From Crisis to Adjustment Disorder: A Medicalization of a Concept?
Tsvi E. Gil, B. Sc., M. A.
Western Galilee Community Mental Health Clinics, Acre and Carmiel, Fligelman (‘Mazra’) Psychiatric Hospital, Acre, and private practice, Haifa, Israel.
POB 3626 Haifa, Israel, 31036
Tel. 04-8100751
((Turkish Journal of Psychiatry 24(1): 58-62, 2013)
Abstract:
Two concepts are discussed and compared, crisis and adjustment disorder. Those concepts stem from different theoretical perspectives, rely upon different (though relatively loose) bodies of data, and may serve different purposes. The crisis concept comes from an approach that could be portrayed as psychodynamic, humanistic, and community oriented, and which leads to less rigorous treatment procedures. The adjustment disorder concept is a part of a more modern diagnostic approach, a phenomenological and objective one, and which may lead to ordinary psychiatric treatment procedures. We conclude that empirical support for both types of diagnoses is rather weak. However, since formal psychiatric diagnosis demands more extensive scientific support, the current usage of the diagnosis of adjustment disorder may seem less justified.
From Crisis to Adjustment Disorder: A Medicalization of a Concept?
The concept of Crisis in psychiatric literature is believed to evolve from the writings of prominent psychiatrists such as Erich Lindemann (1944) and Gerald Caplan (1994). Its roots are to be found within post-Freudian theoreticians, who emphasized Ego psychology, such as Heinz Hartmann, Ernest Kriss, and Rudolph Loewenstein (discussed in Golan, 1978), those who emphasized life-cycle development as Erik Erikson (1963), and Humanistic psychotherapists (Maslow, 1954; Rogers, 1961). During the sixties the concept of Crisis was integrated into the Community approach, wherein crisis was perceived as an inevitable part of the normal development. Crises, albeit unpleasant, were recognized as necessary for development and growth (see (Golan, 1978, and Cohen et al, 1983, among others); crises, therefore, are not pathologies, and should be treated by means of psychological support, rather than by psychiatric aid (see for example Brockopp in Lester & Brockopp, 1976). Treatment, according to the crisis approach, should be carried within the community and in a normal life setting, rather than in psychiatric wards which, by their nature, isolate the person-in-crisis instead of helping him or her to rehabilitate their life in a way which is contained by one's natural surroundings (see Caplan, 1994, among others). Finally, the best helper, according to this approach, is a para-professional, who has received some training in offering empathy and in methods of intervention, rather than the professional psychotherapist who is qualified with theories of personality, psychopathology, and psychotherapy (see for example Brockopp in Lester & Brockopp, 1976, and O’Donnell & George, 1977). The generic approach (Lindemann, 1944) emphasized the similarities among all people who undergo crisis, rather than personal differences. In other words, personality variables of the client are perceived as less important when compared to situational determinants. Accordingly, professional knowledge of the helper in various fields of psychiatry and psychotherapy is perceived to be less relevant than an immediate and empathic response to the person-in-crisis ( Litman’s law, see McGees and Jennings in Lester & brockopp, 1976), and therefore, availability and immediacy of help is of a greater importance than routines of psychiatric work (such as intake, interviewing, diagnosis, and weekly sessions). Crisis treatments emphasize strengths and enhance hope, rather than deals with deprivations, conflicts, and past traumata (see Brockopp's discussion in Lester & Brockopp, 1976). According to those lines of thinking, several models of crisis intervention had been developed and proposed, which will not be reviewed here in detail (see for example Golan, 1978, and Slaikeu, 1984).
Some literature had criticized the crisis approach for lacking satisfactory empirical support for its assumptions (see Cohen et al, 1983, and Ball et al, 2005). However, as some of its prominent advocators noted, the first concern in the aftermath of a crisis is always to provide assistance (McFarlane, 2000), not to conduct systematic research (Raphael et al, 1996). While theoretical and practical literature in the field of crisis had never ceased to proliferate, an accumulated research supplied some empirical support for its value regarding the prevention of long-term mental health problems (Caplan & Caplan, 2000), as well as offering updates regarding its theoretical assumptions (Slaikeu, 1984, Caplan & Caplan, 2000, Myer & Moore, 2006). A recent development in the crisis approach comes from extra-psychiatric context, namely, mass events that call for helping actions, which are not necessarily psychiatric by nature, such as the wars in Yugoslavia and the destruction of the New-York World Trade Center on September 11th 2001 (see Roberts, 2005). The social approach toward such events made clear, on one hand, that immediate aid is highly needed and should be given by available social agents (social workers, clergymen, officials, doctors and so on); on the other hand, such help was not perceived as a ‘psychiatric act’ (i.e., interviewing, diagnosing, prescribing, dating consecutive sessions, and so on). This is not to imply, of course, that psychiatric aid was not provided to some victims of those terrible events, but that the nature of the problem and the required means of aid were not perceived and nor were they treated within the means psychiatry had developed over the last decades. This can be regarded as a move toward the 1960’s community approach, as described above.
Adjustment disorder as a defined diagnostic entity had appeared for the first time in the 3rd edition of the American Diagnostic and Statistical Manual (DSM-3) (American Psychiatric Association, 1980) in 1980, as part of the group of anxiety disorders. In the first edition of the Manual the closest concept offered was of "transient situational personality disorder". The second edition of the DSM had offered the term of "transient situational disturbance". The DSM distinguished adjustment disorders as a response to a varietyof causal stressful events, from the acute stress and post-traumatic stress disorders, which were perceived as responses to exceptionally threatening experiences. The WHO’s current classification system (ICD-10) (WHO, 1992) had added the adjustment disorder as a substitute to the older and ill-defined terms of reactive and endogenous depression, and clustered the accommodation-to-stress situations into four groups. Adjustment disorders are gathered into two groups, acute and not acute; the other two groups in this cluster are post-traumatic stress disorder and prolonged personality change following extreme stress. Being put together this classification may match the varieties of the older concept of crisis. The psychodynamic diagnostic system (PDM Task Force, 2006) had introduced the entity of adjustment disorders quite similarly to the way it was introduced by the DSM, and as a part of the ‘subjective experience section’ (S axis).
The appearance of the newer concept of "adjustment disorder" had been taken place in spite of lack of a satisfactory theoretical ground (see discussion in Greenberg et al, 1995). However, since its appearance, the diagnosis of adjustment disorder had proved to be useful, in terms of popularity of use, and especially in non-psychiatric settings, such as general hospitals (Pollock, 1992). Its frequency in the population is estimated to vary between 5 to 21 percent of adults who apply to outpatient mental health services (Jones et al, 1999) (Other prevalence had been reported as well, presumably due to different operative definitions, see [Ayuso-Mateos et al, 2001] in Europe, and [Strain et al 1993] in America). Adjustment disorder, so it seems, is perceived as a 'light' diagnosis, which is characterized by transiency and lack of stigma (see Greenberg et al 1995). Therefore, one of its uses (which had probably not originally intended to by its creators) was to enable treatment for patients not otherwise diagnosed, and who needed budgeting by health care insurance companies (Despland et al 1995).
Adjustment disorder has yet been unable to provide biological markers, specific symptoms or behavioral parameters (which can make a clear difference from other diagnoses), and is highly attached to contextual factors (Despland et al 1995). Research of this disturbance is relatively poor in its quantity (Despland et al 1995), and what is found seems to be rather critical when concerned with its validity. Many authors view the current definition of adjustment disorder to be inadequate (Maercker et al 2007). Additionally, some authors challenged the lack of clear differentiation between the varied manifestationsof adjustment disorder and normal adaptive reactions (Casey et al 2001).
When taking all of this in account, one may wonder whether this diagnosis does really exist as a valid diagnostic entity, or whether it merely serves pragmatic needs of diagnosticians (Pollock 1992), or is even a context-dependent label, as proposed by Horwitz (2002). Indeed, many clinicians relate to this diagnosis with reservation or suspect, and view it as the 'trash basket' of the psychiatric world of diagnoses (Andreasen & Wasek 1980). Some see diagnosis of adjustment disorder as 'residual' (Maercker et al 2007), ‘marginal' or 'transitory' (Faberga et al 1987), or as vague and useless (Ford et al 1978). On the other hand, some authors think that the concept of adjustment disorder is sufficiently justified (Maercker et al 2007), and that it is under-diagnosed, and should be used more frequently than it is in present practice (Linden 2003).
Adjustment disorder had been found to be indistinguishable (or only insignificantly distinguishable) from other anxiety disorders (Schatzberg 1990), or depression (Bronisch & Hecht 1989). Some found its reliability to be particularly low (Newcorn & Strain 1992, Spalletta et al 1996), and its construct validity to be unfound (Jones et al 1999). In contrast some researchers claimed to find adjustment disorder validity to be significantly distinguishable from other diagnoses (Snyder et al 1990, Andreasen & Hoenk 1982, Kovacs et al 1995), and other authors thought that this diagnosis could be useful if some modifications would be taken in its structure as well as its criteria (see for example Strain et al 1993).
Justification of a diagnosis in terms of validity and usefulness may seem to depend, after al, on its impact upon treatment and prognosis (Spalletta et al 1996). If adjustment disorder functions as inheritor of the concept of crisis, hence its psychological (rather than biological) nature is to be emphasized, psychological intervention is to be recommended, and its prognosis is expected to depend on availability and immediacy of proper aid (see for example Bronisch 1991). On the other hand, interests of a political and economical nature may promote viewing adjustment disorder as a psychiatric disorder which requires pharmacological intervention (see for example Horwitz 2002). From this perspective the emergence of the entity of adjustment disorder may be viewed as one of the representations of the transition of the discipline of psychiatry – as reflected in the proceeding editions of the American DSM – from a psychodynamic and bio-psycho-social approach, to an approach which can be characterized as more empirical and medical (see, for example, Rogler 1997).
Some authors view adjustment disorder as a variant of anxiety disorder (American Psychiatric Association, 1980, Schatzberg 1990). But, as Linden (2003) notes, mental reactions to psychological turmoil do not necessarily involve fear or anxiety. Others view it as type of depression, perhaps what was called in the past 'reactive depression' (Bronisch & Hecht 1989). The DSM-IV editors suggested the term “minor depressive disorder” (American Psychiatric Association , 1994, pp.719) as “provided for further study”, but the essential difference when compared to major depression is that minor depression “involves fewer symptoms and less impairment”. That definition does not seem to meet the characteristic features of crisis, as described above.
Consistent with those views, adjustment disorder would preferably be treated with anxiolytic or anti-depressant medications. However, research regarding this issue raises doubts whether anti-depressant treatment is effective in absence of major depression, especially when the depressive mood is adjunctive to medical illness (Fava & Sonino 1996). Some researchers proposed that demoralization, as part of a response to a stressful event, should be distinguished from depression (De Figueiredo 1993, Slavney 1999). Spalletta et al (1996), on the other hand, suggest that although patients who diagnosed with adjustment disorder may display both anxiety and depression, they are less anxious than anxiety disorder patients, and less depressed than depressive patients. Some other authors, however, see adjustment disorder as a continuum with post-traumatic diagnoses (Linden, 2003), or as stress related (Maercker et al 2007, Horowitz, 1997).
Another perspective on adjustment disorder suggests it can be viewed as a variation of crisis, and hence be treated with psychological means such as crisis intervention, counseling, or even psychodynamic psychotherapy (see for example Battegay 1995).
A possible link between the older concept of crisis to the newer concept of adjustment disorder can be found in the writings of M. Horowitz (1997). Horowitz conceptualized 'stress response', which combined a recognizable stressful event, one's attempts of coping throughout one's familiar coping mechanisms, and pathological symptoms emanating from failure in coping. Adjustment disorder can be viewed, though, as the pathological end of a normal crisis continuum. Putting it differently, people normally face crises and may undergo some distress while coping with them; only those who fail to do so may display the signs of a psychiatrically-diagnosed adjustment disorder, with its characteristic signs. Similarly, some researchers, mostly European, proposed that a useful diagnostic system should contain ‘sub-clinical’ levels of depression (Fava 1999, Schnieder et al 2000), a term that may correspond with the older term of crisis; Crisis, though, may be perceived as the sub-clinical, sub-pathological end of the hypothesized adjustment disorder continuum. This Italian group, emphasizing psycho-social aspects of patient’s response to medical illness, had developed a related diagnostic system as a substitute or complementary to the DSM, aided to assist the liaison psychiatrist (Fava et al, 1995). Maercker and his colleagues (2007) support the view of adjustment disorder as belongs to the stress continuum of diagnoses. Different conceptualization, although similar to Horowitz's in emphasizing the cognitive processing of emotional stimuli, is to be found in Foa et al's model (Foa et al, 1989), who ascribes adjustment disorder to the traumatic continuum.
Discussion
The issue discussed by this article which may be dubbed as ‘crisis vs. adjustment disorder’ can be dealt with by two levels, namely, theoretical and empirical. Theoretically speaking, the two approaches emanate from and within different perspectives. Crisis theory originated from psychoanalysis, human psychology, and community psychology. Adjustment disorder stemmed from nosological psychiatry which strives at being descriptive, phenomenological, and a-theoretic. The crisis approach engages a wide assembly of helpers, many of them para-professionals, while the adjustment disorder is a psychiatric entity, constructed by and for the sake of psychiatrists. Both these approaches belong to the field of mental health, but crisis seem to belong more to the public and to normal life cycle. It relates to health, encompasses an optimist view, and hence is less stigmatizing. On the other hand, adjustment disorder belongs more to mental health professionals, and is part of medical tradition; it emphasizes abnormality and pathology, and hence may be more stigmatizing.
Empirically speaking, both concepts have gained weak support. Adjustment disorder had been brought forth for practical reasons, before it won empirical ground. Its weaknesses – loose definition, slack boundaries, and lack of clear markers – are also its strengths, enabling a quick and handy usage (the ‘waste basket’ approach) and are less stigmatizing when compared to many other psychiatric diagnoses. While it is difficult to find specific guideline for treatment of adjustment disorder (Bisson & Sakhuja, 2006), it gives the psychiatrist the freedom to use whatever comes to mind. Authors in the field of crisis, on the other hand, were busy in ‘what to do’, rather in systematically studying the field. They were attempting to be relevant to the community rather than to examine the basic premises of the approach they have established. They felt that ‘something has to be done’, was more urgent than the study of the effects of their treatments.
A practitioner's choice may therefore be influenced by one’s theoretical standpoint or by one’s reading of the scientific literature. However, in our opinion, the adjustment disorder approach displays a weaker claim, principally due to its directive to present a robust basis. A medical system of diagnoses should rely upon a more solid body of knowledge, rather than on ‘convenience’ in making diagnoses (First et al, 2004). Put differently, the practical usefulness of diagnosing that adjustment disorder provides the diagnosing psychiatrist may not be sufficient to justify the introduction of this new diagnostic entity to the diagnoses manual, and does not necessarily justify the labeling of distressful people in normal life situations as psychiatric patients, especially as long as psychiatry does not offer those patients a specific and effective treatment.
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