Adjustment disorder and the course of the suicidal process in adolescents

doi:10.1016/j.jad.2005.04.009

Journal of Affective Disorders

Volume 87, Issues 2–3, August 2005, Pages 265-270

https://doi.org/10.1016/j.jad.2005.04.009 Get rights and content

Abstract

Background

Adjustment disorders are often associated with suicidal behaviour but there is little information regarding the nature of the relationship and the effect of adjustment disorders on the suicidal process. The authors' goal was to investigate the association of adjustment disorders (with depressed mood) and suicide in adolescents by means of a psychological autopsy study.

Method

Relatives and other informants of 19 suicide victims were interviewed by means of a semi-structured interview schedule. Differences in duration of the suicidal process between suicide victims diagnosed with adjustment disorder and suicide cases diagnosed with other psychiatric disorders were examined.

Results

The suicidal process was significantly shorter in suicide victims diagnosed with adjustment disorder compared with suicide cases diagnosed with other disorders. No indications of a history of emotional or behavioural problems during early adolescence were found in suicide cases diagnosed with adjustment disorder.

Limitations

The study sample consists of a small sample size and retrospective interviews of relatives were used.

Conclusions

The suicidal process in suicide victims diagnosed with adjustment disorder appears to be short and rapidly evolving without any prior indications of emotional or behavioural problems. The importance of assessing the suicidal risk in patients diagnosed with adjustment disorder is underlined.

Introduction

A review of the literature regarding adjustment disorders indicates that there are relatively few studies of the disorder with additional difficulties in establishing its construct validity (Kovacs et al., 1994, Newcorn and Strain, 1992). Nonetheless, the diagnosis of adjustment disorder is frequently made with an estimated incidence of 5–21% in psychiatric consultation services for adults (Jones et al., 1999). Although there is less information regarding the estimated incidence of adjustment disorder in adolescents, there are several reports indicating that adjustment disorder is more often found in young people (Despland et al., 1995, Snyfer et al., 1990).

Adjustment disorders are typically associated with less severe symptoms, a lower level of impairment and a reasonably good short-term prognosis when compared to other psychiatric disorders (Greenberg et al., 1995, Kovacs et al., 1994). However, there is a high association between adjustment disorders and suicidal behaviour. Adjustment disorder with depressed mood is the most common diagnosis in suicide attempts in young people (Bhatia et al., 2000, Ho Kong Wai et al., 1999, Skopek and Perkins, 1998). With regard to fatal suicide, there is however more evidence of the high prevalence of major depression and substance abuse. Nonetheless, psychological autopsy studies have shown a prevalence of adjustment disorder among suicide victims ranging between 5% and 36% (Cavanagh et al., 1999, Schaffer et al., 1996, Henriksson et al., 1993, Marttunen et al., 1991, Rich et al., 1990).

Adjustment disorder is thus a relatively common diagnosis among suicide attempters and suicide victims. However, little is known about the effect of this diagnosis on the suicidal process and thus on the possibilities to prevent suicide, particularly among young people. The concept of the suicidal process is used to describe the onset and development of suicidality as a process within the individual and in interaction with surrounding people. The suicidal process starts with suicidal ideation and implies a progression of suicidality which can evolve through ideation, plans about taking one's life and communication regarding suicidal ideation, and growing through often recurrent suicide attempts with increasing lethality and suicide intent, and ends with fatal suicide (van Heeringen, 2001). More knowledge regarding the suicidal process and adjustment disorder could be crucial for the development of prevention strategies and for clinical practice.

The psychological autopsy study of Runeson et al. (1996) in 15–29 year olds is, to our knowledge, the only study examining the suicidal process in young people according to psychiatric disorder. The results showed that there were no differences in duration of the suicidal process between adjustment disorder and major depression but differences could be found between adjustment disorder and schizophrenia. The duration of the suicidal process was however measured by the time interval between the suicide and first reported suicidal communication or observed attempt, which can not be considered as the starting-point of the process.

This study aimed at further establishing the effect of adjustment disorder on the course of the suicidal process, measured from the starting-point, and examining the possible differences with other psychiatric diagnoses.

Section snippets

Method

The data was provided by a case-control psychological autopsy study. For the purpose of the present study, only data regarding suicide cases will be discussed. Inclusion criteria regarding suicide cases included: relatives or other informants of adolescents (aged 15–19) with a definitive verdict of suicide in Flanders (Dutch-speaking part of Belgium) during 1997–2001. A total of 32 relatives and other informants regarding 19 adolescent suicide victims were recruited from support-groups for

Results

All suicide cases were diagnosed with a ICD-10 psychiatric disorder at the time of death. The most common disorders were affective disorders (N = 13; 68.5%) including 12 subjects (63.2%) with a depressive episode and one subject with bipolar affective disorder, current episode mixed. Adjustment disorder with depressed mood was diagnosed in four suicide victims (21.1%) as principal diagnosis with only one subject diagnosed with co-morbid substance abuse.¹

Discussion

This study showed that one fifth of all suicide cases were diagnosed with adjustment disorder with depressed mood. More importantly, the results indicate the incidence of a very short suicidal process in victims diagnosed with adjustment disorder with an average duration of 3 months between the first signs of suicidal ideation and the suicide, a mean duration of 2 months between the first communication and the suicide and without a history of previous suicide attempts. There were also no

Acknowledgements

The study was supported by the Fund for Scientific Research—Flanders (Belgium).

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Le trouble de l’adaptation est considéré comme un trouble secondaire et invisible selon certains cliniciens. La méconnaissance de la symptomatologie, sa proximité avec le syndrome dépressif ou anxieux et le diagnostic d’exclusion évoqué au sein du DSM-IV permettent d’expliquer ce relatif désintérêt de la part des médecins. Cet article vise, d’une part, à rendre compte des spécificités de ce trouble après avoir parcouru la littérature et, d’autre part, à faire apparaître les premières réactions liées à la nouvelle catégorisation proposée par le DSM-5. Un diagnostic de trouble de l’adaptation bien posé permet un traitement (psychothérapie) adapté et une revalidation rapide.
This paper exposes the complexity and discrete characteristic of the adjustment disorder with reference to its clinical and scientific diagnosis. Even though the disorder occurs in frequent clinical circumstances after important life events, such as mobbing, burn-out, unemployment, divorce or separation, pregnancy denial, surgical operation or cancer, the adjustment disorder is often not considered in the diagnosis since better known disorders with similar symptoms prevail, such as major depression and anxiety disorder. Ten years ago, Bottéro had already noticed that the adjustment disorder diagnosis remained rather uncommon with reference to patients he was working with while Langlois assimilated this disorder with an invisible diagnosis.
In order to maximize the data collection, we used the article review below and challenged their surveys and results: National Center for Biotechnology Information (NBCI – Pubmed) for international articles and Cairn.info for French literature. Moreover, we targeted the following keywords on the search engine and used articles, which had been published from 1 February 1975 to 31 January 2015: “adjustment”, “adjustment disorder” and the French translation “trouble de l’adaptation”.
One hundred and ninety-one articles matched our search criteria. However, after a closer analysis, solely 105 articles were selected as being of interest. Many articles were excluded since they were related to non-psychiatric fields induced by the term “adaptation”. Indeed, the number of corresponding articles found for the adjustment disorder literally pointed-out the lack of existing literature on that topic in comparison to more known disorders such as anxiety disorder (2661 articles) or major depression (5481 articles). This represents up to 50 times more articles in comparison to the number of articles we found on adjustment disorder and up to 20 times more articles for the eating disorder (1994), although the prevalence is not significantly higher than for the adjustment disorder. According to their relevance and their content, we have split the articles into seven subcategories: 1. General description: most scientific articles generally describe the adjustment disorder as being a transition diagnosis, which is ambiguous, marginal and difficult to detect. The findings claim that only a few studies have been conducted on the adjustment disorder despite a high prevalence in the general population and in the clinical field. 2. Classification: the DSM-5 defined the adjustment disorder as a set of different outcomes and syndromes induced by stress after a difficult life event. While the link to other disorders has not been mentioned, the diagnosis of this disorder is no longer excluded or perceived as a secondary diagnosis. The DSM-5 faced criticism from three points of view: the operationalization of the concept of stress, the differential diagnosis and the description. 3. Prevalence: different samples have shown a significantly high prevalence of the adjustment disorder within the population. In addition to the psychiatric pain induced by difficult life events we need to emphasize the fact that 12.5 to 19.4 percent of the patients faced heavy and severe pathologies and depended on clinical care and treatment. 4. Etiology, comorbidity or associated symptomatology: the literature identified the tendency to commit suicide and stressful life events as being two fundamental characteristics of adjustment disorder. The third one is the personality profile. 5. Differential diagnosis: that motivates researchers to focus on the adjustment disorder: the differentiation approach as to the major depression. Indeed, the aetiology, the symptomatology and the treatment differ from the adjustment disorder. 6. Assessment: very recently, Dutch researchers have developed and validated the Diagnostic Interview Adjustment Disorder (DIAD). 7. Treatment: in 2014, no data or meta-analysis recommended drug treatment in addition to therapy. In fact, several authors have demonstrated the ineffectiveness of drug therapy. The literature suggests a psychotherapeutic approach to treat adjustment disorder.
Emotional reactions triggered by life events are responsible for full therapy agendas and for the rush in emergency rooms and hospitals. The reflex when faced with crying, insomnia or suicidal thoughts to give a diagnostic of major depressive disorder s is generally accepted by everyone. The elevated risk to commit suicide and the approved success of remission or healing through treatment (psychotherapy) are two major reasons why several studies promote the importance and the need to identify the adjustment disorder of our patients.
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Little is known about suicidal ideation and behaviours in adjustment disorder (AD). In this paper we sought to examine the variables independently associated with suicidal ideation and behaviour in patients diagnosed with AD or depressive (DE) episode among psychiatric outpatients and in liaison psychiatry.
370 patients who were referred to the liaison psychiatry services (including those seen in the Emergency Department) at 3 Dublin hospitals, and were clinically diagnosed with either DE or AD, based on the ICD 10 diagnostic criteria, were recruited to the study. We examined their demographic and clinical characteristics, and the associations between these and suicidal ideation and behaviour on multivariate analysis.
Younger age, single marital status, and greater severity of depressive symptoms were significantly associated with suicidality across both diagnoses. On multivariate analysis, greater severity of depressive symptoms was associated with suicidality in those with AD (p=0.012) and DE (p=0.009). Those with AD exhibited suicidality at lower symptom scores than did those with DE but in both groups it still occurred at the highest level of severity. There were differences in the objective circumstances measure of suicide intent.
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The coefficient (r = .84) was very high, indicating a good concurrent validity of the two scales of the two inventories. Previous studies have identified the high risk of suicidal tendency in adolescence [22,24], in particular in individuals with AD diagnosis [17–20]. However, studies with AD patients have only used clinical data to identify suicidal tendencies.
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Ninety-seven adolescents with AD were recruited at a public mental health center and included in the AD sample; they were administered the Inventario de Riesgo Suicida para Adolescentes (Suicide Risk Inventory for Adolescents-IRIS) and the Millon Adolescent Clinical Inventory (MACI). Ninety-nine community adolescents were recruited and administered the IRIS inventory. The community sample works as a contrast group.
Girls with AD show higher levels of suicidal symptoms than boys on both the IRIS Suicidal Ideation and Intention scale (t = 8.15, p < .001) and the MACI Suicidal Tendency scale (t = 6.6, p < .001). Girls with AD scored significantly higher than girls from the community contrast group sample in the IRIS Suicidal Ideation and Intention scale, but boys with AD presented no differences with regard to boys form the community contrast group sample. Compared with normative clinical samples of the MACI, no differences in the Suicidal Tendency scale scores were found between AD and normative girls, but AD boys showed significantly lower mean scores than normative boys. Suicidal symptoms were presented by 27% of girls and 18% of boys, although only 6% of the girls and none of the boys presented clear suicidal tendencies.
Considering suicidal tendencies in adolescents with Adjustment Disorder is important—especially in girls, who present high suicidal tendencies in relation both to boys and to community peers and the normative clinical population.
How do adolescents with Adjustment Disorder cope with stressful situations? Relationship with suicidal risk
2020, Revista de Psiquiatria y Salud Mental
Citation Excerpt :
Numerous studies have established the relationship between AD and suicide risk, since suicidal behaviour (understood as the presence of suicidal thoughts, plans or attempts and the suicide itself5) is linked to an individual's reaction to a stressor or stressors that have triggered the symptom.1,6,7 One fifth of all adolescents who committed suicide could be diagnosed with AD.8 Previous work on almost the same population participating in the current study (Spanish adolescents with AD) established that 27% of girls and 18% of boys presented suicidal ideation (thoughts about intentional self-injury or death) and intention (desire to commit self-harm and suicide).9
Little is known about the role of coping in relation to suicidal risk in adolescents with Adjustment Disorder (AD). The present study aimed to assess the relation between suicidal ideation and intention and coping strategies in a clinical sample of adolescents with AD, paying special attention to gender differences.
Self-reported questionnaires about suicidal ideation and intention and coping strategies were administered to 108 adolescents with an AD diagnosis.
Compared with the normative population, adolescents with an AD diagnosis made more use of Acceptance-Resignation (an avoidance-type coping strategy) and less use of Positive Reappraisal (an approach-type coping strategy). Nevertheless, gender introduced some peculiarities. A relationship was observed between the use of certain coping strategies and suicidal ideation and intention, but with notable differences depending on gender: significant and high correlations were found between these two variables in AD boys, both in the total approach score (r = .53, p < .01) and in the total avoidant score (r = .60, p < .01), with coping strategies explaining 41% of suicidal ideation and intention; in girls, in contrast, the only significant relationship was with an avoidant strategy, Emotional Discharge (r = .25, p < .05), although it had low explanatory power.
Coping strategies must be taken into consideration when assessing and treating adolescents with AD at risk of suicide, especially in the case of boys. The absence of association between coping strategies and suicidal risk in girls is discussed, and some therapeutic proposals are presented.
Existe escasa información sobre la función del afrontamiento en relación con el riesgo suicida en adolescentes con trastorno adaptativo (TA). El presente estudio analiza la relación entre la ideación e intencionalidad suicida y las estrategias de afrontamiento en una muestra clínica de adolescentes con TA, enfatizando diferencias de género.
Se aplicaron cuestionarios autoinformados sobre ideación suicida y sobre estrategias de afrontamiento a 108 adolescentes con diagnóstico de TA.
En comparación con la población normativa, los adolescentes diagnosticados con TA utilizaron en mayor medida la aceptación-resignación (una estrategia de tipo evitativo) y menos la reevaluación positiva (una estrategia de aproximación). Sin embargo, el género introdujo algunas peculiaridades. Se detectó relación entre el uso de algunas estrategias de afrontamiento y la ideación e intencionalidad suicida, pero con importantes diferencias dependiendo del género: en los chicos con TA se encontraron correlaciones altas y significativas entre estas dos variables, tanto con el global de estrategias de aproximación (r = 0,53; p < 0,01) como de evitación (r = 0,60; p < 0,01), explicando las estrategias de afrontamiento el 41% de la ideación e intencionalidad suicida. Por el contrario, en las chicas con TA la ideación e intencionalidad suicida solo se relaciona con la estrategia evitativa de descarga emocional (r = 0,25; p < 0,05), que, además, tiene escaso poder explicativo.
Es importante tener en cuenta las estrategias de afrontamiento cuando evaluamos y tratamos adolescentes con TA con riesgo de suicidio, especialmente en los chicos. Se discute la ausencia de asociación entre las estrategias de afrontamiento y el riesgo suicida en las chicas, y se aportan algunas explicaciones, así como propuestas terapéuticas.

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Research reportAdjustment disorder and the course of the suicidal process in adolescents

Abstract

Background

Method

Results

Limitations

Conclusions

Introduction

Section snippets

Method

Results

Discussion

Acknowledgements

Compr. Psychiatry

Gen. Hosp. Psych.

J. Affect. Disord.

Eur. Psychiatr.

J. Affect. Disord.

Psychosocial profile of suicide ideators, attempters and completers in India

Int. J. Soc. Psychiatry

The psychological autopsy: methodological considerations for the study of adolescent suicide

Suicide Life-Threat. Behav.

Suicide and undetermined death in south east Scotland. A case-control study using the psychological autopsy method

Psychol. Med.

Adjustment disorder as an admission diagnosis

Am. J. Psychiatry

Research report
Adjustment disorder and the course of the suicidal process in adolescents