Challenges Adapting to Acute and Ongoing Stressors: Revisiting the Adjustment Disorder Diagnoses 11/13/2020

Social distancing and other pandemic related changes to our lives appear to be correlated with an increase in adult substance abuse, and to an overall increase in mental health symptomatology with onset or exacerbation of mood symptoms, sleep difficulties, irritability, increased worry and cognitive strain. Stress does that; isolation magnifies the hurt; and uncertainty keeps the frustration and the fears going. Coupled with economic losses and reduced social cohesion, distress and dysfunction can increase quite intensely.

Healthcare providers, while adept at marshalling counter-phobic defenses to help themselves stay at the frontline, are also stressed and, even in primary care medical encounters, they are seeing more and are more attuned to see and inquire about and try to address these concerns. What we know about Covid-19 related stressful conditions on children and adolescents continues to grow as well and, in studies from across the world, teenagers and younger children are now reported to be showing higher rates of “symptoms“ that typically are markers of depressive and anxiety disorders.

The Coronavirus pandemic can be considered a significant life change for all of us. For example, 1,143 parents from Italy and Spain reported the following as increased symptoms in their children (Orgilés et al., 2020)

  • Difficulty concentrating ~76%
  • Boredom – 52%
  • Irritability – 39%
  • Restlessness – 38.8%
  • Nervousness – 38%
  • Loneliness – 31.3%
  • Uneasiness – 30.4%
  • Worries – 30.1%

75% of parents have felt stressed about quarantine situation.  While it can be tempting to go translate the reported symptomatology directly into a diagnostic formulation, more often than not, affected individuals may not meet full criteria for a major depressive episode or an anxiety disorder. In this context, it is important to consider the potential relevance and utility of evaluating and utilizing as potential diagnoses the variety of Adjustment Disorders which can help with triage and in planning interventions as this may avoid both patient/parent resistance to active interventions and mitigate against a mindset of stigma that may be associated with a more weighty diagnosis.

Adjustment Disorders have long been recognized in the mental health field as a common phenomenon: a significant change occurs in their life, and the individual (child or adult) has a hard time adjusting, and experiences symptoms that mimic a mild or even a potentially moderate level of depression or anxiety. In normative times, when such adjustment situations come to the attention of medical providers, therapeutic interventions are typically limited to reassurance, brief intervention, and ample focus on applying “tincture of time”— this, as most folks adapt and most symptoms resolve as the stressors impact fades or is accommodated to or compensated for.

While many, if not most, stressful life changes are discrete and time-limited, some, like the COVID 19 pandemic, can linger with prolonged stressful impact on individuals, families and communities, with the result that individuals may experience sustained stress and symptomatology. Under these circumstances, symptoms may persist far beyond the typical expected time frame of several months duration. When this occurs, it is important to recognize that more active intervention strategies may be warranted as symptoms may not resolve on their own in the face of ongoing external impacts, and may need multi-modal treatment interventions.

Where possible, guidance to affected individuals should focus on initiating and sustaining adaptive strategies to normalize their daily lives and optimizing healthy habits, including encouraging exercise and outdoor activity, enabling safe socialization opportunities, and avoiding high risk behaviors such as substance use, excessive involvement with on-line activities, and preventing excessive social isolation.   Typically these strategies will have both individual and family or social group components.

When these sorts of preventive and primary level interventions are not fully effective, more formal treatment for those struggling under chronic stress would be similar to those used to treat those with classical depressive and anxiety disorders. For some, Cognitive Behavioral Therapy (CBT), family therapy and other brief psychotherapeutic interventions, including psychodynamic approaches, can be very are appropriate. At times, psychopharmacologic interventions may be warranted to reduce anxiety, enhance positive mood, and support adequate sleep— the bottom line is that judicious use of medications can ameliorate anxiety, depressive and other maladaptive responses associated with stress and loss.

In conclusion, it is important for providers to recognize that pervasive levels of stress that our patients, and we ourselves, are exposed to during the pandemic and to actively attend to the psychological impacts that can arise under these very atypical circumstances. While we recommend that a parsimonious attitude be taken with regard to diagnostic interpretation of symptoms – thinking first of using an adjustment disorder diagnosis if most relevant to the presenting concerns and problems— we would also recommend taking a proactive and supportive interventional approach judiciously utilizing, as warranted, all the therapeutic tools at our and our patients’ disposal.

 

DSM IV and DSM V Criteria for Adjustment Disorders: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t19/

Orgilés, M., Morales, A., Delvecchio, E., Mazzeschi, C., & Espada, J. P. (2020, April 21). Immediate psychological effects of the COVID-19 quarantine in youth from Italy and Spain. https://doi.org/10.31234/osf.io/5bpfz

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