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DSM-III

In DSM-III, this disorder is called Adjustment Disorder

Diagnostic Criteria

A. A maladaptive reaction to an identifiable psychosocial stressor, that occurs within three months of the onset of the stressor.

B. The maladaptive nature of the reaction is indicated by either of the following:

  1. impairment in social or occupational functioning
  2. symptoms that are in excess of a normal and expectable reaction to the stressor

C. The disturbance is not merely one instance of a pattern of overreaction to stress or an exacerbation of one of the mental disorders previously described.

D. It is assumed that the disturbance will eventually remit after the stressor ceases or, if the stressor persists, when a new level of adaption is achieved.

E. The disturbance does not meet the criteria for any of the specific disorders listed previously or for Uncomplicated Bereavement.

Types of Adjustment Disorder

Adjustment Disorder with Depressed Mood

This category should be used when the predominant manifestation involves such symptoms as depressed mood, tearfulness, and hopelessness. The major differential is with Major Depression and Uncomplicated Bereavement.

Adjustment Disorder with Anxious Mood

This category should be used when the predominant manifestation involves such symptoms as nervousness, worry, and jitteriness. The major differential is with Anxiety Disorders.

Adjustment Disorder with Mixed Emotional Features

This category should be used when the predominant manifestation involves various combinations of depression and anxiety or other emotions. The major differential is with Depressive and Anxiety Disorders. An example would be an adolescent, after moving away from home and parental supervision, who reacts with ambivalence, depression, anger, and signs of increased dependency.

Adjustment Disorder with Disturbance of Conduct

This category should be used when the predominant manifestation involves conduct in which there is violation of the rights of others or of major age-appropriate societal norms and rules. Examples: truancy, vandalism, reckless driving, fighting, defaulting on legal responsibilities. The major differential is with Conduct Disorder and Antisocial Personality Disorder.

Adjustment Disorder with Mixed Disturbance of Emotions and Conduct

This category should be sued when the predominant manifestation involves both emotional features (e.g., depression, anxiety) and a disturbance of conduct (see above).

Adjustment Disorder with Work (or Academic) Inhibition

This category should be used when the predominant manifestation is an inhibition in work or academic functioning occurring in an individual whose previous work or academic performance has been adequate. Frequently there are also varying mixtures of anxiety and depression. Examples include inability to study and to write papers or reports. The major differential is with Depressive Disorders and Anxiety Disorders.

Adjustment Disorder with Withdrawal

This category should be sued when the predominant manifestation involves social withdrawal without significant depressed or anxious mood. The major differential is with Depressive Disorders.

Adjustment Disorder with Atypical Features

This category should be used when the predominant manifestation involves symptoms that cannot be recorded in any of the specific categories.

Differential Diagnosis

Other conditions

In Conditions Not Attributable to a Mental Disorder, such as Other Interpersonal Problem or Phase of Life Problem or Other Life Circumstance Problem, there is neither impairment in social or occupational functioning nor symptoms that are in excess of a normal and expectable reaction to the stressor. No absolute guidelines are available to aid in this fundamental distinction, so clinical judgment will often be required.

Personality Disorders

Personality Disorders are often repeatedly exacerbated by stress, in which case the additional diagnosis of Adjustment Disorder is not made. However, if new features are seen in response to a stressor - such as depressed mood in an individual with Paranoid Personality Disorder who has never been bothered by depression - then the additional diagnosis of Adjustment Disorder may be appropriate.

Psychological Factors Affecting Physical Condition

In Psychological Factors Affecting Physical Condition the individual may be reacting to a psychosocial stressor, but the predominant symptomatology is a physical condition or disorder.

DSM-IV

Diagnostic Criteria

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant as evidenced by either of the following:

  1. marked distress that is in excess of what would be expected from exposure to the stressor
  2. significant impairment in social or occupational (academic) functioning

C. The stress-related disturbance does not meet the criteria for another specific mental disorder and is not merely an exacerbation of a preexisting disorder.

D. The symptoms do not represent Bereavement.

E. Once the stressor (or its consequence) has terminated, the symptoms do not persist for more than an additional 6 months.

Specify if:

  • Acute: if the disturbance lasts less than 6 months
  • Chronic: if the disturbance lasts for 6 months or longer

Adjustment Disorders are recorded based on the subtype, which is selected according to the predominant symptoms.

  • With Depressed Mood
  • With Anxiety
  • With Mixed Anxiety and Depressed Mood
  • With Disturbance of Conduct
  • With Mixed Disturbance of Emotions and Conduct
  • Unspecified

Subtypes and Specifiers

Subtypes

With Depressed Mood

This subtype should be used when the predominant manifestations are symptoms such as depressed mood, tearfulness, or feelings of hopelessness.

With Anxiety

This subtype should be used when the predominant manifestations are symptoms such as nervousness, worry, or jitteriness or, in children, fears of separation from major attachment figures.

With Mixed Anxiety and Depressed Mood

This subtype should be sued when the predominant manifestation is a combination of depression and anxiety.

With Disturbance of Conduct

This subtype should be used when the predominant manifestation is a disturbance in conduct in which there is violation of the rights of others or of major age-appropriate societal norms and rules (e.g., truancy, vandalism, reckless driving, fighting, defaulting on legal responsibilities).

With Mixed Disturbance of Emotions and Conduct

This subtype should be used when the predominant manifestations are both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct.

Unspecified

This subtype should be used for maladaptive reactions (e.g., physical complaints, social withdrawal, or work or academic inhibition) to psychosocial stressors that are not classifiable as one of the specific subtypes of Adjustment Disorder.

Specifiers

The duration of the symptoms of an Adjustment Disorder can be indicated by choosing one of the following specifiers:

Acute

This specifier can be used to indicate persistence of symptoms for less than 6 months.

Chronic

This specifier can be used to indicate persistence of symptoms for 6 months or longer. By definition, symptoms cannot persist for more than 6 months after the termination of the stressor or its consequences. The Chronic specifier therefore applies when the duration of the disturbance is longer than 6 months in response to a chronic stressor or to a stressor that has enduring consequences.

Recording Procedures

The predominant symptom presentation for an Adjustment Disorder should be indicated followed, if desired, by the Acute or Chronic specifier (e.g., Adjustment Disorder With Depressed Mood, Acute).

Differential Diagnosis

Adjustment Disorder is a residual category used to describe presentations that are a response to an identifiable stressor and that do not meet the criteria for another specific mental disorder. For example, if an individual has symptoms that meet criteria for a Major Depressive Episode in response to a stressor, the diagnosis of Adjustment Disorder is not applicable. Adjustment Disorder can be diagnosed in addition to another mental disorder only if the latter does not account for the particular symptoms that occur in reaction to the stressor. For example, an individual may develop Adjustment Disorder With Depressed Mood after losing a job and at the same time have a diagnosis of Obsessive-Compulsive Disorder.

Personality Disorders

Because Personality Disorders are frequently exacerbated by stress, the additional diagnosis of Adjustment Disorder is usually not made. However, if symptoms that are not characteristic of the Personality Disorder appear in response to a stressor (e.g., a person with Paranoid Personality Disorder develops depressed mood in response to job loss), the additional diagnosis of Adjustment Disorder may be appropriate.

Not Otherwise Specified disorders

The diagnosis of Adjustment Disorder requires the presence of an identifiable stressor, in contrast to the atypical or subthreshold presentations that would be diagnosed as a Not Otherwise Specified disorder (e.g., Anxiety Disorder Not Otherwise Specified). If the symptoms of Adjustment Disorder persist for more than 6 months after the stressor or its consequences have ceased, the diagnosis should be changed to another mental disorder, usually in the appropriate Not Otherwise Specified category.

Posttraumatic Stress Disorder and Acute Stress Disorder

Adjustment Disorder, Posttraumatic Stress Disorder, and Acute Stress Disorder all require the presence of a psychosocial stressor. Posttraumatic Stress Disorder and Acute Stress Disorder are characterized by the presence of an extreme stressor and a specific constellation of symptoms. In contrast, Adjustment Disorder can be triggered by a stressor of any severity and may involve a wide range of possible symptoms.

Psychological Factors Affecting Medical Condition

In Psychological Factors Affecting Medical Condition, specific psychological symptoms, behaviors, or other factors exacerbate a general medical condition, complicate treatment for a general medical condition, or otherwise increase the risks of developing a general medical condition. In Adjustment Disorder, the relationship is the reverse (i.e., the psychological symptoms develop in response to the stress of having or being diagnosed with a general medical condition). Both conditions may be present in some individuals.

Bereavement and nonpathological reactions to stress

Bereavement is generally diagnosed instead of Adjustment Disorder when the reaction is an expectable response to the death of a loved one. The diagnosis of Adjustment Disorder may be appropriate when the reaction is in excess of, or more prolonged than, what would be expected. Adjustment Disorder should also be distinguished from other nonpathological reactions to stress that do not lead to marked distress in excess of what is expected and that do not cause significant impairment in social or occupational functioning.

DSM-5

Diagnostic Criteria

A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

  1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
  2. Significant impairment in social, occupational, or other important areas of functioning.

C. The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.

D. The symptoms do not represent normal bereavement.

E. Once the stressor or its consequences have terminated, the symptoms do not persist for more than an additional 6 months.

Specify whether:

  • With depressed mood: Low mood, tearfulness, or feelings of hopelessness are predominant.
  • With anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant.
  • With mixed anxiety and depressed mood: A combination of depression and anxiety is predominant.
  • With disturbance of conduct: Disturbance of conduct is predominant.
  • With mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant.
  • Unspecified: For maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder.

Differential Diagnosis

Major depressive disorder

If an individual has symptoms that meet criteria for a major depressive disorder in response to a stressor, the diagnosis of an adjustment disorder is not applicable. The symptom profile of major depressive disorder differentiates it from adjustment disorders.

Posttraumatic stress disorder and acute stress disorder

In adjustment disorders, the stressor can be of any severity rather than of the severity and type required by Criterion A of acute stress disorder and posttraumatic stress disorder (PTSD). In distinguishing adjustment disorders from these two posttraumatic diagnoses, there are both timing and symptom profile considerations. Adjustment disorders can be diagnosed immediately and persist up to 6 months after exposure to the traumatic event, whereas acute stress disorder can only occur between 3 days and 1 month of exposure to the stressor, and PTSD cannot be diagnosed until at least 1 month has passed since the occurrence of the traumatic stressor. The required symptoms profile for PTSD and acute stress disorder differentiates them from the adjustment disorders. With regard to symptoms profiles, an adjustment disorder may be diagnosed following a traumatic event when an individual exhibits symptoms of either acute stress disorder or PTSD that do not meet or exceed the diagnostic threshold for either disorder. An adjustment disorder should also be diagnosed for individuals who have not been exposed to a traumatic event but who otherwise exhibit the full symptom profile of either acute stress disorder or PTSD.

Personality disorders

With regard to personality disorders, some personality features may be associated with a vulnerability to situational distress that may resemble an adjustment disorder. The lifetime history of personality functioning will help inform the interpretation of distressed behaviors to aid in distinguishing a long-standing personality disorder from an adjustment disorder. In addition to some personality disorders incurring vulnerability to distress, stressors may also exacerbate personality disorder symptoms. In the presence of a personality disorder, if the symptom criteria for an adjustment disorder are met, and the stress-related disturbance exceeds what may be attributable to maladaptive personality disorder symptoms (i.e., Criterion C is met), then the diagnosis of an adjustment disorder should be made.

Psychological factors affecting other medical conditions

In psychological factors affecting other medical conditions, specific psychological entities (e.g., psychological symptoms, behaviors, other factors) exacerbate a medical condition. These psychological factors can precipitate, exacerbate, or put an individual at risk for medical illness, or they can worsen an existing condition. In contrast, an adjustment disorder is a reaction to the stressor (e.g., having a medical illness).

Normative stress reactions

When bad things happen, most people get upset. This is not an adjustment disorder. The diagnosis should only be made when the magnitude of the distress (e.g., alterations in mood, anxiety, or conduct) exceeds what would normally be expected (which may vary in different cultures) or when the adverse event precipitates functional impairment.