maercker et al. (2008) found a prevalence of AJD at 2.3% with older age demonstrating more stressful life events or situations; higher pathogenic stressors were related to time, finances, and severe illness.   AJD-New Model shows a plausible concept and merits further research.

Demographic Variables and Stressors

Adjustment disorder is a common diagnoses brought on by subjective and emotional stress of a significant life experience.  Carta, Balestrieri, Murru, & Hardoy (2009) cite the core feature of AD “…is clinically significant emotional and behavioral symptoms, often depressive in nature, that develop after an identifiable stressor.”   Common demographic variables were education, marital status, children in the home, age, gender, first time and/or recurrent diagnosis, and dependent or independent living status (Barrow et al., 2002; Despland et al., 1995; Jones et al., 1999; Maercker et al., 2008; Strain et al., 2008).  The demographic data was divided in categories of adolescents (8-17), adults (18-64) and the elderly (65-96).   Each age group demonstrated a difference in emotional intensity, behavioral manifestations, and trigger for an occurrence and/or recurrence of the diagnosis. Bisson et al. (2006) proposed that “AD is the only psychiatric disorder that requires an external event to have occurred before the diagnosis can be made.”   Identifiable stressors were defined as life events that might be considered normal causing a negative psychological reaction in an individual’s emotions or behavior response that results in impairment of social and/or work related functioning (APA, 2000).  A stressor can be a single event (death of loved one, divorce, romantic break up, illness, loss of job, financial loss, debt, new school, leaving home, getting married, parenthood, and retirement, etc) or compounded stressors (leaving home and starting college), a recurrent or continuous stressor (seasonal job or poor living environment) (APA, 2000; Barrow et al., 2002; Carta, 2009 Maercker, 2008). The influence of stressors on an adolescent children with AD is often “…characterized by emotional and behavioral symptoms, which occur in close temporal relationship to stressful events, and is time-limited” (Presicci, Lecce, Ventura, Margari, Tafuri, & Margari, 2010). Adolescents often have physical complaints of headaches, stomachaches, lack of sleep, or loss of appetite, they may demonstrate failing performance in school, inability to concentrate, aggressiveness and disruptive behavior (Presicci, et al.).    In adults female subjects often showed greater vulnerability to psychosocial stressors connected to AD (marital status, female roles, children and education), while men showed less vulnerability suggesting significant gender difference (Barrow et al., 2002).  Adult females also scored lower on mental health scales then males (Jones et al.)  Older adult males and females who experience a stressor didn’t differ in vulnerability to different stressors except regarding family conflict with female showing a higher affinity for negative reaction (Maercker et al).

Treatment

Researchers believe that appropriate and conscientious treatment is necessary for AD patients to aid in the elimination of symptoms and their recovery process (Carta et al., 2009; Presicci et al., 2010; Strain et al., 2008).  Research on treatment is limited despite the common diagnosis of AD, this may be reflective of the short-lived manifestation of the presenting symptoms and its criteria in its diagnoses, making efficacy of psychotherapies limited because of an inability to produce controlled clinical trials (Carta et al.).  Despite the unavailability of extensive research it is the common consensuses that psychotherapies are the treatment of choice for AD and its subcategories (Carta et al.).  However research data shows that referrals from psychiatric consults had a higher treatment plan that combined psychotropic medicines with psychotherapies (Carta et al.; Presicci et al Strain, Smith, Hammer, McKenzie, Blumenfield, Muskin, Newstadt, Wallack, Wilner, & Schleifer, 1998; Strain et al., 2008). Carta et al. (2009) cites several psychotherapies used in AD: 1) autogenic training is a relaxation technique that uses visualization in elevating the effects of stress by lowering heart rate and blood pressure, 2) a cognitive behavioral approach of “activating intervention” consisting of 3 stages a. information, understanding the cause and do less demanding activity, b. list stressors and develop problem solving strategies, c. do problem solving strategies and more demanding activities; this involves patient taking active responsibility in recovery,  3) for the elderly ego-enhancing therapy that encourages  coping strategies and recognition  of stressors, 4) psychotherapy and drug therapy, 5) drug therapy; antidepressants, benzodiazepines, and anxiety medicines, 5) natural recovery.  All these treatments can be used on all age groups. These lines of treatment still require continued research to better treat individuals and their specific presenting problems associated with an AD.

Author’s Perspective on Causation and Treatment

Carta et al. (2009) cites that stress in adjustment disorders maybe influenced by other variables originating within the family setting, “the presence or absence of affective support, relational strength, economic status.”  Studies by Brown on stress, a vulnerability to it and consequences have clear implications for AD (as cited by Carta et al.).  Carta et al. (2009) says, “…research into personal predisposition to a depressive reaction to stress and attachment style during childhood suggested that this may influence a stress vulnerability.”  How a person is nurtured (biopsychosocial) genetic endowment, their family environment and socialization has an effect on an individual’s coping skills.  Human development begins in childhood with parents creating the blueprint for healthy relationships providing security and significance in a child (Wilson, 2001).  Children look to their parents for nurturing that will teach them how to be human in regards to social skills involving relationships, love, appropriate behavior, beliefs, and reasoning.  A fourth element is the spiritual connection or identity that is either God sustained (healthy Christian worldview) or sin nurtured (broken world and fallen man).  Using the theory of Hawkins (2010) concentric circles that says the spirit of man directly influences the soul of man, if the spiritual part of man doesn’t know God then the psychological health of man is sick. The author believes that the perceptions of a person hold the key to understanding the ideologies that drive his/her behavior.  Encarta dictionary defines personality as, “the totality of somebody’s attitudes, interests, behavioral patterns, emotional responses, social roles, and other individual traits that endure over long periods of time.”  Therapy for a patient would incorporate this form 0f understanding that recognizes the indivisibleness of a person and uses a holistic approach (unity of thinking, feeling, and behavior) which follows an Adlerian form of Individual Psychotherapy (IP) (Murdock, 2009).  Man should be treated holistically by considering his beginning through his environment; in cultural terms, evolution and cognition. Psychotherapy would begin with the counselor and client creating a working relationship.  The process includes defining therapeutic goals, identifying counselor and client responsibilities, and an assessment of the clients presenting problem constructed from family history, cultural influences (westernized or collectivist), and the clients ideologies (core beliefs).  An Adlerian form of assessment and analysis would be utilized “…in which interview techniques are used to understand how clients see themselves and their world” (Jones & Butman, 1991, p 231). The interview would also give insight into their coping skills; how they have dealt with conflict and stress in the past. Do they have a direct coping strategy or defensive coping strategy (Thomas, 2012)?  The spiritual aspect would look at the fundamental characteristic of the clients coping strategy.  Is it self-directing independent of God, deferring waiting on God, collaborative working with God, or surrender coping releasing the situation to God (Thomas).  By understanding how the client was socialized, what kind of community support, and cultural connectedness he/she has makes it is possible to understand how a client deals with difficulties.  The interview provides insight and identification of the client’s stressors and its onset and the negative thinking that is bringing conflict and manifesting in a diagnosis of AD.  Once the stressors are identified, the client and the counselor can work on problem solving strategies that would eliminate or minimize the effect of the stressor, or the stressor altogether.  The client and the counselor would work together in developing positive coping skills and a social support network to diminish the return of a maladaptive coping mechanism. Positive coping skills would allow the client to develop “…realistic views of situations which have an effect on their personality and relationships” (Thomas).  The core values of individuals will always define their perception processes that give meaning to the concepts that guide their ability to discern a truth that could change their worldview.  An unregenerate spirit of a man is sin sick, it lacks the ability to make choices that satisfy the soul, to bring significance in purpose, have healthy interpersonal relationships, and an accurate sense of self that creates emotional stability, this allows a person to  walk in truth that sets him free and keeps him free.

References

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