Adjustment disorders are characterized by an emotional response to a stressful event. It is one of the few diagnostic entities in which an external stressful event is linked to the development of symptoms. Typically the stressor involves financial issues, a medical illness, relationship problems etc. This articles focuses on Adjustment Disorder, its General management and Homoeopathic Approach.
Adjustment disorder, PTSD, Psychotherapy, Crisis Intervention, Homoeopathy, Constitution.
Adjustment disorder is a very common disorder in the present time. An average of 12% of the total population suffers from Adjustment Disorder.1 In a worldwide survey of 4887 psychiatrists, conducted by the WHO WPA, it was found that Adjustment Disorder is among the most often diagnosed mental disorders.2 It also ranked the 7th most frequently diagnosed category (where 44 categories were provided) in a global sample of 5000 psychiatrists.3,4
Even though it is a very common disorder, it is very much under researched and only little attention is given to this disorder. 5
Re conceptualization of Adjustment Disorder in the recent times, especially in the formation of new definition in the ICD 11, takes the disorder from residual category to a full syndromal category. It is a stimulus for further advances and further studies in this area.
So it is important in the present scenario to understand, diagnose and treat this condition.
‘Adjustment Disorder (F43.2) are the states of subjective distress and emotional disturbance, usually interfering with social functioning and performance, and arising in the period of adaptation to a significant life change or to the consequences of stressful life events.’
The onset is usually within one month of occurrence of the stressful event or the life change, and the duration of symptoms usually does not exceed six months, except in the case of prolonged depressive reaction.
The manifestations vary, and include depressed mood, anxiety, worry (or a mixture of these), a feeling of inability to cope, plan ahead or continue in the present situation and some degree of disability in the performance of daily routine.6
First recognizable clinical description of Adjustment Disorder and its appropriate treatment was given by the physician – philosopher Avicenna in the 11th century.7
Adjustment disorder has been recognized since DSM I, in the year 1952. It was then called Transient Situational Personality Disorder, which was changed to Adjustment Disorder in DSM III in 1980. It was incorporated into ICD 9 in the year 1978.
It was a diagnosis that was neglected in research and clinical practice until recent times. It had many controversies related to it. It was considered as a manufactured condition to facilitate the clinicians for treating mild condition which otherwise would not come under any other diagnosis. Some others argued that it was the medicalised problems of living. However its status have been enhanced by its new positioning under Neurotic, stress related and Somatoform Disorders in ICD 108. Recent studies have proposed Adjustment Disorder as a full threshold diagnosis with specific criteria for the diagnosis.
AETIOLOGY (Role of stress)
1. Nature of stressor: Adjustment disorder group had greater recognition of stressor compared with the other diagnosis. It was over represented in the “higher stress category”.
2. Modifiers of stressor: Stress has been described as the etiological factor for Adjustment Disorder.
Vulnerability to stress is another risk factor. Diverse variables and modifiers are involved regarding who will experience Adjustment Disorder following a stress.
● Acute and chronic stresses are different
● The meaning of stress is affected by modifiers like ego, strength, support system.
● Manifestation and latent meaning of the stressors maybe associated with differential impact.9
FACTORS AFFECTING ADJUSTMENT DISORDER
Individual predisposition or vulnerability plays a greater role in the risk of occurrence and shaping of the manifestation of adjustment disorder. Factors that has an effect on the vulnerability are childhood adverse experiences, early maternal deprivation, individuals with ongoing psychiatric symptoms and pre-existing conduct disorder.
Diagnosis depends on a careful evaluation of the relationship between:
a. form, content and severity of symptoms
b. previous history and personality
c. Stressful event, situation or life crisis.
The presence of this third factor should be clearly established and there should be strong, though perhaps presumptive, evidence that the disorder would not have risen without it.
1. Brief Depressive Reaction F43.20
A transient, mild depressive state of duration not exceeding one month.
2. Prolonged Depressive Reaction F43.21
A mild depressive state occurring in response to a prolonged exposure to a stressful situation but of duration not exceeding two years.
3. Mixed Anxiety and depressive reaction F43.22
Both anxiety and depressive symptoms are prominent, but at levels no greater than specified in mixed anxiety and depressive disorder or other mixed anxiety disorder.
4. With predominant disturbance of other emotions F43.23
The symptoms are usually of several types of emotions, such as anxiety, depression, worry, tensions and anger.
5. With predominant disturbance of conduct F43.24
The main disturbance is one involving conduct.
6. With mixed disturbance of emotions and conduct F43.25
Both emotional symptoms and disturbance of conduct are prominent features.
7. With other specified predominant symptoms F43.286
Although uncomplicated bereavement often produces temporarily impaired social and occupational functioning, the person’s dysfunction remains within the expectable bounds of a reaction to the loss of a loved one and, thus, is not considered adjustment disorder. Other disorders from which adjustment disorder must be differentiated include major depressive disorder, brief psychotic disorder, generalized anxiety disorder, somatic symptom disorder, substance-related disorder, conduct disorder, and PTSD. These diagnoses should be given precedence in all cases that meet their criteria, even in the presence of a stressor or group of stressors that served as a precipitant. Patients with an adjustment disorder are impaired in social or occupational functioning and show symptoms beyond the normal and expectable reaction to the stressor. Because no absolute criteria help to distinguish an adjustment disorder from another condition, clinical judgment is necessary. Some patients may meet the criteria for both an adjustment disorder and a personality disorder. If the adjustment disorder follows a physical illness, the clinician must make sure that the symptoms are not a continuation or another manifestation of the illness or its treatment.
ACUTE AND POST-TRAUMATIC STRESS DISORDERS
The presence of a stressor is a requirement in the diagnosis of adjustment disorder, PTSD, and acute stress disorder. PTSD and acute stress disorder have the nature of the stressor better characterized and are accompanied by a defined constellation of active and autonomic symptoms. In contrast, the stressor in adjustment disorder can be of any severity, with a wide range of possible symptoms. When the response to an extreme stressor does not meet the acute stress or posttraumatic disorder threshold, the adjustment disorder diagnosis would be appropriate.
COURSE AND PROGNOSIS
With appropriate treatment, the overall prognosis of an adjustment disorder is generally favorable. Most patients return to their previous level of functioning within 3 months. Some persons (particularly adolescents) who receive a diagnosis of an adjustment disorder later have mood disorders or substance-related disorders. Adolescents usually require a longer time to recover than adults.7
Many questions prevail with regard to the concept of adjustment disorder diagnosis. Even though it is a very common disorder, it is very much under researched and only little attention is given to this disorder. One of the reasons for the very less attention given to Adjustment Disorder is that it is often not recognized and may also be mistaken for other disorders and treated accordingly. When compared with other psychiatric disorders, it was considered as a mild condition, but the further studies in this areas, concluded that it is a much more serious condition and should be treated as a full threshold diagnosis.5
Even though it’s one of the most common diagnoses in both adults and adolescents dying by suicide, it is also a disorder that has received very little academic attention and the studies for assessing the effectiveness of medical intervention has only recently begun. So there is scope for much further studies in this field.
Psychotherapy remains the treatment of choice for adjustment disorders. Group therapy can be particularly useful for patients who have had similar stresses. After successful therapy, patients sometimes emerge from an adjustment disorder stronger than in the premorbid period, although no pathology was evident during that period. Because a stressor can be clearly delineated in adjustment disorders, it is often believed that psychotherapy is not indicated and that the disorder will remit spontaneously. Psychotherapy can help persons adapt to stressors that are not reversible or time limited and can serve as a preventive intervention if the stressor does remit.
Crisis intervention and case management are short-term treatments aimed at helping persons with adjustment disorders resolve their situations quickly by supportive techniques, suggestion, reassurance, environmental modification, and even hospitalization, if necessary. The frequency and length of visits for crisis support vary according to patient’s needs; daily sessions may be necessary, sometimes two or three times each day.7
Homoeopathy is a system of drug therapeutics based on the Law of Similars. The successful application of the Law of Similars depends on the concepts of Individualization and Susceptible Constitutions.
Disease is a total response of an organism to adverse environmental factors, external or internal, it is conditioned by constitutional factors inherited and acquired and manifests itself through symptoms in the three spheres – emotional, intellectual and physical.10 Also according to Kent, the will and understanding forms a unit, making the internal man, vital force, which is immaterial and then the body which is material. All the diseases flow from the innermost to the outer.11
The clinical approach of the Homoeopath, directed to perceive the integrity of the patient in the essentiality of his spiritual being as an individual, of his true ego, cannot then limit itself to the isolated examination of the symptoms or in the partial analysis of the organic dysfunction, without referring them strictly to the general interweaving of the patient and perceiving the vital attitude.12
Since the sickness represents the reaction of a person to his unfavorable environment, the pattern of his reaction will be determined not only by the factors which caused the illness but also by the constitution of the affected person.10
Constitution is defined as a person’s physical and mental makeup which is revealed through his physical built, his characteristic desires and aversions, reactions as well as emotional and intellectual attributes.13
According to our master Dr Hahnemann, the disease is disturbance in the vital which governs and regulates our body. The deranged vital force manifests itself in the form of morbid signs and symptoms. There is no local disease and no organ can become diseased without a preceding disturbance in the vital force. Therefore it is a mistake to treat a part as if it stood alone. It is the individual patient as a whole who should be the object of treatment.
In the same way, even if the same stressor is present in different individuals, it affects each individual differently according to the individuality of the patient. Thus each patient should be treated individualistically and holistically for a proper cure.
1. Lakshmi, Guru Prasanna, Effectiveness of an Integrative Approach on Adjustment Disorder, Psychology and Behavioural Science International Journal. 2017 Aug 10, 5:4.
2. Reed GM, Correia JM, Esparza P, Saxena S, Maj M. The WPA‐WHO global survey of psychiatrists’ attitudes towards mental disorders classification. World Psychiatry. 2011 Jun;10(2):118-31.
3. Maercker A, Lorenz L. Adjustment disorder diagnosis: Improving clinical utility. The World Journal of Biological Psychiatry. 2018 Jun 22;19(sup1):S3-13.
4. Bachem R, Casey P. Adjustment disorder: A diagnosis whose time has come. Journal of Affective Disorders. 2018 Feb 1;227:243-53.
5. Casey P, Doherty A. Adjustment disorder: implications for ICD-11 and DSM-5. The British Journal of Psychiatry. 2012 Aug;201(2):90-2.
6. WHO Geneva, The ICD 10 Classification of Mental and Behavioral Disorder, A.I.T.B.S Publishers and Distributors, 149-151.
7. Benjamin James Sadock , Virginia AlrottSadock , PeroRiuz, Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 9th Edition, Vol II, 2187- 2196.
8. Patricia Casey, Adjustment disorder from controversy to clinical practice, Oxford University Press.
9. Micahel G. Gelder, Nancy. C. Andreasen, Juan J Lopez, John R Geddes, New Oxford Textbook of Psychiatry, 2nd edition, Vol I, Oxford University Press, 716-721.
10. Luc De Schepper, Hahnemannian Textbook of Classical Homeopathy for the the Professional, B Jain Publications, 143-153
11. Kent, J T, Lectures on Homoeopathic Philosophy, 7th edition, B Jain publishers,31-38.
12. ML Dhawale, Hahnemannian Totality Symposium, Standardization V,Symposium Council, B.4-B.7, B.53.
13. DrAtulRajgurav and DrParthAphale, Study of various constitutions with the help of Clarkes and Murphys Repertory, Imperial Journal of Interdisciplinary Research Vol 2, issue 11, 2016, 327-336