Clinical Practice Guideline
for
ADJUSTMENT DISORDER
Developed for the
Aerospace Medical
Association
by their constituent
organization
American Society of
Aerospace Medicine Specialists
Overview: Adjustment
disorders are characterized by the development of clinically significant
emotional or behavioral symptoms in response to an identifiable psychosocial
stressor or stressors. These symptoms
are clinically significant if marked distress is in excess of what would be
expected from exposure to the stressor or there is significant impairment in
social or occupational functioning. The
symptoms should not represent bereavement for the death of a loved one but, may
be considered as an adjustment disorder if the reaction is in excess of, or
more prolonged than, would be expected.
Adjustment disorders can be viewed as a function based disorder
(inability to maintain role function) whereas, major depression is seen as a
symptom-based diagnosis (5 of 9 specific symptoms for more than two weeks) (3). An adjustment disorder
must begin within three months of the onset of a stressor and resolve within
six months of the termination of the stressor or its consequences. Adjustment disorders may be either acute or
chronic. Chronic adjustment disorders
are characterized by the persistence of symptoms for six months or longer in
response to an enduring stressor or its consequences. Stressors may be a single event or there may
be multiple stressors. Stressors may be
recurrent or continuous. If the
disturbance meets the criteria for another Axis I disorder or is an
exacerbation of a preexisting Axis I or II disorder, the diagnosis of
adjustment disorder should not be used.
Adjustment
disorders are classified by the subtype that best characterizes the predominate
symptoms:
A) With depressed mood - when the
symptoms are depressed mood, tearfulness, or feelings of hopelessness.
B) With anxiety – with symptoms such as
nervousness, worry, or jitteriness.
C) With mixed anxiety and depressed
mood – when symptoms are a combination of depression and anxiety.
D) With disturbance of conduct – with
conduct disturbance involving the violation of the rights of others or of major
societal norms and rules.
E) With mixed disturbance of emotions
and conduct – involving both emotional symptoms and a disturbance of conduct.
F) Unspecified – for maladaptive
reactions to stressors that are not classifiable as a specific subtype.
Aeromedical Concerns: Adjustment
disorders are one of the most common psychiatric diagnoses among aviators. These disorders are commonly associated with
functional impairment resulting from decreased concentration, depression,
anxiety, inattention, insomnia, fatigue, temporary changes in social
relationships and problems with decision making. These impairments are all incompatible with aviation
duties.
Medical Work-up: If the
adjustment disorder appears mild and improves in the first few weeks the flight
surgeon may choose to manage the case with consultation from mental
health. Early interventions with
psychotherapy to strengthen coping mechanisms and short-term pharmacotherapy
have been shown to ameliorate recovery (4,5). If the patient is not responding to stress
reduction and coping skills an initial trial of benzodiazepines may calm the
patient and induce needed sleep. If the
patient continues to be symptomatic and overly distressed, antidepressants and
continued psychotherapy should be of benefit.
However, if the disorder is more severe and/or fails to improve in 1-2
weeks consider referring the case to mental health. Early mental health treatment can lead to
early symptom resolution and possible return to flying status without the need
for a waiver. Delay in treatment can
lead to progression of symptoms to a more severe Axis I diagnosis (6). Adjustment disorders tend to resolve and only
21% ever develop into a diagnosis of depression (2).
Aeromedical Disposition (military): Air Force: If
the DSM-IV-TR diagnostic criteria for adjustment disorder are met, then
aviators should be placed DNIF until the disturbance is resolved. If the disorder resolves within 60 days the
aviator is placed back on flying status and no waiver is required. If the disorder persists beyond 60 days the
aviator is disqualified and a waiver is required. An evaluation by a qualified mental health
professional is required prior to waiver consideration. There is no mandated recovery period before
waiver application. The period of
remission should be of such length that the flight surgeon and mental health
consultant feel confident that the aviator will not suffer a recurrence.
The
aeromedical summary should include:
A) Copies of mental health evaluation
and treatment summary (evaluation within three months of submission).
B) An aeromedical summary outlining any
social, occupational, administrative or legal problems associated with the
case.
C) Letters from the aviator’s
supervisor and treating psychiatrist or psychologist supporting a return to
flying status.
Navy: No requirement for waiver. Once the aviator has symptom resolution, has
discontinued all meds and clearance from mental health, approval for flight
status is granted.
Army: Requirement for waiver after 90 days of symptoms
requires resolution of symptoms with no meds and same guidelines required by
Air Force. New Army regulations are
allowing flight status using SSRIs. When medication is required for stabilization
and will be continued, require 90 days usage with stability and flight
evaluation for waiver.
Aeromedical Disposition (civilian): No antidepressants, antipsychotic or anxiolytics are
presently permitted in civil aviation.
Adjustment disorders are granted medical certification once they have
resolved. Depending on the length of
time medication was used, the airman may be asked to discontinue all
psychotropic medications for 90 days before consideration for return to
flying. A current status of the medical
condition is required at that time.
Waiver Experience (military): Review of a
large military waiver database from 2001 through mid-August 2007 showed 269
cases of adjustment disorder; 13 were pilot candidates (5%), 87 were pilots or
navigators (32%) and 169 were non-pilot aircrew (63%). Of the 269 cases, 104 (39%) were disqualified
and 165 (61%) were granted waivers. A
random review of 76 waivers (48 qualified/28 disqualified) revealed that all
the disqualifications were due to aviators with ongoing adjustment disorders. Of these disqualifications six were prior
approvals with subsequent recurrence. Of
the approved waivers the minimal time of remission was 5 months and the average
was one year or more.
Waiver
Experience (civilian): There
is no single pathology code for adjustment disorder in the FAA’s Aeromedical
Certification system so civil aviation experience with this condition cannot be
determined at this time.
References:
1. Adjustment Disorders. Diagnostic and Statistical Manual of Mental
Disorders, Fourth edition, Text Revision. DSM-IV-TR. American
Psychiatric Association,
2. Andreasen N, Hoeuk
P. The Predictive Value of Adjustment Disorder.
American Journal of Psychiatry.
1982: 139; 584-590.
3. Kirch KL, et al. Difficulties in Screening for Adjustment
Disorder. Palliative and Supportive
Care. 2004: 2123-2131.
4. McGlynn TJ, et al. Diagnosis and Treatment of Anxiety Disorders,
A Physicians Handbook. American Psychiatric Press,
5. Stewart JW, et al. The Pharmacotherapy of Minor Depression. American Journal of Psychotherapy. 1992; 46: 23-36.
6. Strain J. Adjustment Disorders, Psychooncology.
7. USAF. Aircrew Medical Waiver Guide, Adjustment
Disorder, revised Sept. 2007.
8.
9. US Federal Aviation Administration.
Guide for Aviation Medical Examiners.
10. US Navy.
Aeromedical Reference and Waiver Guide.
Adjustment Disorder, Update March 2007.
Update:
January 18, 2008