No criteria or guidelines exist in DSM-IV to quantify the nature of the psychosocial stressor(s). Given individual differences in coping abilities, certain stressors are likely to be very stressful for one patient and not stressful at all for another patient. With no quantifiable guidelines for measuring stressors, a diagnosis is often determined by the nature of an individual's response. If a person responds with marked distress or significant impairment in functioning, it is often assumed that the life event was an identifiable stressor. However, the identification of a response that evidences marked distress or significant impairment also lacks specificity and is thus very subjective. Many of these diagnostic terms are too vague to be valid or reliable; thus, there is considerable variation in the use of the adjustment disorder category.
Despite these problems, the adjustment disorder category does provide a means of identifying an emotional or behavioral response in need of further treatment. Cancer patients are regularly confronted with a variety of stressors and thus face the potential of experiencing an adjustment disorder.
Individual and group counseling and psychotherapy
Although only one study has been targeted specifically at a population of cancer patients diagnosed exclusively with adjustment disorder, a number of studies have shown the benefits of psychosocial interventions with adult cancer patients (e.g., meta-analysis).[Level of evidence: I] These interventions have included both individual [Level of evidence: I] and group counseling [Level of evidence: IV];[12,13][Level of evidence: I] and have utilized a variety of theoretical approaches. In a randomized clinical trial for the treatment of adjustment disorders, 57 patients with mixed cancer types were randomly assigned to either an 8-week individual, problem-focused, cognitive-behavioral psychotherapy intervention or an 8-week individual, supportive counseling intervention.[Level of evidence: I] Results showed that those receiving the problem-focused, cognitive-behavioral therapy exhibited a significant change in fighting spirit, coping with cancer, anxiety, and self-defined problems, both at the conclusion of the intervention and at the 4-month follow-up.
Cognitive-behavioral interventions have been widely studied. A cognitive-behavioral approach is based on the idea that mental, emotional, and even physical symptoms partly stem from one's thoughts, feelings, and behaviors, resulting in poor adaptation. Interventions focus directly on a patient's thoughts, feelings, and behaviors with the goal of altering specific coping strategies and alleviating emotional distress. Cognitive-behavioral interventions include a variety of techniques such as:
- Relaxation training.
- Contingency management.
- Problem-solving.[Level of evidence: I]
- Cognitive restructuring.
- Thought stopping.
- Coping self-statements.
- Mental imagery exercises.
Most studies have combined a variety of these approaches into a multicomponent treatment strategy designed to alleviate specific symptoms. Cognitive-behavioral approaches tend to be relatively short-term, brief interventions, well-suited to the oncology setting.[15,16] One study [Level of evidence: I] randomly assigned 382 patients with different types of cancer to one of three groups: usual care, professionally led stress management, or self-administered stress management. The two intervention groups received stress management training that included abdominal breathing, progressive muscle relaxation training with guided imagery, and coping self-statements prior to the start of chemotherapy. The professionally led intervention group met with a mental health professional who taught them the stress management skills in one 60-minute session. The self-administered group received a packet of training materials that included a 15-minute videotape of instructions, a 12-page booklet on coping with chemotherapy, and a 35-minute audiotape of relaxation training instructions. Results showed enhanced quality of life over usual care in the self-administered group only. The professionally led group did not show any improvement in quality of life when compared with usual care.