Adjustment Disorders: Treatment

Treatment

There are no reported randomized controlled trials regarding the psychological, social, or pharmacological treatment of AD. In lieu of any substantive randomized controlled trials to guide treatment, the choice of intervention remains a clinical decision.

There are two approaches to treatment. One is based on the understanding that this disorder emanates from a psycho-logical reaction to a stressor. The stressor needs to be identified, described and shared with the patient; plans must be made to mitigate it, if possible. The abnormal response may be attenuated if the stressor can be eliminated or reduced. Popkin and cowork-ers (1990) have shown that, in the medically ill, the most com-mon stressor is the medical illness itself; and the AD may remit when the medical illness improves or a new level of adaptation is reached. The other approach to treatment is to provide interven-tion for the symptomatic presentation, despite the fact that it does not reach threshold level for a specific disorder, on the premise that it is associated with impairment and that treatments that are effective for more pronounced presentations of similar pathology are likely to be effective. This may include psychotherapy, phar-macotherapy, or a combination of the two.

Psychotherapy

Psychotherapeutic intervention in AD is intended to reduce the effects of the stressor, enhance coping to the stressor that cannot be reduced or removed, and establish a mental state and support system to maximize adaptation. Psychotherapy can involve any one of several approaches: cognitive–behavioral treatment, inter-personal therapy, psychodynamic efforts, or counseling.

The first goal of these psychotherapies is to analyze the nature of the stressors affecting the patient to see whether they may be avoided or minimized (e.g., assuming excessive respon-sibility out of keeping with realistic goals; putting oneself at risk, such as dietary indiscretions for a type I diabetic). It is necessary to clarify and interpret the meaning of the stressor for the pa-tient. For example, an amputation of the leg may have devastated a patient’s feelings about himself or herself, especially if the in-dividual was a runner. It is necessary to clarify that the patient still has enormous residual capacity; that he or she can engage in much meaningful work, does not have to lose valued relation-ships, and can still be sexually active; and that it does not neces-sarily mean that further body parts will be lost. (However, it will also involve redirecting the physical activity to another pastime.) Otherwise, the patient’s pernicious fantasies (“all is lost”) may take over in response to the stressor (i.e., amputation), make the patient dysfunctional (at work, sex) and precipitate a painful dys-phoria or anxiety reaction.

Some stressors may elicit an overreaction (e.g., the pa-tient’s attempted suicide or homicide after the abandonment by a lover). In such instances of overreaction with feelings, emo-tions, or behaviors, the therapist would help the patient put his or her feelings and rage into words rather than into destructive actions and gain some perspective. The role of verbalization andthe joining of affects and conflicts cannot be overestimated in an attempt to reduce the pressure of the stressor and enhance cop-ing. Drugs and alcohol are to be discouraged.

Psychotherapy, medical crisis counseling, crisis inter-vention, family therapy, group treatment, cognitive–behavioral treatment and interpersonal therapy all encourage the patient to express affects, fears, anxiety, rage, helplessness and hopeless-ness to the stressors imposed. They also assist the patient to reas-sess reality in the service of adaptation. Following the example given above, the loss of a leg is not the loss of one’s life. But it is a major loss. Sifneos (1989) believed that patients with AD could profit most from brief psychotherapy. The psychotherapy should attempt to reframe the meaning of the stress, find ways to minimize it, and diminish the psychological deficit due to its oc-currence. The treatment should expose the concerns and conflicts that the patient is experiencing; help the patient gain perspective on the adversity; and encourage the patient to establish relation-ships and to attend support groups or self-help groups for assis-tance in the management of the stressor and the self.

Wise (1988), drawing from his experience in military psy-chiatry, emphasized the variables of brevity, immediacy, central-ity, expectance, proximity and simplicity (BICEPS principles). The treatment structure encompasses a simple straightforward approach dealing with the immediate situation at hand which is troubling the patient. The treatment approach is brief, usually no more than 72 hours.

In another sample, interpersonal psychotherapy was ap-plied to depressed outpatients with human immunodeficiency virus, (HIV), infection and found to be useful (Markowitz et al., 1992). Some of the attributes of interpersonal psychotherapy are psychoeducation regarding the sick role; using a here-and-now framework; formulation of the problems from an interpersonal perspective; exploration of options for changing dysfunctional behavior patterns; and identification of focused interpersonal problem areas. Lazarus (1992) described a seven-pronged ap-proach in the treatment of minor depression. The therapy in-cludes assertiveness training, enjoyable events, coping, imagery, time projection, cognitive disputation, role-playing, desensitiza-tion, family therapy and biological prophylaxis.

Support groups have been demonstrated to help patients ad-just and enhance their coping mechanisms, and they may prolong life as well although the data is conflicting regarding the latter

Pharmacotherapy

Stewart and colleagues (1992) emphasized the need to consider psychopharmacological interventions as well as psychotherapy for the treatment of minor depression, and this recommenda-tion might be extrapolated to other subthreshold disorders. This group recommends antidepressant therapy if there is no benefit from 3 months of psychotherapy or other supportive measures. Although psychotherapy is the first choice treatment, psychother-apy combined with benzodiazepines may be helpful, especially for patients with severe life stress(es) and a significant anxious component. Tricyclic antidepressants or buspirone are appropri-ate in place of benzodiazepines for patients with current or past heavy alcohol use because of the greater risk of dependence in these patients.

Psychotropic medication has been used in the medically ill, in the terminally ill and in patients who have been refractory to verbal therapies. Amphetamine derivatives appear helpful in the treatment of these groups of patients. Whether methylphe-nidate is similarly useful in AD with depressed mood remain to be examined. Bereavement-related syndromal depression also appears to respond to antidepressant medication. The medication chosen should reflect the nature of the predominant mood that accompanies the AD (e.g., benzodiazepines for AD with anxious mood; antidepressants for AD with depressed mood). The degree to which pharmacotherapy is used for AD has remained elusive.

Some have begun to examine the effect of homeopathic treatments. From a 25-week multicenter randomized placebo-controlled double-blind trial, a special extract from kava-kava was reported to be effective in AD with anxiety and without the adverse side-effect profile associated with tricyclics and benzo-diazepines (Volz and Kieser, 1997). Tianeptine, alprazolam and mianserin were found to be equally effective in symptom im-provement in patients with AD and anxious mood. In a random double-blind study trazodone was more effective than cloraz-epate in cancer patients for the relief of anxious and depressed symptoms. Similar findings were observed in HIV positive pa-tients with AD.

Refractory Patients and Nonresponse to Initial Treatment

Those patients who do not respond to counseling or the various modes of psychotherapy that have been outlined and to a trial of antidepressant or anxiolytic medications should be regarded as treatment nonresponders. It is essential to reevaluate the patient to ensure that the diagnostic impression has not altered and, in particular, that the patient has not developed a major mental dis-order, which would require a more aggressive treatment, often biological. The psychiatrist must also consider that an Axis II dis-order might be interfering with the patient’s resolution of the AD. Finally, if the stressor continues and cannot be removed (e.g., the continuation of a seriously impairing chronic illness), additional support and management strategies need to be employed to assist the patient in optimally adapting to the stressor that she or he is confronting (e.g., experiencing the progression of HIV infection).

DSM-IV allows the use of the diagnosis of AD even after 6 months, and then it is described as AD, chronic. With such a contingency (e.g., AD lasting a few years), it is necessary to en-sure that the patient is not experiencing dysthymic disorder or an unremitting depressive disorder. However, these diagnoses have a symptom profile that should distinguish them from the AD.