The Adjustment Disorders
The adjustment disorders, a diagnostic category of the fourth revised edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), are defined as reactions to an identifiable psychosocial stressor (e.g., cancer diagnosis) with a degree of psychopathology that is less severe than diagnosable mental disorders such as major depressive disorder or generalized anxiety disorder and yet are “in excess of what would be expected” or result in “significant impairment in social or occupational functioning.”
Diagnostic Criteria for the Adjustment Disorders
- Criterion A. 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).
- Criterion B. These symptoms or behaviors are clinically significant as evidenced by either of the following:
- Marked distress that is in excess of what would be expected from exposure to the stressor.
- Significant impairment in social or occupational (academic) functioning.
- Criterion C. 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.
- Criterion D. The symptoms do not represent bereavement.
- Criterion E. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months. Specify:
- Acute if the disturbance lasts less than 6 months.
- Chronic if the disturbance lasts for 6 months or longer.
- Specific subtypes represent the predominant symptoms and include:
- With depressed mood.
- With anxiety.
- With mixed anxiety and depressed mood.
- With disturbance of conduct.
- With mixed disturbance of emotions and conduct unspecified.
[Note: Adapted from American Psychiatric Association, 2000.]Prevalence
In the general population, adjustment disorders are thought to be common, although prevalence rates vary by population studied. In studies of community samples of children, adolescents, and the elderly, prevalence estimates have ranged from 2% to 8%. In outpatient mental health settings, prevalence rates have been as high as 10% to 30%; while in general hospital inpatients, prevalence rates have been as high as 12% of those referred for a mental health consultation.
Nearly every cancer patient experiences what could be considered an identifiable stressor, whether that is diagnosis, treatment, recurrence, or side effects. The presence of an adjustment disorder is determined more by the patient’s response to the identifiable stressor, and whether that response is considered in excess of what would be expected or results in significant impairment, typically in social or occupational functioning.
One study  evaluated 215 randomly selected hospitalized and ambulatory cancer patients in three different cancer centers and found that of this group, slightly fewer than half (47% or 101 patients) met the diagnostic criteria for any mental disorder (DSM-III criteria). From this group of 101, 68% (69 patients) met the diagnostic criteria for an adjustment disorder. Of the entire 215 patients evaluated, approximately 32% were identified as meeting the diagnostic criteria for an adjustment disorder—the highest prevalence of any diagnostic category.
Additional reviews  have continued to find adjustment disorders to be the most common mental disorder. In patients with advanced cancer, prevalence ranges from 14% to 34.7%; in terminally ill patients, rates range from 10.6% to 16.3%. These variable prevalence rates are influenced by stage of disease, type of cancer, diagnostic procedures used, and other patient variables. In a study of women with breast cancer undergoing adjuvant chemotherapy, a 36.1% prevalence rate was found.
In another study of terminally ill Japanese cancer patients referred to a palliative care unit, 16.3% were diagnosed with an adjustment disorder at the time of their initial referral, and 10.6% were diagnosed with an adjustment disorder at the time of their admission to the palliative care unit. Of patients diagnosed with adjustment disorder at initial referral, 42% had progressed to major depression at admission to the unit, and 42% had no diagnosis.
Adjustment disorders are the most commonly diagnosed mental disorder in the oncology setting.Course
As defined in the diagnostic criteria, an adjustment disorder begins within 3 months of the onset of an identifiable stressor and lasts no longer than 6 months after the stressor or its consequences have ceased. Two specifiers exist to discriminate between an acute adjustment disorder (≤6 months) and a chronic adjustment disorder (>6 months). The cancer patient may experience a sequence of multiple, sequential stressors such as the diagnosis, the start of treatment, side effects of treatment, conclusion of treatment, and return to work.
It is often difficult to determine when a stressor has ceased. It is not unusual to see a chronic adjustment disorder that persists because of the presence of multiple, sequential stressors. The persistent adjustment disorder may also progress to become a more serious mental disorder (e.g., major depressive disorder). Chronic adjustment disorders that persist and progress to more severe mental disorders appear more common in children and adolescents than in adults. (Refer to the PDQ summary on Pediatric Supportive Care for more information.)Problems in Diagnosing Adjustment Disorders
The adjustment disorders are an intermediate category between normal adjustment and a specific diagnosable mental disorder. In terms of their location within a hierarchy of increasingly severe mental disorders, the adjustment disorders are an intermediate category as follows:
- Major mental disorders (e.g., major depressive disorder, panic disorder, posttraumatic stress disorder, generalized anxiety disorder).
- Disorders not otherwise specified.
- Adjustment disorders.
- Problem-level diagnoses (e.g., partner relational problems, bereavement, physical abuse of child).
- Fluctuations in mood that represent normal adaptation.
Screening instruments for the identification of adjustment disorder have been difficult to identify.[7,8] This intermediate status and the lack of any specific list of symptoms raise a number of problems with the adjustment disorder’s diagnostic category. Most of the problems stem from lack of specificity and resulting subjectivity. This lack of specificity applies to both the identifiable stressor and the marked distress/significant impairment.
No criteria or guidelines exist in DSM-IV-TR to quantify the nature of the psychosocial stressor(s). Given individual differences in coping abilities, certain stressors are likely to be very stressful for one patient and not stressful at all for another patient. With no quantifiable guidelines for measuring stressors, a diagnosis is often determined by the nature of an individual’s response. If a person responds with marked distress or significant impairment in functioning, it is often assumed that the life event was an identifiable stressor. However, the identification of a response that evidences marked distress or significant impairment also lacks specificity and is thus very subjective. Many of these diagnostic terms are too vague to be valid or reliable; thus, there is considerable variation in the use of the adjustment disorder category.
Despite these problems, the adjustment disorder category does provide a means of identifying an emotional or behavioral response in need of further treatment. Cancer patients are regularly confronted with a variety of stressors and thus face the potential of experiencing an adjustment disorder.Treatment
Individual and group counseling and psychotherapy
Although only one study has been targeted specifically at a population of cancer patients diagnosed exclusively with adjustment disorder, a number of studies have shown the benefits of psychosocial interventions with adult cancer patients (e.g., meta-analysis).[Level of evidence: I] These interventions have included both individual [Level of evidence: I] and group counseling [Level of evidence: IV];[12,13][Level of evidence: I] and have utilized a variety of theoretical approaches. In a randomized clinical trial for the treatment of adjustment disorders, 57 patients with mixed cancer types were randomly assigned to either an 8-week individual, problem-focused, cognitive-behavioral psychotherapy intervention or an 8-week individual, supportive counseling intervention.[Level of evidence: I] Results showed that those receiving the problem-focused, cognitive-behavioral therapy exhibited a significant change in fighting spirit, coping with cancer, anxiety, and self-defined problems, both at the conclusion of the intervention and at the 4-month follow-up.
Cognitive-behavioral interventions have been widely studied. A cognitive-behavioral approach is based on the idea that mental, emotional, and even physical symptoms partly stem from one’s thoughts, feelings, and behaviors, resulting in poor adaptation. Interventions focus directly on a patient’s thoughts, feelings, and behaviors with the goal of altering specific coping strategies and alleviating emotional distress. Cognitive-behavioral interventions include a variety of techniques such as:
- Relaxation training.
- Contingency management.
- Problem-solving.[Level of evidence: I]
- Cognitive restructuring.
- Thought stopping.
- Coping self-statements.
- Mental imagery exercises.
Most studies have combined a variety of these approaches into a multicomponent treatment strategy designed to alleviate specific symptoms. Cognitive-behavioral approaches tend to be relatively short-term, brief interventions, well-suited to the oncology setting.[15,16] One study [Level of evidence: I] randomly assigned 382 patients with different types of cancer to one of three groups: usual care, professionally led stress management, or self-administered stress management. The two intervention groups received stress management training that included abdominal breathing, progressive muscle relaxation training with guided imagery, and coping self-statements prior to the start of chemotherapy. The professionally led intervention group met with a mental health professional who taught them the stress management skills in one 60-minute session. The self-administered group received a packet of training materials that included a 15-minute videotape of instructions, a 12-page booklet on coping with chemotherapy, and a 35-minute audiotape of relaxation training instructions. Results showed enhanced quality of life over usual care in the self-administered group only. The professionally led group did not show any improvement in quality of life when compared with usual care.
A meta-analysis of 45 such studies investigating 62 treatment-control comparisons found significant beneficial effects in emotional adjustment.[Level of evidence: I] Beneficial effect sizes for emotional adjustment ranged from .19 to .28, indicating that the average cancer patient receiving treatment was better off than 56.5% to 59.5% of those patients not receiving treatment. These interventions have been administered in both individual [Level of evidence: I] and group formats,[Level of evidence: II] indicating benefits in emotional adjustment from both formats at the conclusion of the intervention and at 6-month and 12-month follow-up assessments. One novel approach adapted a 6-week group format to a telephone conference call structure for breast cancer survivors; there was high acceptability and modest treatment effects immediately after the intervention but not at the 3-month follow-up.[Level of evidence: I]
Another study found that a cognitive behavioral intervention to teach problem solving was effective in promoting better self-management of cancer-related symptoms, especially for patients aged 60 years or younger.[Level of evidence: I]Pharmacotherapy
No studies have specifically targeted a population of cancer patients diagnosed exclusively with adjustment disorder, in which the primary intervention was some form of pharmacotherapy. Given the nature of the adjustment disorders, clinical experience suggests that, if available, an initial trial of short-term counseling or psychotherapy designed to alter or eliminate the identified stressor (and thus alleviate symptoms) should be tried before pharmacotherapy.
As mentioned previously, sometimes the adjustment disorder may progress to a more severe mental disorder (e.g., major depressive disorder) and thus warrant consideration of pharmacotherapy. In addition, when the patient does not benefit from short-term psychotherapy, adding an appropriate psychotropic medication for a brief period of time (e.g., 2–3 weeks for antianxiety medications, 12 months for antidepressants) may facilitate the psychotherapy, allowing the patient to better employ available coping strategies. The specific pattern of emotional or behavioral symptoms will determine which type of psychotropic medication to consider. (Refer to the PDQ summary on Depression for more information.)Current Clinical Trials
Check NCI’s list of cancer clinical trials for U.S. supportive and palliative care trials about adjustment disorder that are now accepting participants. The list of trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.References
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.
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- Akechi T, Okuyama T, Sugawara Y, et al.: Major depression, adjustment disorders, and post-traumatic stress disorder in terminally ill cancer patients: associated and predictive factors. J Clin Oncol 22 (10): 1957-65, 2004. [PUBMED Abstract]
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- Kirsh KL, McGrew JH, Dugan M, et al.: Difficulties in screening for adjustment disorder, Part I: Use of existing screening instruments in cancer patients undergoing bone marrow transplantation. Palliat Support Care 2 (1): 23-31, 2004. [PUBMED Abstract]
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- Penedo FJ, Dahn JR, Molton I, et al.: Cognitive-behavioral stress management improves stress-management skills and quality of life in men recovering from treatment of prostate carcinoma. Cancer 100 (1): 192-200, 2004. [PUBMED Abstract]
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