Effectiveness of an Integrative Approach on Adjustment Disorder

Adjustment disorders are defined as reactions of an individual, when fails to cope with an identifiable stressor event or situation which exceeds normally expected response results in subjective distress and emotional disturbance followed by an interruption of the functioning in social and personal entities. It is one of the diagnostic categories given in DSM and ICD -10 which is characterized by an emotional or behavioral response to a stressful event. Adjustment disorder was reported to be varied per different studies, the kind of population studied and the assessments applied Depressed mood was the most common subtype assigned (11.6%), followed by anxious mood, mixed anxiety and depressed mood, and disturbance of conduct. Factors that may contribute to the development of adjustment disorders Tomb 1996 are the nature of the stressor, individual vulnerability, Intrinsic factors-Age; sex; intellectual, emotional, and ego development; coping skills; temperament; and past experiences and Extrinsic factors-Parents and support systems; expectations, understanding, skills, maturity, and support available from the child’s larger environment plays a greater role in the risk of occurrence and shaping of the manifestations of Adjustment disorders. The stressor may involve only individual or even the community. Aim is to understand the factors involved considering certain cultural background and to enhance the quality of life through the application of integrated Evidence based approach by treating the Adjustment disorder.


Introduction
Adjustment disorders are defined as reactions of an individual, when fails to cope with an identifiable stressor event or situation which exceeds normally expected response results in subjective distress and emotional disturbance followed by an interruption of the functioning in social and personal entities. It is one of the diagnostic categories given in DSM and ICD -10 which is characterized by an emotional or behavioral response to a stressful event. Adjustment disorder was reported to be varied per different studies, the kind of population studied and the assessments applied Depressed mood was the most common subtype assigned (11.6%), followed by anxious mood, mixed anxiety and depressed mood, and disturbance of conduct. Factors that may contribute to the development of adjustment disorders Tomb 1996 are the nature of the stressor, individual vulnerability, Intrinsic factors-Age; sex; intellectual, emotional, and ego development; coping skills; temperament; and past experiences and Extrinsic factors-Parents and support systems; expectations, understanding, skills, maturity, and support available from the child's larger environment plays a greater role in the risk of occurrence and shaping of the manifestations of Adjustment disorders. The stressor may involve only individual or even the community. Aim is to understand the factors involved considering certain cultural background and to enhance the quality of life through the application of integrated Evidence based approach by treating the Adjustment disorder.
there may exist pan cultural uniformities in each of these forms of qualification. Juan E Mezzich 2002 Society draws its own distinctions regarding which forms of behavioral break downs and anomalies are medical in nature. Juan E Mezzich 2002 Stress and coping is closely associated with socio-cultural factors. The presentation of the symptoms by the individual differs across a culture. It matters with the meaning assigned by the medical professional considering the cultural background. An evidence based tool for specific population according to various cultures is lacking in order to diagnose the adjustment disorder. So knowledge of stating what is normal in the process of coping to the illness in the context of specific culture is essential and to the extent the individual symptoms which are in excess of this Casey et al. 2011. Because the diagnosis is frequently made in the context of any stressor followed by an event which might leads to a labeling of an individual. Thus clinical judgment plays a major role in making the diagnosis differentiating normality and abnormality by considering the context of cultural background, personal circumstances and should meet the current classifications and criteria Factors Associated With Adjustment Disorders were more severe fatigue, greater concerns about financial issues, loss of independence and dignity, less satisfaction with confidantes Tatsuo Akechi et al. [1]; University of Chicago Comer Children's Hospital [2], Adjustment disorders occur at all ages; however, the symptomatology i.e the presentation, duration, frequency of symptoms in children and adolescents differs from those in adults. The scenario of presentation of symptoms is more of behavioral in children and adolescents but adults experience more of depressive symptoms.
There is no single trigger between the stressor and the child's reaction to it Medical Center of Central Georgia, 2002. The developmental stage of the child and the strength of the child's support system influence their reaction to the stressor Benton and Lynch 2009. There is no evidence to indicate that biological factors influence the cause of adjustment disorders. The common thread is that stress is the precipitating factor Benton and Lynch 2009. Studies suggested that the individual who is suffering with adjustment disorder will be experiencing as insecurely attached or detached in the interpersonal relations and fails to maintain the bonding with the life partner and other significant family members who leads to distress and poor functioning. This will be deteriorated further by the poor support of the family members and friends due to unawareness about the situation undergoing by the individual.

Pathophysiology
Adaptation to the change occurs in human life occurs as a continues process and at the physical level involves the activity of monoamine neurotransmitters, hormones, and other neuromodulators. These neurotransmitters and neuromodulators functions as to regulate the bodily activities to maintain the physiological and psychological equilibrium but when the persons capacity exceeds the tolerance level towards the stress the equilibrium get disrupted. Di Rosa et al conducted a study that analyzed serum levels of protein carbonyl groups and nitrosylated proteins, which are biologic markers of oxidative stress. These biomarkers were higher in 19 individuals who experienced psychological abuse and suffered from workplace mobbing−associated adjustment disorders, in comparison to 38 healthy subjects; this finding suggested a direct role of oxidative stress in adjustment disorders.

Co Morbidity
Benton and Lynch 2009 indicate that adjustment disorders are most likely to occur with personality disorders, anxiety disorders, and affective disorders. In children, adjustment disorders are also most likely to occur with conduct or behavioral problems Wood 2003. Patients with adjustment disorders may engage in deliberate self-harm at a rate that surpasses most other disorders and may also have an increased risk for substance abuse disorders Benton and Lynch 2009. Research is needed in this area to understand the association between other mental disorders and adjustment disorder.

Risk of Suicidality
Lack of efficient coping skills, inability to deal with the situations and people leads to suicidal ideations. studies reveal that it is prominent in all age groups, people with adjustment disorder but found to be one fifth of adolescents as victims due to the unstable parental families an emotional deprivation during childhood. Bronish and Hecht 1989 found that 70% of a series of patients with Adjustment disorder attempted suicide immediately before their index admission and they remitted faster than a comparison group with major depression. Asnis et al. 1993 found that Adjustment disorder patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression. Bolu et al. 2012 found that patients with adjustment disorder were admitted due to suicide attempt, remitted faster than a group of Major depressive disorder. Henriksson et.al 2005 states statistically that the stressors are of one-half related to parental issues, and one-third in peer issues. A study by Pelkonen et al. reported 89 patients who received a diagnosis of adjustment disorder those who made suicide attempts, were characterized by poor psychosocial functioning, dysphoric mood and psychomotor restlessness.

Participant's Information
Patient S was a 21-year-old female married, studied up to PUC, currently Home maker, hails from sub urban area middle socio economic strata, presented with a history of adjustment issues in marital life associated with increased distress in meeting the demands of spouse and In-laws. She often gets irritated and involves in an argument with spouse and feels sad with frequent crying spells thinking about her life was not up to her expectations any more. She always had a dream about the partner who has a job and would take good care of her by fulfilling her needs and demands. Patient disclosed about her past relationship which was ended due to financial crisis. After sometime got married in 2015 January with consent, but was unable to adjust with the lifestyle and orthodox beliefs of spouse and In-laws family. Patient was trying to cope with difficulty but increased stressful situations like his parents proposal for 2nd marriage, spouse interest in sexual act were acting as perpetuating factors. Based on therapeutic view the positive prognostic factors seen in client were the level of motivation towards change in life and supportive Spouse. Negative factors were dealing with poor coping skills. She was referred to psychological evaluation on May 2016 in view of her distress in marital life and decreased quality of life.
Provisional diagnosis of Adjustment disorder with prolonged depressive reaction was considered and was Under taken for the therapy by understanding her short term and long term goals ,attempted a integrated approach using techniques from the CBT and IPT collaboratively with Couple therapy and Family therapy.

Depression Anxiety Stress Scale (DASS)
The DASS is a set of three self-report scales designed to measure the negative emotional states of depression, anxiety and stress. The DASS was constructed not merely as another set of scales to measure conventionally defined emotional states, but to further the process of defining, understanding, and measuring the ubiquitous and clinically significant emotional states usually described as depression, anxiety and stress. In addition to the basic 42-item questionnaire, a short version, the DASS21, is available with 7 items per scale. The Depression scale assesses dysphoria, hopelessness, and devaluation of life, self deprecation and lack of interest/involvement, anhedonia, and inertia. The Anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and subjective experience of anxious affect. The Stress scale is sensitive to levels of chronic nonspecific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset/agitated, irritable/over reactive and impatient. Subjects are asked to use 4-point severity/frequency scales to rate the extent to which they have experienced each state over the past week. Scores for Depression, Anxiety and Stress are calculated by summing the scores for the relevant items. Psychology foundation of Australia 2014.

Quality of marital life scale (QOL)
This scale consists of 50 items, 4-point liker scale measures the severity/frequency of important aspects of the marital relationships on the following areas, Support, Openness, Intimacy, Connectedness , Autonomy, Empathy , Love, Dominance and Conflict. The scoring has two dimensions i.e. some questions were mentioned as positively worded items and some of the questions were scored reverse which were mentioned as negatively worded items Anisha Shah 1995.

Design
A single case experimental design with pre-and postassessment was used, to evaluate the changes in the patient in response to the intervention.

Procedure
The pre-assessment (i.e. pre intervention) was carried out following the presenting symptoms, history and clinical observation. Based on the assessment profile and considering her goals to be focused an integrative intervention approach was developed to address distress in marital life and improve quality of life. The program consisted of sessions held 2 times a week during beginning and continued for once in a week on followed sessions for a period of 2 months, each session lasting on an average for 45 minutes. A total of 10 sessions were conducted in the hospital setting on an out-patient basis. During this period, the patient and the family were also psycho educated and counseled. The completion of the program was followed by a post-assessment (i.e. post-intervention) ( Table 1).

Assesment Results
Pre-assessment: The psychological profile obtained from the base line assessment revealed increased levels of stress at severe range and depression, anxiety were at mild range. On the other test, higher level of distress in marital life. The post-assessment results, post the completion of integrative intervention revealed marked improvement on the same assessments i.e insignificant levels of stress, depression and anxiety and high quality in marital life.

Psycho education
Disorder specific -given by clinical expert to patients or his family to learn knowledge and skills and better long-term management of issues related to illness as well as psychosocial adjustment -a part of the overall treatment plan and includes communication treatment plan. Hatfield 1988 the value of the psycho part of psycho education and suggested that education is just as informative and less confusing.

Interpersonal Psychotherapy (IPT)
IPT is a unique departure from other types of psychotherapeutic interventions because its focus is on current interpersonal conflicts, and the treatment is based on the premise that, regardless of the underlying cause of depression, the depression is inextricably intertwined with the patient's interpersonal relationships. IPT's goals are (1) to decrease depressive symptomatology and (2) to improve interpersonal functioning by enhancing communication skills in significant relationships Klerman 1984.

Cognitive Behavioral Therapy (CBT)
Cognitive-behavioral therapy is based on the interrelationship of thoughts, actions, and feelings. In order to work with feelings of depression, this model establishes the importance of identifying the thoughts and actions that influence mood. In this manner the person learns to gain control of his/her feelings. Ricardo F Muñoz et al. 2007 Family Therapy and Couple Therapy Family therapy: It is helpful for identifying needed changes within the family system. These changes may include improving communication skills and family interactions and increasing support among family members. Primary goal was to enhance the growth potential of the individual (self actualization) and also to integrate the needs of each individual family member for independent growth with the integrity of the family system Satir and Baldwin 1983.
Couple therapy: It is to focus on encouraging positive sentiment over ride and to improve effective communication skills. To help partners negotiate behavior change.

Session-1
Patient was discussed about Psychological assessments results, in which Stressors were significant. Distress was attributed towards Illness. Patient along with the family members were psycho educated through information model. Feedback was taken from the patient to know her level of understanding. CBT model was explained using practical situations. Patient was allowed to ventilate, was given a reassurance & encouraging the positive behaviors. Thought diary was given as home task, aim was to identify the cognitions. Her activities were scheduled collaboratively, to engage in useful tasks in order to improve her problem solving and judgmental abilities.

Session-2
Patient expressed positive feelings about the activity scheduling. Formulation of IPT was emphasized by discussing about the possible factors Biological (Neuro-endocrine factors), Psychological (attachment style, cognitive style, Personality factors), and Social (Interpersonal factors) for the depressive symptoms which can occur within an interpersonal context that is often interdependent with the illness process. Daily mood scale was added to home task to understand the intensity of depressive symptoms or mood at the end of each day Recardo F Munoz 2000, Thought diary was asked to continue (Tables 2  & 3).

Session-3
Patient expressed that from the thought diary she could see the change of intensity in her thoughts and mood. Cognitive model was reinforced and made her understand that the situations and the people would respond the way we react and vice versa. Thought diary followed by mood scale were discussed how the thoughts would affect mood and behavior. IPT interpersonal inventory was administered to understand her perception and actual need from her spouse and In-laws as well.
As a part of couple counseling, informed spouse to give support in therapy and co operate accordingly and not to have sexual contact without consent of her. He was committed for this contract. In the first session of family therapy, In -laws were discussed about the roles of the family members and was asked to change some practices at home, like sharing some activities, discussion took place on this as there is a cultural belief (certain parts of the country) that the duties has to be performed by the daughter in law, but finally agreed for this contract on explaining how it can help the patient and other family members. Patient was asked to continue to do the home task (Daily Mood scale, Thought diary) and in this session credit list was added, to list out the positive things of her life (Table 4). Sister in law -She is the one who is provoking for 2nd marriage, she should not involve in my matters

Session-4
Patient said that she could see only 1 or 2 positive things but still she expressed satisfactory about those and was reasoning how her spouse cooperates and denies for second marriage. By taking her words once again reattributed how thoughts affect mood. The concepts of difference between the depressed and non depressed thinking, necessary and unnecessary thinking, Positive vs. Negative thinking was discussed with practical situations. Patient was asked to sort out the necessary and unnecessary thoughts from the Thought diary she mentioned to till date and was asked to continue Daily mood scale. In F.T family members were explained the importance of Warmth and positive remarks i.e. how the concern and empathy for the patient would be helpful in improving well being of the patient. A warm tone indicates a positive attitude towards patient and positive remarks refers to the patient's abilities, skills and positive attributes. Family members were asked to practice.

Session-5
Patient informed about her understanding that how much she was involving in unnecessary thinking and how it's affecting her mood and behavior. Cognitive distortions were explained that how the individual starts bias thinking about oneself and the world around us, which further leads to depressive thinking and makes person to view negative towards self , world and the future.
In IPT (Clarification) Socratic questionnaire (Changing view towards comparison) was administered to make her understand the cons and pros of comparison and how comparison itself making herself to perceive the things stressful. She was also explained by changing these behaviors how it reduces the distress. Patient was asked to list out the positive thoughts and negative thoughts to see which is creating distress, and which makes you feel better from the Thought diary and was asked to mark Daily mood scale.

Session-6
Patient informed about her understanding, that her distress was related to her negative thinking and motivated to change herself to have a better life. Explained about Automatic thoughts and how her thoughts can be defined as automatic thoughts in the way to make her understand that how the person thinking itself sometimes get distorted or even though the thought is valid but conclusion may be distorted and these distorted thoughts makes the individual to become dysfunctional. Thus if one can identify, evaluate and then responds to it produces positive shift in affect.
In IPT (Role transition), patient was acknowledged the losses and was explained to move on in the life rather being in the past. She was reminded about the existing supports and to think how to develop a balanced new role by utilizing them. Wanting to be in comfortable zone will not bring a change in view of a person towards the surroundings, so by exploring new things will make the person to learn new skills to have new attachments. To make her emotionally strong patient was asked to practice Diaphragmatic breathing at least 3 times a day and also to observe the automatic thoughts and notice a shift in affect and increase thoughts which can produce a better mood.

Session-7
Patient was satisfied with the positive outcome from breathing exercise. Distancing technique was used imagery was induced to reduce the distress and help her to see problems in greater perspective; this technique would help her to understand difficulties are likely to be time limited. Communication analysis was discussed as a part of Couple counseling, five aspects were discussed i.e. importance of being clear and specific while communicating will resolve the problems easily and also listening to others in order to understand their perspective, during the process of resolution, being flexible in give and take policy should be prioritized. Thinking in a broader prospect expressing the feelings positively would enhance the bonding in relationship. Same was asked to practice the couple.

Session-8
Patient expressed the positive outcome by practicing communication skills, during this session patient was explained the healthy management reality by changing what is under their control. How to influence their objective world by altering with engaging activities, maintaining contacts and communicating assertively. At the same time altering the subjective world with healthy thinking.
In Family therapy, Members were explained how to increase their self control and respecting the views of other family members. They were informed to talk to the patient and not to talk about him/her. This can help in reducing the negative emotions between the patient and the other family members. Instructed the family members that the patient has lower tolerance for stress and one can help in reducing fights, nagging behaviors and also not showing extreme concern or being enthusiastic which can upsets the patient. Patient was asked to list out the pleasant activities and the reason behind considering them as positive.

Session-9
Patient was discussed with the Cognitive continuum to modify beliefs, which was focused on both automatic thoughts and beliefs that reflect polarized thinking (all or nothing). Patient believes that following certain behaviors will give satisfaction in life. A session was continued with skills management in which she was explained each step to overcome the situations by identifying and analyzing the problem. Listing out possible Solutions and weighing their advantages and disadvantages, selecting best One out of them and implementing it. In Couple counseling informed spouse to be clear about his decisions with other family members so that they should not commit for second marriage, this will help in building trust on spouse, which is very important for relationship. Patient spouse was asked to spend time (Table 5).

Session-10
Patient expressed hope, where she can live her life with complete happiness and was also confident about coping towards situations. This session was followed by a post assessment which was revealed insignificant scores on DASS 3 areas i.e. Depression: 5; Anxiety: 4; stress: 9 and on Quality of marital scale score was 66 indicates high quality in marital life. Therapy was concluded by informing about follow ups through telephone for more 2 sessions. Summary of conclusion: Informed patient to observe the changes within herself and with her family members as a result of intervention. Highlighted her ability to resolve problems through change of pattern in communication and behavior. Asked her to rehearse coping strategies and implement in action for various problems.

Discussion
Adjustment disorders are common, the risk of pathologizing normal emotional reactions to stressful events on the one hand and on the other of over diagnosing depressive disorder with the consequent unnecessary prescription of antidepressant treatments. There are very few intervention studies. Patricia Casey et al. [3] World Psychiatry 2011 According to Psychodynamics factors implicated in the predisposition to this disorder includes unmet dependency needs, fixation in an earlier level of development, and under developed ego. The client with predisposition to adjustment disorder is seen as having an inability to complete the grieving process in response to a painful life change.
The presumed cause of this inability to adapt is believed to be psychic overload -a level of intra psychic strain exceeding the individual's ability to cope. Normal functioning is disrupted and psychological or somatic symptoms occur. According to Vygotsky Individuals with adjustment difficulties have experienced negative learning through inadequate rolemodeling in dysfunctional family systems. These dysfunctional patterns impede the development of self-esteem and adequate coping skills, which also contribute to maladaptive adjustment responses. There are intervention studies targeting depression, anxiety and stress using mindfulness in group therapy which found non inferior to the primarily individual-based CBT Jan Sundquist et al. [4]. Psychotherapy is the treatment of choice for adjustment disorders, since the symptoms are a direct reaction to a specific stressor Turkington 1995. Interpersonal The type of therapy depends on the needs of the individual, with the focus being on addressing the stressors and resolving the problem. Limited studies were found in Indian cultural setting focusing on intervention. The current study reports on the psychotherapeutic integrative approach and the outcome of the Patient treated for Adjustment disorder. This study has provided an opportunity to explore the effect of the techniques used in integrative approach on patient outcome within clinical set up. The results of Pre and Post assessments showed that the adjustment difficulty in the delivery of treatment improved over the duration of 2 months. Post assessment scores improved significantly over time and also improved the quality of life. This finding adds further support to the Cultural base study and also to the existing evidence that it is possible to treat from diverse back grounds [5][6][7][8].

Conclusion
The present study combines CBT, IPT with Couple therapy and Family therapy in the form of Integrative approach to improve the quality of life in personal and marital life. Our results suggest that instead of single therapeutic intervention, Integrative approach for individuals with Adjustment disorder would predict the positive outcome. Therapy was focused in treating the patient cognition and also by involving the family members to make her adapt to the environment with consent. Adjustment difficulty may start with one generic thought and makes the individual to take decisions emotionally which fogs the appropriate way of thinking and the individual acts accordingly. In addition our study mentioned treating the patient holistically would enhance the quality of life.