When stressful situations arise, many people seek help from a therapist to manage the symptoms that occur. After experiencing a job loss, a move to a new home, or a broken leg, people can develop a variety of symptoms ranging from sadness or anxiety to behavior problems that warrant the assistance of a mental health professional to process emotions and offer coping skills. Clients must be diagnosed with a mental disorder in order for therapists to bill insurance companies for providing those necessary services, and Adjustment Disorder is often the default diagnosis therapists use under these circumstances. However, using this diagnosis as a catch-all can be dangerous, both for treatment planning if it is not accurate and for professional ethics for misusing a diagnosis for billing purposes.
According to the Diagnostic and Statistical Manual (DSM-IV-TR), an Adjustment Disorder diagnosis is warranted when there is a clinically significant development of emotional or behavioral symptoms that occur within three months of the onset of an identifiable stressor. The symptoms do not meet the same level of distress as another diagnosable condition (such as a Major Depressive Episode) and is not a worsening of an existing diagnosable condition (such as someone already experiencing a Major Depressive Episode that feels even worse as a result of a specific stressor).
Adjustment Disorders fall into six different categories:
- With Depressed Mood – most symptoms related to sadness, tearfulness, or hopelessness
- With Anxiety – most symptoms related to nervousness, worry, or restlessness
- With Mixed Anxiety and Depressed Mood – symptoms combine depression with anxiety
- With Disturbance of Conduct – most symptoms related to violating rules and societal norms
- With Mixed Disturbance of Emotions and Conduct – symptoms combine mood and behavioral elements
- Unspecified – symptoms that do not fall into another category such as physical complaints, non-depressive isolation, and problems at work or school
When seeking support from a mental health professional, understanding which form of adjustment disturbance is taking place is crucial to developing an appropriate treatment plan.
Much of the misuse of the Adjustment Disorder diagnosis lies in the qualifier “clinically significant.” In order to qualify as a “clinically significant” symptom, the amount of distress experienced must be greater than what would normally be expected given the nature of the stressor. For example, sadness and grief over the loss of a loved one would be an expected reaction, so symptoms related to bereavement do not constitute an Adjustment Disorder diagnosis.
Because the symptoms of Adjustment Disorders can resemble other mental disorders, it is important for an accurate diagnosis to be made prior to developing a plan for treatment. While the depressive symptoms of either a Major Depressive Episode and Adjustment Disorder with Depressed Mood may look similar, there are other important factors to consider when providing treatment to the person as a whole. For example, some forms of depression are endogenous (biology-based) rather than exogenous (situation-based), which impacts whether or not adding a prescription antidepressant would be helpful. Medication is rarely appropriate to prescribe for Adjustment Disorder because the symptoms resolve when the stressor is gone or coping skills are developed. It is essential for therapists to perform a comprehensive evaluation in order to determine the most appropriate diagnosis to then guide treatment.
Although many of the people who seek out therapeutic services do carry legitimately diagnosed mental conditions, others wish to seek treatment and would benefit from therapy who are diagnostically sub-threshold. For example, a person who is experiencing sadness following a long-term relationship breakup may be experiencing a reasonable level of distress given the nature of the situation; a typical person would feel sad and upset when a relationship ends, and as long as the person continues to function as he or she normally would (by going to work, eating normally, and getting enough sleep), a mental health diagnosis would not be appropriate. However, in order for that person to seek the support of a therapist, a diagnosis of Adjustment Disorder would typically be given for no other reason than to convince that person’s insurance company to reimburse services.
For most insurance companies today, there is not an option for members to seek mental health services unless they are diagnosed with a mental disorder. If insurance companies were willing to develop a new billing option that allowed their members to utilize therapeutic services without requiring a mental health diagnosis, people could have opportunities to develop coping skills to better manage stressful situations before they arise. This skill building and symptom management could prevent the development of an actual mental disorder and avoid higher costs of emergency services such as crisis visits, longer-term therapy, and inpatient admissions.
Reference
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
