Adjustment disorder and its homoeopathic management

Dr Diana R ¹,  Dr Manu Manjith ² ,Dr Saja P ³

ABSTRACT
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, medical illness or relationship problems. 

KEY WORDS : Adjustment disorder, Homoeopathy, Remedies, Psychotherapy.

INTRODUCTION
Adjustment disorder is a very common disorder in the present time. An average of 12% of the total population suffers from Adjustment Disorder. 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. It also ranked the 7^th most frequently diagnosed category (where 44 categories were provided) in a global sample of 5000 psychiatrists.

Adjustment Disorders (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 6 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.

EPIDEMIOLOGY
The prevalence of this disorder is estimated to be from 2 to 8 % of the general population. Women are diagnosed with the disorder twice as often as men and single women are generally overly represented as most at risk. The disorders can occur at any age but the most frequently diagnosed in adolescents. Among adolescents of either sex common precipitating stressors are school problems, parental rejection and divorce and substance abuse. Among adults common stressors and marital problems, divorce, moving to a new environment and financial problems. Adjustment disorder are one of the most common psychiatric diagnosis for disorders of patients hospitalized for medical and surgical problems.

ETIOLOGY
By definition, an adjustment disorder is precipitated by one or more stressors. The variety of stressors does not always predict the severity of the disorder. The stressor severity is a complex function of degree, quantity, duration, reversibility, environment and personal contact.

Modifiers of stress
Diverse variables and modifiers are involved regarding who will experience adjustment disorder following stress :
a) Acute stresses are different from chronic stresses in both psychological and physiological terms.
b) The meaning of stress is affected by modifiers (eg: ego strength, support systems, prior mastery)
c) Manifest as latent meanings of the stress may be associated with differential impact.

A reason minus stress superimposed on a previous underlying (major) stress that has no observable effect of its own may have a significant addictive impact.

Psychodynamic factors
Pivotal to understanding adjustment disorder is an understanding of three factors – the nature of the stressors, the conscious and unconscious meaning of the stressors, and the patient’s preexisting vulnerability. A concurrent personality disorder or organic impairment may make a person vulnerable to adjustment disorder.

Several psychoanalytic researches have been pointed out that the same stress can produce a range of responses in various persons. They also has emphasized the role of the mother and the surrounding environment in a person’s later capacity to respond to stress. Throughout early development, each child develops a unique set of defence mechanisms to deal with stressful events. Because of greater amount of trauma or greater constitutional vulnerability some children have less mature defensive constellations than other children. This disadvantage may cause them as adults to react with substantially impaired functioning when they are faced with a loss, a divorce or a financial setback. Those who have developed a mature defence mechanisms are less vulnerable and bounce back more quickly from the stressor.
Family and genetic factors
Some studies suggest that certain persons appear to be at increased risk both for the occurrence of these adverse like events and for the development of pathology once they occur. Findings from a study of more than 2000 twin pairs indicate that life events and stressors are modestly correlated in twin pairs with monozygotic twin showing greater concordance than dizygotic twins.

CLINICAL FEATURES
The symptoms do not necessarily begin immediately after the stressor. Up to 3 months may elapse between a stressor and the development of symptoms. Symptoms do not always subside as soon as the stressor ceases. If the stressor continuous the disorder may become chronic. The disorder can occur at any age, and its symptoms very considerably with depressive, anxious and mixed features.
DSM 5 list 6 adjustment disorder:

1. Adjustment disorder with depressed mood.
   Depressed mood, fearfulness, hopelessness adolescence with this type of adjustment disorder are at increased risk of major depressive disorder in young adulthood.
2. Adjustment disorder with anxiety. 
   Symptoms of anxiety suggest palpitation and vegetation are present in adjustment disorder with anxiety
3. Adjustment disorder with mixed anxiety and depressed mood
   Patient exhibit features of both anxiety and depression that do not meet the criteria for an already established anxiety disorder or depressive disorder.
4. Adjustment disorder with disturbance of conduct
   In this predominant manifestation involves conduct in which the rights of others are violated or age appropriate social norms and rules are disregarded. Examples of behaviour in this category are abstinence, vandalism, reckless driving and fighting
5. Adjustment disorder with mixed disturbance of emotion and conduct
6. Adjustment disorder unspecified
   It is a residual category for a typical maladaptive response to stress, examples include inappropriate responses to the diagnosis of physical illness such as massive denial, severe noncompliance with treatment and social withdrawal, without significant depressed or anxious mode.

DIFFERENTIAL DIAGNOSIS
Other disorders from which adjustment disorder must be differentiated include major depressive disorder, brief psychotic disorders, GAD, somatic symptom disorder, substance related disorders and PTSD. This diagnosis should be given precedence in all cases that make their criteria, even in the presence of a stressor or group of stressors that served as a precipitant

Acute and post-traumatic stress disorders
The presence of a stressor is a requirement in the diagnosis of AD, PTSDand acute stress disorder.
PTSD and acute stress disorder have the nature of the stressor better characterized and are accompanied by a detailed consultation of affective and autonomic symptoms. In contrast the stressor in AD 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 PTSD threshold, the AD 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. Adolescence usually require a longer time to recover than adults.
Research over the past five years has disclosed a rise for suicide especially in adolescence patient. Common diagnosis of substance abuse and personality disorder contributed to the suicide risk profile.

TREATMENT

1. Psychotherapy and counselling
   Though brief therapeutic intervention are usually all that are needed , Ongoing stressors or enduring character pathology that may make a patient vulnerable to stress intolerance that may signal the need for cognitive treatments.
   Treatment of adjustment disorder initially focuses on psychotherapy and counselling interventions to reduce stress and has a capacity to cope with stressor that cannot be reduced or removed and establish a system of support to maximize adaptation. The patient needs to be made aware of significant dysfunction that the stressor has caused and considered strategies to manage the disability. The therapist would assist the patient to verbalize his or her disappointed feelings and rage rather than behaving destructively.
2. Crisis intervention
   Crisis intervention and case management are short term treatment aimed at helping persons with adjustment disorder resolve their situations quickly by supportive techniques, suggestion, reassurance, environmental modification and even hospitalization if necessary. The frequency and length of visit for crisis support vary according to patients need. Flexibility is essential in this approach.

HOMOEOPATHIC THERAPEUTICS 

1. Gelsemium sempervirens
   – Emotional excitement, fear leading to physical ailments.
   – Delirious falling asleep.
   – Bad effects from fright, fear, exciting news.
   – Sleepless from nervous irritation.
2. Ignatia amara
   – Changeable mood, introspective, silently brooding, sad.
   – Fearful.
   – Not communicative.
   – Sighing and sobbing.
   – After shock, grief, disappointment.
   – Dreams continuing a long time, troubles him/her.
3. Staphysagria
   – Peevish, sad, very sensitive, Hypochondriacal
   – Impatient, violent outbursts of passion.
   – Prefers solitude, dwells on sexual matters.
   – Abdominal colic after anger.
4. Aurum metallicum
   – Emotional sphere to intellectual sphere.
   – Feeling of self-contemplation and after worthlessness.
   – Profound despondency.
   – A thorough disgust for life.
   – Suicidal thoughts.
   – Great fear of death, confusion.
5. Silicea terra
   – Anxious, faint hearted, yielding.
   – Nervous and excitable.
   – Sensitive to all impressions.
   – Abstracted, fixed ideas. 

CONCLUSION
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 a 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. 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 have only recently begun. Re conceptualization of Adjustment Disorder in 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’s 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 and help the patients for a better living.

REFERENCE

1. Gelder MG et al. New Oxford textbook of Psychiatry. 2^nd Edition. New York: Oxford university press; 2009.
2. Sadock BJ et al. Kaplan and Sadock’s Synopsis of Psychiatry. 10^th Edition. New Delhi: Wolters Kluwer; 2013.
3. Vyas JN. Textbook of Postgraduate Psychiatry. 2^nd Edition. New Delhi: Jaypee Brothers Medical Publishers; 2008.
4. Kent JT. Repertory of the Homoeopathic MateriaMedica. New Delhi: B Jain Publishers.
5. Boericke W. Homoeopathic MateriaMedica. New Delhi: B Jain Publishers.
6. The ICD 10. Classification of Mental and Behavioural disorders, clinical description and diagnostic guidelines. Reprint Edition. New Delhi: AITBS Publishers and Distributors; 2007.
7. CASEY P, BAILEY S. Adjustment disorders: the state of the art. NEW IMPACT FACTOR: 4.375. 2011.

¹Asst Professor, Department of Psychiatry and Homoeopathic Therapeutics, Father Muller Homoeopathic Medical College and Hospital, Mangaluru. drdianar@gmail.com, 9663475174

²PG Scholar, Dept of Psychiatry and Homoeopathic therapeutics, Father Muller Homoeopathic Medical College and Hospital, Mangaluru.

³PG Scholar, Dept of Psychiatry and Homoeopathic therapeutics, Father Muller Homoeopathic Medical College and Hospital, Mangaluru.drsajap2@gmail.com, 9446959146