Adjustment Disorders in Medically Ill Inpatients Referred for Consultation in a University Hospital

Adjustment Disorders in Medically III Inpatients Referred for Consultation in a University Hospital K. POPKIN. M.D. L. CALLIES. B.A.

MICHAEL ALLAN

EDUARDO A. COLON. M.D. VICTOR STIEBEL. M.D.

The study examined medical records of 121 medical-surgical illpatil'llts diagllOsl'd with adjustmellt disorder hy psychiatric cOl1Sultallts in a ullil'ersity hospital. Medical illlless was the primary stressor. e\'(/king the maladaptil'e reaction in H3 (6R.6lJc) cases. These patiellts were largelyji-ee ofpreceding psychiatric prohlems. sufferillg protracred hospitali:atiollsfor adrallced illnesses. particularly malignancy and diahetes: ill cOlltrast.the 3H (3/Ao/c) patients whose adjustmellt disorder was precipitated hy a stressor Olher thall medical illlless had estahlished psychiatric histories and recurrellt prohlems with relatiollships orfillances. The data suggest that in the medically ill. idelltifyillg the primary stressor producing all adjustmellt disorder is more instrucri"e than!()cusing UpOIl "predominant" symptomatology and "suhtypes."

aligned in past years as a "wastebasket" by some investigators. ' the diagnostic category of adjustment disorders has received surprisingly little systematic investigation. In 1982 Andreasen and Hoenk~ found the category to have "at least descriptive and face validity" among adults (but only "panially" so among adolescents). Despite the paucity of formal studies of the category. clinicians have long recognized its utility. It has traditionally referred to short-term disturbances of non psychotic proportions that are provoked by an explicit stressor or stressors.' The

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Received June 26. 19l\9: revised October 31. 19l\9: accepted November 9. 19l\9. From the Depanmenls of Medicine and Psychiatry. University of Minnesota Medical School. Minneapolis. Address reprint requesls to Dr. Popkin. Box 345. Mayo Building. Universily Hospitals.420 Delaware Street. S.E.. Minneapolis. MN 55455. Copyright © I'NO The Academy of Psychosomalic Medicine.

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framework is drawn exclusively in psychological terms; adjustment disorders entail one or more untoward or maladaptive psychogenic responses to specific. if sundry. insults (including medical illness). DSM-II1-R introduced a new criterion for the category consisting of a maximal duration of 6 months. with the intent of excluding cases "whose chronicity is inconsistent with the construct of a transient reaction to psychosocial stress.·.. In the consultation psychiatry setting. prior investigations'7 have reported that the diagnosis of adjustment disorder is assigned to between 9 and 21 percent of medical-surgical patients referred for psychiatric intervention. In most studies. adjustment disorder is the third most frequent consultation-liaison diagnosis (after organic mental disorder and affective disorder). In a collaborative three-site study." the prevalence of adjustment disorder in a random sample of newly hospitalized cancer patients was reponed at 32lJc. PSYCHOSOMATICS

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(These patients were not referred for psychiatric consultation. ) Despite such prevalence rates, cases of adjustment disorder in medical-surgical patients have received surprisingly little scrutiny. We sought in a retrospective study to examine a series of cases assigned the diagnosis of adjustment disorder by psychiatric consultants in the medical-surgical inpatient setting. We were particularly interested in comparing cases in which the medical illness was identified as the primary stressor and cases in which a stressor other than the medical illness was judged to be central to the condition.

tem (CLOES) methodology,9 these groups were compared on a variety of parameters including demographics, psychiatric history. characteristics of the consultation, and characteristics of the hospitalization. Groups I and 2 were also compared to those cases in which a patient with a major medical illness was assigned a primary psychiatric diagnosis other than adjustment disorder. This comparison group of cases was drawn from the most recently completed update of the CLOES data base (January 1982 through July 1983) available at the time of the study. Comparisons were effected using t tests for continuous data and chi-square tests for discrete data.

METHODS

RESULTS

Using service records, we reviewed a series of consultations performed by the adult consultation psychiatry service between January 1982 and December 1984 at the University of Minnesota Hospital. The consultations were done by psychiatry residents and staffed by the service's fellows and attending physicians. All cases assigned a diagnosis of adjustment disorder by the consultants were identified, and the medical records reviewed. Entries of the psychiatric consultants were used to determine whether the patient's medical illness constituted the primary cause of the "maladaptive" reaction. Cases were then categorized as adjustment disorder with medical illness as primary stressor (Group I) or adjustment disorder with primary stressor other than medical illness (Group 2). Patients with adjustment disorder and no identified medical illness were assigned to Group 2. For example, when a record noted "patient is having extreme difficulty adjusting to his illness (osteosarcoma, right distal femur) and is without suitable coping mechanisms and with minimal support systems," a Group I assignment was made. When another record noted, "patient indicates that family conflicts over his relationship with girlfriend have resulted in suicidal thoughts," a Group 2 assignment was made. (This patient had been hospitalized for chronic renal failure secondary to Type I diabetes.) Using the Consultation-Liaison Outcome Evaluation Sys-

Between January 1982 and December 1984, a total of 1,048 consultations were performed by the adult psychiatry service (excluding repeat consultations for the same patient, and consultations involving patients routinely evaluated for bone marrow or pancreas transplantation). Of the 1,048 cases, 134 (11.5%) were assigned a diagnosis of adjustment disorder by the psychiatric consultants. To increase consistency with criteria set forth in DSM-III-R (which was not in routine use at the time the consultations were done), cases in which the duration of the adjustment disorder exceeded 180 days at the time of consultation (n= 13) were excluded from further analysis. The final sample consisted of 121 cases. Thirty-one (26%) of the 121 cases had a prior psychiatric history. Only three patients (2%) had previously received a diagnosis of adjustment disorder. In 83 (68.6%) of these cases, the patient's medical illness was determined to be the primary stressor (Group I). Of these 83, 30 (36.1 %) had neoplastic disease, 14 (16.9%) had diabetes mellitus, and the remaining 39 (47%) had a variety of other illnesses. A total of 38 (31.4%) cases of adjustment disorder were assigned to Group 2 because the primary stressor was other than medical illness. These stressors were problems in marriage or major relationship (including divorce) (n=14), job loss or financial problems

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(11=7), illness or death of family members or friends (11=5), children moving away from home (11=3), change of residence (11=3), job stress (11=2), difficulties with other family members or friends (11=3), and assault (11= I).

Of the 83 patients in Group I. 75 (90%) evidenced prominent depressive features, resulting in the diagnostic subtyping of adjustment disorder with depressed mood or adjustment disorder with mixed emotional features. At the time of psychiatric consultation. 76% of Group I had had the adjustment disorder for less than a month. The mean age for Group I patients was 45, and 45 (54%) were male. A total of 73% had had previous University of Minnesota hospitalizations. For those cases (11=54) in which the medical record objectified outcome. the adjustment disorder resolved in 66.7%. Of these cases, 65% resolved within 30 days of initial consultation. In the remaining cases, no evidence was found in the record of resolution of the mood disturbance. When Group I was compared to the 38 Group 2 cases. a number of significant differences were found. Group I patients were more likely than Group 2 patients to be male (54% and 24%, respectively; p=.OO3); were more likely 10 have malignancy (36% and 8%, respectively; p=.0(3); were less likely to have a psychiatric history (19% and 39%. respectively; p=.033); and had longer mean length ofhospitalization (37 days and 12 days. respectively; p<.OO I). Differences in treatment between the groups were also identified. Recommendations for psychotropic medication were more often made for Group I patients than for Group 2 patients (51 % and 16%, respectively; p<.OOI); follow-up visits were more often effected (82% and 63%. respectively; p=.(44); and consultations other than psychiatry were more common (76% and 29%; p<.OO I). Notably, concordance rates for psychotropic drug recommendations, diagnostic recommendations. and representation of psychiatric diagnoses did not differ for the two groups of patients. A total of 297 patients with established major medical illnesses and a primary psychiatric diagnosis other than adjustment disorder were identified in the January 1982-June 1983

CLOES database update. When the group of patients with adjustment disorder with medical illness as primary stressor were compared to this group of general consults. several differences were found. The distribution of primary medical diagnoses differed significantly (X~= 18.63; df=2; p<.OOI). Patients with adjustment disorder had higher rates than the comparison group of neoplastic disease (36% and 20%) and diabetes mellitus (17% and 8 Ck) and a lower rate of other illnesses (47% and 72 Ck). The adjustment disorder group was also more likely than the comparison group to have had a previous University of Minnesota hospitalization (73% and 54%; p=.OO2). A somewhat higher percentage of males was observed in the adjustment disorder group than in the comparison group (54% and 42%; p=.058). and fewer patients in the former group had a psychiatric history (19% and 44%; p<.OO I ). While the frequency of psychotropic drug recommendations was similar in the two groups (51 ck and 49%). concordance was decreased in the adjustment disorder group (61 % and 79%; p=.028). In contrast, diagnostic recommendations were less frequently offered for the adjustment disorder group than for the comparison group (31 % and 52%; p=.OO2), although concordance rates did not significantly differ (38% and 51%). When the Group 2 cases of adjustment disorder were compared to the general consult group (11=297). several variables showed differences. The Group 2 patients were younger (mean age. 39.6 years); more likely to be female (76% vs. 58% in the comparison group; p=.(49); referred earlier for consultation (4.9 and 13.4 days. p<.OO I); and hospitalized for briefer periods (12.3 and 28.1 days; p<.OO I). They were less likely than the comparison group to have previously been treated with a psychotropic (21 % and 40%; p=.(39); less likely to be currently receiving a psychotropic (3% and 19%; p=.(25); and less likely to receive a recommendation for a psychotropic from the consultant (8% and 39%; p<.OO I ). Group 2 patients received fewer followup visits than the comparison group (63% and 82%; p=.022) and fewer nonpsychiatric consultations (29 Ck and 69%; p<.OOI). No differences PSYCHOSOMATICS

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were found between Group 2 and the general consult group in the distribution of primary medical diagnosis, history of psychiatric illness, familial psychiatric history, or concordance with psychotropic or diagnostic recommendations. Group I and the consult group did differ significantly on these parameters. DISCUSSION The data reported by this study reconfirm that the diagnosis of adjustment disorder is used frequently by psychiatric consultants working in the medical-surgical inpatient setting. They further indicate that consultants' use of the diagnosis in medical inpatients encompassed two cohorts with distinctive features and associated with differences in treatment and clinical management. Subtypes of adjustment disorder are presently classified in DSM-III-R by the nature of "the predominant clinical symptoms." Since the study included only patients referred for psychiatric consultation, it does not address the actual prevalence of adjustment disorders in the medically ill or examine the full distribution of subtypes in that population. Several investigators 10.1 I have indicated that consultees refer only a portion of patients with psychopathology for consultation. The referral patterns observed here may signal consultees' tolerance of certain symptomatology, their failure to recognize certain symptomatology; or their willingness to manage certain symptomatology without psychiatric assistance. Alternatively, the range of nine subtypes of adjustment disorder listed in DSM-III-R may not be encountered in the medically ill. Conservatively, our data suggest that in the medically ill referred to psychiatry, attention to the identification of the primary stressor evoking the adjustment disorder may have more utility than focusing on "predominant symptomatology." In two-thirds of the study's cases, the patient's medical illness was judged to be the primary stressor evoking the maladaptive reaction. These cases (Group I) almost invariably were characterized by depressive features or "mixed emotional features" (e.g., depression and VOLUME 31· NUMBER 4· FALL 199(}

anxiety). In very few instances did the consultant use a diagnosis of adjustment disorder with anxious mood. Group I cases tended to emerge acutely in patients (male more often than female) without preceding psychiatric histories. These patients had experienced repetitive, protracted medical-surgical hospitalizations for advanced illnesses, particularly malignancy and diabetes. The extent of their emotional or psychiatric distress was reflected in the clinicians' and consultants' liberal use of psychotropics (despite the absence of studies or data showing the merits of such interventions). Medical records showed prompt resolution in approximately two-thirds of the Group I cases. Of 28 patients started on a psychotropic medication at the consultant's suggestion, 15 received an antidepressant. In these 15 trials, four patients (27%) responded favorably, four patients (27%) failed to respond, and three patients (20%) were taken off the drug due to side effects. In the remaining cases (27%), the record did not clarify the outcome of the trial. The data do not permit firm conclusions about psychotropics in the management of medically ill patients with adjustment disorder. The second group of patients assigned the diagnosis of adjustment disorder were those whose primary stressor was judged to be other than the medical illness. Most often, the stressor involved disruption of a major interpersonal relationship or a problem with work or finances. In contrast to Group I, this cohort was characterized primarily by women with established psychiatric histories. Thirty-nine percent of Group 2 patients had a preceding psychiatric history, compared with only 19% of Group I. Of the Group 2 patients with a psychiatric history, fewer than a third had a prior depressive disturbance, and the majority had anxiety, personality, or somatoform disorders. In contrast, over half of the Group I patients with a prior psychiatric condition had been depressed, and none were noted to have personality or somatoform disorders. Clinicians and consultants were both loath to intervene with psychotropics in this group. In short, Group 2 appears to have been made up of individuals with recurrent emotional 413

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problems, largely independent of their medical difficulties. Arguably, their psychiatric problems may have contributed to or facilitated their physical illnesses. Looking ahead to DSM-IV, it is probable that the category of adjustment disorder will require extensive revision, especially in tenns of the current roster of subtypes. We believe more attention should be directed to the nature of the precipitating stressors. We are inclined to conceptualize adjustment disorder as a psychological burden or insult that prompts, if briefly, an aberration of autonomic regulation or emotional lability. This aberration is similar to the effects of transient sleep deprivation, being "overloaded" on caffeine, anxiety regarding perfonning in public, or feeling distraught by a loss or bereavement. In the medically ill hospitalized patient, this disruption of autonomic and emotional regulation may relate to any of a number of factors, including the uncertainty surrounding the physical illness, its treatment, and its course: issues of dependency, regression, and infantilization associated with hospitalization: and physiological concomitants of the illness and its treatment. "Maladaptive responses" may resolve with c1ar-

ification, improvement of the medical status, closure of the hospitalization, or a process of accommodation (with or without psychotropic medication). Of note, only three subjects in our study (2%) had been previously assigned a diagnosis of adjustment disorder. A small number of "maladaptive responses" may evolve toward a more pronounced psychiatric disturbance (such as major depression). This study suggests the pressing need for further investigation of patients assigned the diagnosis of adjustment disorder in a range of settings. The diagnosis is commonly used, yet we know surprisingly little regarding its course or the effectiveness of intervention (both psychological and phannacological). We believe the diagnosis merits attention, especially as it is used in the psychiatric outpatient setting: comparisons of its use with psychiatric outpatients to its use with patients such as those in Groups I and 2 would be instructive-they might shed light on medical illness as a possibly unique, if heterogeneous, stressor. Comparisons with patients diagnosed as having secondary (organic) mood syndrome would be similarly of interest.

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