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This article examines the diagnostic criteria for adjustment disorder and outlines the diagnostic process, both clinically and using structured interviews. It also discusses the differential and co-morbid diagnoses, while the controversy surrounding the diagnosis itself is briefly considered. Various approaches to management conclude the article. Throughout, the lacunae in our knowledge regarding adjustment disorder are highlighted.
1. Diagnostic Criteria
Adjustment disorder has been recognized since the DSM-I[1] was introduced in 1952, although at this time it was called transient situational personality disorder, finally changing to adjustment disorder in DSM-III (1980).[2] Adjustment disorder has been incorporated into the International Classification of Diseases (ICD) since the ninth revision in 1978.[3]
Despite its long history, the criteria for adjustment disorder in DSM-IV-TR[4] continue to be vague and largely unhelpful. The core criterion is that the person must not meet the criteria for any other psychiatric condition, a bar that is set very low indeed, especially for major depression, which requires only five symptoms to be present for 2 weeks. Notwithstanding this criticism, DSM-IV-TR does specify that adjustment disorder occurs:
* In response to a stressful event.
* When the onset of symptoms is within 3 months of exposure to the stressor.
* When the symptoms are distressing and in excess of what would be expected by exposure to the stressor.
* When there is significant impairment in social or occupational functioning.
* When the symptoms are not due to another axis I disorder or bereavement.
* When, once the stressor or its consequences is removed, the symptoms resolve within 6 months.
Moreover, DSM-IV-TR recognizes that adjustment disorder may be acute, if lasting less than 6 months, or chronic, if lasting longer. Six subtypes are described based on the predominant symptom pattern and these include: with depressed mood; with anxiety; with mixed depression and anxiety; with disturbance of conduct; with mixed disturbance of emotions and conduct; and unspecified. The criteria for these are not specified in greater detail.
The ICD-10 has similar criteria[5] but specifies that the onset is within 1 month of exposure to the stressor and it specifically excludes psychosocial stressors of an unusual or catastrophic nature. Seven subtypes broadly similar to those in DSM-IV-TR are identified in ICD-10 but the depressive reactions are divided into brief...