INTRODUCTION

Adjustment disorder is a mental disorder which develops consequent to psychosocial stressors and is characterized by emotional or behavioral symptoms and signs. According to DSM-IV-TR diagnostic criteria, the symptoms should impair functionality or consequent distress should be more than expected impact of the stressor (1). Stressors causing adjustment disorder consist of frequent events of daily life such as separation from loved one(s), job change, milieu change or economic difficulties rather than devastating events such as natural disasters (2). Adjustment disorder is frequently encountered in clinical practice and its prevalence is between 7-35% (3,4). Although it is a frequent disorder, suicidal behavior in adjustment disorder has not been previously studied.

DSM-IV-TR defines 6 sub-types according to specific symptom structure. In adjustment disorder of depressive type, predominant symptoms are depression, insomnia, low self-esteem and suicidal behavior. Generalized or situational anxiety and increased motor activity are predominant symptoms in adjustment disorder of anxious type. In adjustment disorder with disturbance of conduct, impulsivity, lack of insight and violent behavior are observed. Predominant symptoms of the type with mixed anxiety and depressive mood are combination of depression and anxiety. In mixed disturbance of emotions and conduct , predominant symptoms are excessive alcohol consumption, paranoia, anger, cheating behavior and murder thoughts. In unidentified type, inappropriate reactions to unclassified specific psychosocial stressors such as physical complaints and social withdrawal as one of the sub-types of adjustment disorder are predominant (1).

Suicidal behavior generally occurs in response to emotions such as hopelessness, hindered stress or despair (5,6). These emotions are frequently seen in adjustment disorder as well as in several psychiatric disorders. Suicidal risk is 3-12 times higher in patients with psychiatric disorder than the ones that do not have any disorder. At least one psychiatric disorder was reported in 94% of people who committed or attempted suicide (7). Main mental disorder found in people committed suicide is depressive disorders with 35-80% frequency followed by schizophrenia with 10% frequency and dementia or delirium with 5% frequency. There is alcohol dependence in 25% of people committed suicide (7-9). Mood disorders are psychiatric disorders with the highest risk of suicide (9). Suicidal rates in depressive episodes are 30 times higher than normal population. Dysthymic and adjustment disorders have an important role among causes of suicide (10). In the study of Pelkonen et al. (11) which was performed in 89 outpatients diagnosed with adjustment disorder, suicidal attempt or thought was reported in 25% of patients. Socio-economical level of patients admitted by suicidal thought or behavior were found lower and psychiatric follow-up stories of these patients were found significantly higher than patients without suicidal behavior (11).

We aimed to examine the scope of suicidal behavior in adjustment disorder which has relatively been less studied but is a widespread disorder in context of the information mentioned above.

METHODS

Participants

Records of 82 patients who were admitted to psychiatry outpatient department of Gülhane Military Medical Academy (GATA) between January 1, 2009 and December 30, 2009 and diagnosed as adjustment disorder according to DSM-IV TR criteria were reviewed retrospectively. Diagnosis of adjustment disorder (and its sub-types) was confirmed by admitting to hospital and by structured Clinical Interview Form (SCID-I) (1,12). Cases were patients who were referred to GATA Psychiatry Department due to adjustment problems and were not followed-up with any other psychiatric diagnosis.

Suicidal Attempt style: Suicidal attempts of patients diagnosed as adjustment disorder were divided into two categories: Highly probably to be saved (taking low doses of medications, superficial wrist cutting) and less probably to be saved (be hanged, jumping from high altitude, attempting suicide with fire weapons).

Assessment

Information about these patients was examined by data from inpatient logbooks and inpatient files (educational level, age, marital status, adjustment sub-type, type of admission) retrospectively. Diagnostic distribution of patients was based on DSM-IV TR diagnostic and classification system.

Clinical Global Impression Scale (CGI): This scale can be used to evaluate severity, level of improvement and side effects of mental disorders (13). It has three sub-scales which show severity, global improvement and level of side effects. In this study, severity sub-scale was used to assess the severity of adjustment disorder. Severity values in the scale was as follows: 1. Normal-not ill, 2. Borderline ill, 3. Mildly ill, 4. Moderately ill, 5. Evidently ill, 6. Severely ill, 7. Very severely ill.

Statistical Evaluation

Collected data were analyzed by SPSS 15.0 software. Continuous variables were given as mean ± standard deviation; categorical variables were given as number and percent. For comparison of adjustment disorder cases with and without suicidal behavior and for comparison of cases with suicidal behavior highly probably to be saved and without suicidal behavior highly probably to be saved, Mann-Whitney U test was used for continuous variables and chi-square test for non-continuous variables. Statistical significance value was taken as p<0.05.

RESULTS

8.6% (n=82) of 952 privates and noncommissioned officers who were admitted to inpatient clinic in 2009 were diagnosed as adjustment disorder. Mean age of patients was 23.6±5.7 and was between 18 and 46. Mean duration of education was found 8.79±2.4 years and 54.5% (n=12) were primary school graduates; others were graduated from high school or more. No substance abuse was present except smoking. 20.7% of patients (n=17) were married and 79.3% (n=65) were single.

When severity of the disorder was evaluated by CGI, disease severity was found mild in 32.9% (n=27), moderate in 51.2% (n=42) and severe in 15.8% (n=13) of cases. Sub-types of adjustment disorder were found as adjustment disorder with depressive mood in 47.6 % (n=39), adjustment disorder with anxiety in 13.4% (n=11), adjustment disorder with disturbance of conduct in 13.4% (n=11), adjustment disorder with mixed disturbance of emotions and conduct in 12.2% (n=10), unspecified type in 9.8% (n=8) and adjustment disorder with mixed anxiety and depressive mood in 3.7% (n=3) consecutively.

Patients were admitted to hospital with suicidal attempt in 26.8% (n=22), with somatic complaints in 23.1% (n=19), with anxiety and distress in 17% (n=14). 27.2% of patients (n=6) who committed suicide were married. 54.5% of patients (n=12) were primary school graduates and others were graduated from high school or more. Among patients who committed suicide, 68.1% (n=15) chose methods highly probable to be saved. When sub-types of adjustment disorder were compared in context of suicidal behavior, suicidal behavior was found to be significantly higher in sub type with depressive mood (χ2=14.49, p=0.013) (Table 1). When educational levels were compared according to style of suicidal attempt (highly or less probable to be saved), educational level was found to be lower in patients attempted suicide in a way that it was highly probable to be saved (10.2±2.0 years in patients highly probable to be saved, 7.2±1.3 years in patients less probable to be saved) (Z=3.07, p=0.02).

DISCUSSION

Adjustment disorder is widely seen in the field of military psychiatry. In a study, maladjustment symptoms were seen in 95% of raw recruits of Polish army in the first year and 25% of dismissals from army were due to adjustment disorder syndromes (14). This disorder is a clinical entity triggered by changing living conditions (military service, immigration) at individuals prone to the disease in premorbid period. Behavioral pathologies with anxiety and depressive symptoms are generally seen in this clinical condition. Coping mechanisms with a stressor is weak in people with this diagnosis. Exacerbations can be observed due to a coercive situation, stimulus or environment. Severity and duration of exacerbation may impair adjustment and functionality of the patient. Inappropriate behaviors can occasionally be observed in solution seeking efforts. Patients diagnosed with adjustment disorder may apply to physician by various complaints. Previous studies showed that suicidal attempt has an important part among reasons of admission. Moreover, suicidal thoughts were found to be one of the most frequent symptoms observed in a study done to determine the symptom structure of this disorder (15). Suicidal attempt or thought has been reported in 25% of these patients (16). In another study, history of suicidal attempt was found in 60% of cases with adjustment disorder (17). In psychological autopsy studies, one fifth of adolescent suicides were proposed to be adjustment disorders (18-20). In another study, it was found that 26.5% of patients diagnosed as adjustment disorder were admitted as crisis cases with suicidal attempt (21). Frequency of suicidal behavior in our study (26.8%) was found consistent with the literature. Highly frequent suicidal attempt in our study may be due to lower level of education in our population and working on a population which secondary gains are predominant.

Depressive symptoms are predominant in patients with adjustment disorder in general. Previous studies showed that depressive symptoms are more frequent in 63% of adolescents and in 87% of adults (22). Sub-types of adjustment disorder are defined according to predominant symptom appearance. Although depressive mood is the most frequent sub-type of adjustment disorders (23,24), there are studies which showed that sub-type with anxious mood is the most frequent sub-type (25). In our study, among cases diagnosed as adjustment disorder, adjustment disorder with depressive mood was found in the first rank (47.6%) and adjustment disorder with anxiety was found in the second rank (13.4%). Different results about this subject show that studies in wider populations are needed

When limitations of our study is evaluated, being a retrospective study, relatively low number of patients, not being evaluated suicidal thoughts other than suicidal behaviors of patients and personality systems are of note.

Studies about adjustment disorder in our country and admission types or complaints of patients with this diagnosis are limited.

We think that further studies on this subject will contribute to have adjustment disorder understood better, prevent work loss from public health point of view and help to think of this diagnosis among pathologies that are thought to underlie the suicidal attempts.

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