Adjustment disorder

Adaptation disorder (adaptive reaction disorder) occurs as a result of significant changes in lifestyle caused by an emergency. According to the handbook of diagnostics and statistics of mental disorders, adaptation disorder, which can be triggered by stressors of varying intensity, has various manifestations.

Adaptation disorder usually occurs after the transition period. In most cases, depressive disorders of varying duration and structure are observed; in some patients, depression within the framework of adaptation disorder manifests itself as a subjective feeling of low mood, hopelessness and lack of prospects.

Externally, the victims look older than their age. They note a decrease in skin turgor, early appearance of wrinkles and graying of hair. They do not actively engage in conversation, have difficulty maintaining a conversation, speak in a quiet voice, the rate of speech is slow. The victims note that it is difficult for them to collect their thoughts, any undertaking seems impossible, an effort of will is required to do anything. They note difficulty concentrating on one issue, difficulty in making decisions, and then in implementing them. The victims, as a rule, are aware of their failure, but try to hide it, inventing various reasons to justify their inaction.

Sleep disturbances are almost always observed (difficulty falling asleep, frequent night awakenings, early awakenings in anxiety), lack of a feeling of vivacity in the morning regardless of the total duration of sleep. Nightmarish dreams are sometimes noted. During the day, the mood is low, tears easily "come to the eyes" for little reason.

They observe fluctuations in blood pressure before a change in weather, previously uncharacteristic attacks of tachycardia, sweating, cold extremities and a feeling of tingling in the palms, deviations in the functioning of the digestive system (loss of appetite, a feeling of discomfort in the abdomen, constipation). In some cases, in people who suffer from an adaptation disorder, a feeling of anxiety comes to the forefront, along with a subjectively barely noticeable decrease in mood.

Outwardly, the victims look tense, and during the conversation they sit in a “closed pose”: slightly leaning forward, crossing their legs and crossing their arms over their chest. They enter into the conversation reluctantly and cautiously. At first, they do not voice any complaints, but after the conversation begins to touch on a “current topic”, the pace of speech accelerates, and a “metallic tone” appears in their voice. During the conversation, they have difficulty following the outline of the conversation, cannot wait for the interlocutor to express his opinion, and constantly interrupt him. Answers to questions are often superficial and ill-considered. They are easily suggestible and quickly succumb to persuasion. They take on the assigned task with great responsibility, but subsequently, due to difficulty concentrating, they cannot track the sequence of execution of tasks, make gross mistakes and either do not complete the task or complete it very late.

Sleep disturbances also occur, however, unlike the representatives of the previous group, difficulties in falling asleep in these cases are primarily expressed in the fact that before going to bed "various disturbing thoughts" come to mind concerning important issues. From the side of the cardiovascular system, as in the previous group, an increase in blood pressure is observed (however, it is more stable and less dependent on changes in weather conditions), abnormalities in the digestive system (decreased appetite, moving with the appearance of a feeling of hunger, often accompanied by the consumption of a large amount of food).

In some people with adjustment disorder, anxiety develops along with a subjectively felt decrease in mood. Moreover, in the early morning hours, immediately after waking up, an anxious mood prevails, which “does not allow one to lie in bed for long.” Then, within 1-2 hours, it decreases, and melancholy begins to predominate in the clinical picture,

During the day, victims of this group are inactive. They do not seek help on their own initiative. During a conversation, they complain of low mood and apathy. Representatives of this group complain of anxiety only during an examination in the evening or if a doctor draws attention to its presence.

Anxiety increases in the evening and gradually decreases by midnight. The victims themselves consider this period of time to be “the most stable and productive”, when there is no feeling of melancholy and anxiety. Many of them emphasize and realize that it is necessary to rest during this period of the day, but they start doing household chores or watch “an interesting film” on TV, and go to bed only deep after midnight.

In some cases, adaptation disorder manifests itself in a change in lifestyle. Sometimes a person subconsciously removes responsibility for the well-being and health of their family members. In some cases, victims believe that it is necessary to change their place of residence. Often they move to a new place of residence, where they also cannot adapt to the living conditions. Representatives of this group begin to abuse alcohol, gradually break ties with their family and join an environment with lower social demands and needs. Sometimes, subconsciously removing responsibility for the well-being and health of their family members, they join sects. As the victims themselves explain in these cases, "new friends help to forget old grief."

In a number of victims, adaptation disorder manifests itself in disregard for generally accepted norms of behavior. In this case, it is not a matter of a person considering this or that unseemly act unacceptable, but “need forces one to act this way,” but rather that it is consciously defined as “quite acceptable.” In these cases, it is a matter of a reduction in the individual moral criteria of the individual.

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Adjustment Disorder and Grief Reaction

Adjustment disorders include pathological grief reactions.

Before describing the clinical picture of pathological grief reaction, it is appropriate to outline how uncomplicated grief reaction associated with loss (the body's emotional and behavioral response to an irreparable loss) proceeds.

Initially, the word "loss" was understood as a personal experience associated with the loss of a loved one. Somewhat later, divorce and other types of breakups with a loved one began to be considered loss. In addition, loss includes the loss of ideals and a previous way of life, as well as amputation of a body part and loss of an important function of the body, caused by a somatic disease. There is a special form of loss observed in people suffering from a chronic disease. For example, with chronic cardiovascular diseases, a person is forced to lead a semi-invalid life, to which he gradually adapts, and then gets used to. After the necessary surgery and restoration of function, a grief reaction for a limited life may occur. 

There are losses of a slightly different type that can also trigger a grief reaction: loss of social status, membership in a certain group, job, home. A special place among losses (mainly among lonely people) is the loss of beloved pets.

Losses include not only the loss of a loved one. A significant loss can also be the loss of an individual's ideals or way of life.

The grief reaction is to some extent a natural reaction to loss. According to S. T. Wolff and R. C. Simons, the "purpose" of the grief reaction is to free the personality from ties to the individual who is no longer there.

The intensity of the grief reaction is more pronounced in the case of sudden loss. However, the degree of expression of the grief reaction is affected by the family relationship with the deceased. As is known, in 75% of cases, married couples who have lost children stop functioning as a single family for a certain period of time, and subsequently the family often breaks up. Among these married couples, cases of depression, suicide attempts, alcoholism and sexual problems are common.

When a person dies, it's not just the parents who suffer. Surviving siblings not only feel guilty about being alive, but also perceive the parents' suffering as confirmation that the dead children were loved more.

The external expression of grief (mourning) is largely determined by cultural affiliation. Ethnocultural traditions (rituals) either help to weaken the grief reaction or prohibit its display.

There are three phases in the grief reaction. The first phase is the protest phase. It is characterized by a desperate attempt by the individual to restore relations with the deceased. This is expressed in the first reaction of the type "I do not believe that this happened." Some individuals cannot accept what happened and continue to behave as if nothing happened. Sometimes the protest is manifested in a subjective feeling of dulling of all feelings (they hear nothing, see nothing and feel nothing). As some authors point out, such blocking of the surrounding reality at the very beginning of the protest phase is a type of massive defense against the perception of loss. Sometimes, realizing that the individual has died, close relatives try to bring him back in an unrealistic way, for example, a wife, hugging the body of her deceased husband, turns to him with the words: "Come back, don't leave me now." The protest phase is characterized by sobbing and lamentation. At the same time, pronounced hostility and anger are quite often observed, often directed at doctors. The protest phase can last from several minutes to several months. Then it gradually gives way to the disorganization phase (loss awareness phase). In this phase, there is an awareness that the loved one is no longer there. Emotions are very intense and painful. The main mood is deep sadness with the experience of loss. The personality may also experience anger and guilt, but the predominant affect remains deep sadness. It is important to note that, unlike depression, the self-esteem of the personality does not decrease during the grief reaction.

The grief reaction is accompanied by various somatic sensations that can be provoked by the surrounding environment. These include:

• loss of appetite:
• feeling of emptiness in the stomach:
• a feeling of constriction in the throat;
• feeling of shortness of breath:
• feelings of weakness, lack of energy and physical exhaustion.

They can also be triggered by surrounding events. Sometimes these memories are subjectively experienced so hard that the individual tries to avoid them. 

One of the manifestations of adaptation disorder is the unwillingness to communicate and the reduction of contacts with the surrounding microsocial environment. Patients become introverted, they are unable to show spontaneity and warmth to others that were previously characteristic of them.

People with grief reactions often report feelings of guilt toward their deceased loved one. At the same time, they may express irritability and hostility. People with grief reactions want to hear the words "I will help you bring him back" from their relatives, rather than words of sympathy.

In general, during this phase of the grief reaction, the patient notes disorganization, aimlessness, and anxiety. Individuals themselves, evaluating this time retrospectively, say that everything they did was "done automatically, without feeling, and it required a lot of effort."

In this phase, the individual gradually begins to acknowledge the loss. He increasingly remembers the deceased, his last days and minutes. Many try to avoid these memories, because they are very painful: the individual understands that this connection is no longer there.

Many individuals dream of seeing the deceased in a dream. Some quite often see the deceased alive in a dream. For them, waking up (returning to reality) is often extremely painful. Sometimes during the day, individuals experience auditory hallucinations: "someone tiptoed down the hallway and slammed the window," "the deceased calls out by name." These hallucinations often cause severe fear and force people to seek help from specialists due to fears of "going crazy." It should be noted that, as some researchers believe, the fear of going crazy that occurs in individuals with an adjustment disorder is not related to an adjustment disorder and does not lead to the development of serious diseases.

The disorganization phase is followed by the reorganization phase, which lasts from several weeks to several years. In this phase, the personality again turns to face reality. The individual begins to remove objects belonging to the deceased from visible places. By this time, unpleasant memories associated with the death of a loved one gradually fade, and pleasant memories associated with the deceased begin to emerge.

In the third stage, the individual often begins to show interest in a new field of activity and simultaneously reestablish old connections. At times, the individual may experience a sense of guilt due to the fact that he is alive and enjoying life when the deceased is absent. This syndrome was once described as the survivor syndrome. It should be noted that the emerging sense of guilt is sometimes expressed quite strongly and can sometimes be projected onto a new person who has appeared in the individual's life.

Although much changes, most people with adjustment disorder retain some common patterns of relating to the deceased:

• memories of the deceased;
• internal support of fantasies about reunification with the deceased (the idea of such a possibility in the future is supported by most religions);
• the connection with the deceased is maintained through the process of identification (over time, people gradually begin to identify themselves with the deceased in terms of habits, values and activities, for example, a wife begins to continue her husband's business in the same vein, sometimes without realizing it at all).

Finally, it should be said that a person who has experienced a loss (test) becomes more mature and wiser. If an individual has gone through the grief reaction with dignity without losses, he develops new values and habits, which allows him to become more independent and better able to cope with life's adversities.

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Pathological grief reaction

The most severe manifestation of a pathological grief reaction is the absence of a grief reaction as such: individuals who have lost a loved one do not experience any mental pain or melancholy, and have no memories of the deceased. They do not exhibit any somatic adaptation disorders. Sometimes, after the loss of a loved one, an individual expresses anxiety and fear for his health due to the presence of a real chronic disease.

Often, in pathological adaptation disorder, the individual begins to recognize his loss only after 40 days or after the anniversary of the death of a loved one. Sometimes the loss of a loved one begins to be perceived very acutely after another significant loss. A case is described where an individual's wife died, after whose death he began to mourn his mother, who had died 30 years earlier.

Sometimes a person begins to grieve for a loved one who died at the same age that the individual has currently reached.

In some cases, progressive social isolation may develop, when the individual practically ceases to communicate with the surrounding microsocial environment. Social isolation may be accompanied by constant hyperactivity.

The resulting deep sadness and survivor's guilt may gradually develop into clinically expressed depression with a feeling of self-hatred. Often, hostile feelings towards the deceased arise simultaneously, which are unacceptable both for the individual and for the surrounding microsocial environment. Rarely, individuals with pronounced hostility subsequently develop paranoid reactions. Especially towards the doctors who treated the deceased.

Among individuals with adjustment disorder, mortality and morbidity from the loss of a significant other during the first year of mourning are increased compared to the general population.

In some cases, people with adaptation disorder continue to mentally communicate (talk) with the deceased and in their fantasies believe that everything they do, they do the same as they did with the deceased. At the same time, they understand that their loved one is no longer alive.

Currently, there is no unified classification of adaptation disorders associated with emergencies. Different classifications interpret the concepts of the type of course (acute and chronic) differently and define the duration of a particular syndrome differently.

According to ICD-10, in adaptation disorder, “symptoms show a typical mixed and changing picture and include an initial state of stupefaction with some narrowing of the field of consciousness and decreased attention, inability to respond adequately to external stimuli, and disorientation.” This condition may be accompanied by either further withdrawal from reality (up to dissociative stupor), or agitation and hyperactivity (flight reaction or fugue). Vegetative signs of panic anxiety are often present, and partial or complete dissociative amnesia of the episode is possible.

When it is possible to eliminate the stressful situation, the duration of acute adjustment disorder does not exceed a few hours. In cases where stress is persistent or by its nature cannot be stopped, symptoms begin to disappear after 24-48 hours and are reduced to a minimum within three days. At the same time, according to the diagnostic criteria for adjustment disorder, the response of the person exposed to the traumatic event includes intense fear, helplessness, or horror.

At the time of exposure to the distressing event (stressor) or after it, the individual must have three or more of the following adjustment disorders:

• a subjective feeling of numbness, alienation, or lack of emotional resonance;
• reduction of perception of the surrounding reality (state of being “stunned” or “dazed”);
• derealization;
• depersonalization;
• dissociative amnesia (inability to remember important aspects of the trauma).

The individual continually re-experiences the traumatic event in at least one of the following ways:

• recurrent ideas, thoughts, dreams, illusions, flashback episodes; a feeling of revival of the lived experience;
• distress when exposed to reminders of the traumatic event.

Avoidance of stimuli that trigger memories of the traumatic event is observed: thoughts, feelings, conversation, activity, location, people involved. Significant symptoms that cause anxiety and increase arousal are found: difficulty sleeping, irritability, difficulty concentrating, supervigilance, excessive startle response, motor restlessness.

The existing adjustment disorder causes clinically significant distress or inability to perform various functions.

Adjustment disorder lasts for at least two days, but no more than four weeks.

As can be seen from the data provided, the OBM-GU-TI classification itself is more detailed. However, it differs significantly from ICD-10. Firstly, acute adaptation stress disorder includes some symptoms that, according to ICD-10, are classified as diagnostic criteria for ASS. Secondly, the duration of the acute stress reaction, according to ICD-10, “is reduced to a minimum of three days, even in cases where the stress continues or cannot stop by its nature.” According to ICD-10, “if the symptoms persist, the question of changing the diagnosis arises.” Thirdly, according to OBM-GU-TI, if the symptoms inherent in acute stress disorder last more than 30 days, the diagnosis of “acute adaptation stress disorder” should be replaced by the diagnosis of ASS. Consequently, according to OBM-GU-TI, ASS can be diagnosed only within the first 30 days after the traumatic event.

The diagnosis of "transitional period" does not exist in any classification. However, we have identified it for the following reasons:

• during the transition period, the clinical picture of subsequent psychopathological disorders is formed;
• It is precisely during the transition period that, as a rule, it is possible to provide victims with highly qualified psychological and psychiatric assistance;
• The volume and quality of psychological and psychiatric assistance provided and social activities carried out during the transition period largely determine the effectiveness of the entire range of rehabilitation measures aimed at the resocialization of victims.