Adjustment disorders, posttraumatic stress disorder, and depressive disorders in old age: findings from a community survey

doi:10.1016/j.comppsych.2007.07.002

Comprehensive Psychiatry

Volume 49, Issue 2, March–April 2008, Pages 113-120

https://doi.org/10.1016/j.comppsych.2007.07.002 Get rights and content

Abstract

Based on a new psychopathological model of adjustment disorders (AJD), we propose that AJDs are particular forms of stress response syndromes, in which intrusions, avoidance of reminders, and failure to adapt are core symptoms. We aim to demonstrate that these AJD symptom groups constitute a disorder that is distinct from posttraumatic stress disorder (PTSD), complicated grief disorder, major depressive disorder, and subsyndromal depression, by estimating their prevalence and comorbidities. A representative sample of elderly persons from Zurich, aged 65 to 96 years, was assessed by standardized interviews or self-report questionnaires. Index events for AJD were indicated by 52% of the sample set, with a 2.3% current prevalence of AJD. Prevalence rates for other disorders were 0.7% PTSD, 4.2% subsyndromal PTSD, 4.2% complicated grief disorder, 2.3% major depressive disorder, and 9.3% subsyndromal depression. The comorbidity rate for AJD and other Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition disorders is 46%, and that between AJD and subsyndromal disorders is 38%. Use of mental health care for AJD is low. This article concludes that the new concept of AJD constitutes a meaningful psychopathological model and thus warrants a place in standardized psychiatric taxonomies. Although this study was restricted to a sample of the elderly, it provides evidence regarding AJD prevalence, comorbidity, and associated health care use, all of which indicate its utility.

Introduction

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) definition, adjustment disorder (AJD) is a transient maladaptive reaction to identifiable psychosocial stressors or changes in life circumstances. Several authors have pointed out that the current definition of AJD is rather loose, that the debate on its validity has been unsatisfactory, and that the concept in general has suffered academic neglect [1], [2]. At the same time, AJD is frequently used as a residual category for patients who do not meet full diagnostic criteria for other disorders, mainly major depressive disorder (MDD).

To overcome the scientific neglect of this diagnosis, Maercker et al [3] proposed a new diagnostic model. This model is based on the assumption that AJD is a stress response syndrome, such as posttraumatic stress disorder (PTSD), acute stress disorder, and complicated grief [4]. In this model, AJD is characterized by a psychosocial stressor of a different magnitude or quality (non–life-threatening) than in PTSD, for example, divorce or separation, severe illness, family or work-related problems, or moving home, as well as 3 central symptom groups of intrusion, avoidance, and failure to adapt. A comprehensive list of proposed diagnostic criteria for AJD is given in [3]. Subtypes of AJD were specified in gross concordance with DSM-IV: depressed mood, anxiety, mixed emotional features, disorders of impulse control, and mixed or unspecified subtypes. One major characteristic of the new AJD model is that it can be diagnosed if other axis I disorders are present, in contrast to DSM-IV, which can only be diagnosed in the absence of other psychopathological syndromes.

The previous AJD study [3] explored the new AJD model in a clinical sample of patients with implanted cardiac defibrillators and showed its utility and provided the first evidence regarding its internal and discriminant validity. Seventeen percent of the patients met the AJD diagnosis.

The current study aims to estimate the point prevalence of AJD using the new criteria in a representative community sample. In addition, concurrent estimation of the prevalence or comorbidities of other stress-related disorders, particularly PTSD, or depressive disorders, particularly MDD, provides data on the distinctiveness and validity of the new AJD model. Data on the use of mental health care for the different assessed disorders should deliver further indicators of therapeutic consequences.

Section snippets

Sample and procedures

The Zurich Older Age Study on trauma-, bereavement-, and stress-related disorders [5], [6] provided the opportunity to investigate our research questions in a representative community sample. Recruitment took place in a 2-phase process. A random sample of the 65 512 older people in Zurich (65-96 years old) was provided to the authors by the residents' registration office of the city of Zurich. It was stratified for age, sex, and living situation (alone, with partner or family, in institution for

Adjustment disorder

Among the subjects, 52.1% had experienced an index stressor for AJD. Specifically, 20.4% reported a severe illness, 17.5% the illness of a relative, and 9.6% conflicts in the family (see Table 3for the frequencies of all categories). Sample cases for the category of “other stressors” were relocation, (nontraumatic) accidents, or worries about one's (adult) child. Men and women did not differ in most stressor categories, except for family conflicts (women, 11.9%; men, 6.6%; χ²₁ = 4.49 [n = 570];

Discussion

The main goal of this study was to estimate the prevalence of AJD—following a new psychopathological model [3]—in a representative sample of elderly persons. Fifty-two percent reported identifiable stressors or stressful events with potential relevance for adjustment problems or disorders. The overall prevalence of AJD was 2.3%, with the most frequent subtypes being mixed emotions, mixed emotions and impulse disturbance, anxiety and impulse disturbance, and the unspecified subtype. It is

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Adjustment disorder has three main subtypes: adjustment disorder with depressed mood, adjustment disorder with anxiety, and adjustment disorder with disturbance of conduct. The disorder is moderately heritable and has lifetime comorbidities with major depressive disorder (MDD), anxiety disorders, or risk-tolerant personality. However, it remains unclear whether the degrees of genetic correlations between adjustment disorder and other psychiatric disorders and intermediate phenotypes are similar or different to those between MDD, anxiety disorders or risk-tolerant personality and these other psychiatric disorders and intermediate phenotypes. To compare patterns of genetic correlations, we utilized large-scale genome-wide association study summary statistics for adjustment disorder-related disorders and personality trait, eleven other psychiatric disorders and fifteen intermediate phenotypes. Adjustment disorder had highly positive genetic correlations with MDD, anxiety disorders, and risk-tolerant personality. Among other psychiatric disorders, adjustment disorder, MDD, anxiety disorders and risk-tolerant personality were positively correlated with risks for schizophrenia (SCZ), bipolar disorder (BD), SCZ + BD, attention-deficit/hyperactivity disorder, and cross disorders. In contrast, adjustment disorder was not significantly correlated with risks for obsessive-compulsive disorder, Tourette syndrome, or posttraumatic stress disorder despite significant genetic correlations of MDD or anxiety disorders with these disorders. Among intermediate phenotypes, adjustment disorder, MDD, anxiety disorders, and risk-tolerant personality commonly had a younger age at first sexual intercourse, first birth, and menopause, lower cognitive ability, and higher rate of smoking initiation. Adjustment disorder was not genetically correlated with extraversion, although the related disorder and personality were correlated with extraversion. Only adjustment disorder was correlated with a higher smoking quantity. These findings suggest that adjustment disorder could share a genetic etiology with MDD, anxiety disorders and risk-tolerant personality trait, as well as have a disorder-specific genetic etiology.
A longitudinal resting-state functional connectivity analysis on trauma exposure and post-traumatic stress symptoms in older individuals
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Given the present demographic shift towards an aging society, there is an increased need to investigate the brain’s functional connectivity in the context of aging. Trauma exposure and post-traumatic stress disorder (PTSD) symptoms are factors known to impact healthy aging and have been reported to be associated with functional connectivity differences. In the present study, we examined and compared differences in within-default mode network (DMN), within-salience network (SN) and between-DMN-SN functional connectivity, between trauma-exposed individuals with and without PTSD symptoms as well as non-traumatized individuals in a non-clininical older adult sample. METHODS: Resting state functional MRI and behavioral data is taken from the Longitudinal Healthy Aging Brain Database Project (LHAB). For the present analysis, participants who completed the questionnaires on trauma exposure and PTSD symptoms (N = 110 individuals of which n = 50 individuals reported previous trauma exposure and n = 25 individuals reported PTSD symptoms; mean age = 70.55 years, SD = 4.82) were included. RESULTS: The reporting of PTSD symptoms relative to no symptoms was associated with lower within-DMN connectivity, while on a trend level trauma-exposed individuals showed higher within-SN connectivity compared to non-trauma exposed individuals. Consistent with existing models of healthy aging, between-DMN-SN functional connectivity showed an increase across time in older age. CONCLUSION: Present results suggest that alterations in within-DMN and within-SN functional connectivity also occur in non-treatment seeking older adult populations with trauma exposure and in association with PTSD symptoms. These changes manifest, alongside altered between-DMN-SN functional connectivity, in older age supposedly independent of aging-related functional desegregation.
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Older adults experience greater risk than their younger counterparts for mental health problems, including stress, depression, and anxiety. This chapter begins by describing the biological mechanisms and genetic susceptibility underlying the complex relationship between stress, aging, and mental health problems. Next, we discuss the associations between stress, aging, and objective and subjective cognitive functioning. We then review the literature on the impact of stress on depression, anxiety, and everyday functioning, using spousal Alzheimer’s disease caregivers and older veterans as use-case examples. In addition to stress as a risk factor for negative outcomes, we highlight the protective role of positive psychological traits, namely social support and resilience. Lastly, we describe evidence-based treatments to decrease stress and improve mental health in older adults.
Prolonged grief disorder: Its co-occurrence with adjustment disorder and post-traumatic stress disorder in a bereaved Israeli general-population sample
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Prolonged grief disorder (PGD) is a new disorder included in the WHO International Classification of Diseases 11th version (ICD-11). This study is the first to use these new ICD-11 PGD guidelines to examine prevalence rates, predictors of PGD and disorder co-occurrence with other stress-related disorders in a survey of 544 bereaved Israelis.
Descriptive statistics, correlation, linear regression and mediation analysis examined the validity of the ICD-11 diagnostic algorithm.
Prevalence of PGD in the Israeli population sample is low (2%). The prevalence rate of post-traumatic stress disorder (PTSD) was 7.2% and for adjustment disorder (AjD) was 17.8%. A significant positive correlation found between scores on these measures indicates concurrent validity. Mediation analysis found that symptoms of PGD were predicted by serious life events, and significantly mediated by symptoms of PTSD and AjD. A regression analysis found significant predictors of PGD symptom severity, including socio-demographic and person-specific predictors.
This study did not assess the index-death of the grief questionnaire. No conclusions could be made regarding the relationship between the type of loss and grief severity. Furthermore, the time since loss (time criterion) was not assessed.
This study is the first to examine prevalence rates of ICD-11 PGD in a population-based survey. The mediation relationship between serious life events, AjD, PTSD and PGD supports a vulnerability model of stress related disorders whereby the number of stressful life events may predict symptoms of stress related disorders.
Screening of adjustment disorder: Scale based on the ICD-11 and the Adjustment Disorder New Module
2018, Journal of Psychiatric Research
Citation Excerpt :
In addition, construct and convergent validation were conducted by correlation coefficients that were calculated between the various ADNM instruments and PTSD, CPTSD and complicated Grief. These stress related conditions are known to be related to AjD (Maercker et al., 2008). Finally, in order to examine the reliability of the various ADNM instruments measuring Adjustment Disorder, internal consistency was calculated for each instrument.
In line with ICD-11 new conceptualization of Adjustment disorder (AjD), a self-report Adjustment Disorder–New Module (ADNM) was developed and validated. Nevertheless, the ADNM-20 is a long research tool and potentially problematic in the use in epidemiological and clinical studies. The present study introduces the brief ADNM-8 and the ultra-brief ADNM-4, examines their validity and establishes cut-off scores for their clinical use. The study used a representative national sample of 1003 Israelis who reported on the ICD-11 stress spectrum ranging from AjD, PTSD, complex PTSD and complicated grief. Construct validity was assessed via confirmatory factor analysis and cut-off scores were established through ROC analysis. The original and brief instruments were highly correlated (r > 0.918 or better). Cronbach's Alpha for the Brief ADNM-8 and the Ultra-Brief ADNM-4 were above 0.800. Correlations with stress related conditions indicated a good convergent and construct validity for both instruments as well. The ultra-brief ADNM-4 was found to have a very good fit with the data.
These findings indicate that the brief ADNM-8 and the ultra-brief ADNM-4 can serve as a brief screening tools for assessing AjD symptoms according to the ICD-11 definition.
A systematic review of the association of anxiety with health care utilization and costs in people aged 65 years and older
2018, Journal of Affective Disorders
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For PTSS, higher use and costs for drugs, including antidepressants and benzodiazepines, were reported (Lamoureux-Lamarche et al., 2016). For full/subthreshold PTSD, no significant association with use of pharmacotherapy for mental problems was reported (Maercker et al., 2008). For PTSS, significantly higher physician fees were reported (Lamoureux-Lamarche et al., 2016).
In older people, anxiety disorders are among the most prevalent mental disorders and a high proportion suffers from clinically relevant anxiety symptoms. Despite studies suggesting an association of anxiety with health care utilization (HCU) and a resulting economic burden to the health care system, we found no review systematically analyzing evidence on this association in older people.
To analyze and synthesize evidence on the association of anxiety disorders and symptoms with HCU and costs in people aged 65 years and over in a systematic review.
A systematic search of peer-reviewed literature was conducted in three electronic databases. Additional references were identified through reference lists of included studies. Inclusion criteria were: studies reporting the association of anxiety disorders or symptoms with HCU or costs, specifically in people aged 65 years and over, with observational study design, in German or English language. Findings were synthesized qualitatively and study quality was assessed.
N = 15 studies (HCU n = 10, costs n = 5) were included in the final synthesis. Overall, studies either reported significantly increased HCU in anxiety disorders compared to a healthy comparison group/according to degree of symptoms, or found no significant association between these variables. Total excess costs for anxiety disorders ranged from -116 to 19,003 $PPP per year.
Differences in methodology limited the comparability of included studies.
Most studies suggest an increased economic burden due to anxiety in older people. Studies using standardized instruments are needed.

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Adjustment disorders, posttraumatic stress disorder, and depressive disorders in old age: findings from a community survey

Abstract

Introduction

Section snippets

Sample and procedures

Adjustment disorder

Discussion

Adjustment disorders. Fault line in the psychiatric glossary

Br J Psychiatry

Adjustment disorders as stress response syndromes: a new diagnostic concept and its first exploration in a medical sample

Psychopathology

Stress response syndromes

Comparison of two diagnostic systems for Complicated Grief

J Affect Disord

Psychotherapy service utilization and psychotherapy motivation in a representative community sample of the elderly—results of the Zurich older age study

Psychother Psychosom Med Psychol

The Structured Clinical Interview for DSM-III-R personality disorders

J Personal Disord

DIA-X-Interviews: Manual für Screening—Verfahren und Interview

Short screening scale for DSM-IV posttraumatic stress disorder