Adjustment disorder (AD) or stress response syndrome (SRS) is a kind of ‘no man’s land’. It’s a clinical entity that requires great skill for it to be diagnosed since there’s an extremely fine line between the normal and the pathological. So much so that people who face or have faced highly stressful and prolonged situations could well receive this diagnosis.
However, what exactly is adjustment disorder? We’ll explain.
“What allows us to survive as a species is not intelligence or strength, but our ability to adapt.”
-Natalia Gómez del Pozuelo-
Adjustment disorder/stress response syndrome
This condition consists of the development of affective symptoms as a result of perceived pressure. The source of stress must be identifiable. For example, a sentimental breakup, cancer, or a dismissal. In addition, in order to make the diagnosis, these symptoms must occur in the three months following said stressors (APA, 2015) and last for a maximum of six months.
Like any clinical entity, the discomfort this disorder produces must be intense enough to affect different important areas of life. For instance, interpersonal, family, or work. In addition, the sufferer feels intense discomfort (WHO, 2021).
Sufferers of adjustment disorder experience feelings of extreme concern. They might say things like “Now that my partner’s left me, what am I going to do?” or “I’ve lost my job, I’m a failure”. In addition, they find it difficult to ‘adjust’ to the source of stress and, consequently, they suffer. However, the symptoms they develop are far from being as serious as in other conditions like depression or generalized anxiety disorder.
“Adjustment disorder is a maladaptive reaction to an identifiable psychosocial stressor or multiple stressors.”
-World Health Organization-
The controversy regarding adjustment disorder
Is it useful to label stress that becomes overwhelming in a specific situation as a mental disorder? Remember that, at most, this reaction of discomfort lasts half a year. In this regard, Belloch (2020) points out that the dividing line that separates ‘the normal’ from ‘the pathological’ is extraordinarily fine.
The American Psychiatric Association claims that a diagnosis of AD/SRS can only be made if suffering exists after a stressful event. But surely, most job losses or break-ups make people suffer? Therefore, they (and many other stressful situations) would potentially trigger AD/SRS in people.
“Historically, the simplicity and laxity of the criteria that define adjustment disorders have given rise to controversy about their clinical utility.”
Is the disorder clinically significant?
In the case of social anxiety disorder, we know how to deal with it, what its causes may be, and what the optimal treatment would be. However, this doesn’t happen in AD/SRS. Therefore, is a diagnosis really useful?
What’s really ambiguous about AD/SRS is that its diagnosis is made based on the stressor (Belloch, 2020). The stressor lacks the potency to cause another ‘more serious’ mental disorder (ie, it’s far from being life-threatening, as in the case of post-traumatic stress disorder). In effect, it’s a ‘minor’ stressor. That said, it still leads to the development of a disorder.
In addition, if the symptoms must ‘appear and disappear’ (Belloch, 2020) in a specific period (three and six months, respectively), it could be said to be a normal reaction to the impact of a painful event that resolves within a relatively short period of time.
For this reason, AD/SRS could well lack the status of a disorder and simply be the normal evolution of coping with an upsetting event that causes pain and suffering.
“We can find that they are pictures in evolution or resolution, or transitory conditions that resolve spontaneously.”
The defining element of AD/SRS
In AD/SRS, affective symptoms can develop, such as those that characterize depression. These are symptoms of anxiety or even behavioral disturbances. In other words, the characteristic symptoms of depressive disorder, anxiety disorders, and conduct disorders. However, far from diagnosing these symptoms under these diagnostic labels, AD/SRS exists. It’s a hodgepodge, a kind of ‘multi-symptom mixed bag’.
Scientific evidence exists on the absence of differences between AD/SRS and major depressive disorder (MDD). It seems that the severity of symptoms and functional deterioration are similar in both cases (Belloch, 2020).
Functional recovery is faster in AD/SRS than in MDD. The absence of elements that define AD as a ‘pure’ clinical entity, well defined and delimited, forms the basis of the controversies surrounding the usefulness of this diagnostic label.
Is there sufficient scientific evidence?
There are many subtypes of AD/SRS. According to the APA (2015), it occurs with:
- Feelings of depression.
- Symptoms of anxiety.
- Symptoms of anxiety and depression together.
- Behavioral disturbances.
- Behavioral disturbances and anxious-depressive symptoms.
This means AD/SRS is the clinical entity with the most subtypes (Belloch, 2020). But, they lack the relevance or specificity necessary for their use. For this reason, the World Health Organization prefers to eliminate AD/SRS subtypes.
“Longitudinal studies indicate that the most common symptom profile is the mixed anxious-depressive one”.
As you can see, the topic is controversial. The diagnosis of AD/SRS can be useful in some cases, because it can provide clues as to how the patient might evolve to other more defined and serious clinical entities, such as depression.
On the other hand, it’s a ‘mixed bag’ of poorly defined symptoms that could lead to erroneous diagnoses. In fact, it could even ‘pathologize’ normal reactions, albeit maladaptive, to a deeply painful situation, such as the loss of a job or a partner.
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