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ESSENTIALS OF DIAGNOSIS

The diagnoses of adjustment disorders should be relatively straightforward provided the clinician considers a wide range of stressors and other Axis I diagnoses, but they can present a number of pitfalls. Challenging diagnostic situations can arise when the stressor is subtle. For example, a change in a previously stable life situation may occur without the patient complaining of an obvious stressor. The clinician should exclude any specified symptom complex that meets diagnostic criteria for another Axis I disorder even if it may be related to a specific stressor. Only the other Axis I diagnoses should be recorded if its criteria are met. However, when a discrete recent stressor is identifiable, an adjustment disorder diagnosis may be more appropriate than, for example, anxiety disorder not otherwise specified or depressive disorder not otherwise specified.

The need to establish an adjustment disorder diagnosis is sometimes underestimated because of the disorder's generally mild, transient clinical course, relatively high incidence, and relatively low prevalence (see later discussion). Although its symptoms usually come and go without presenting significant treatment challenges, in some individuals the acute consequences may be quite severe. Because adjustment disorders are very common, even the very small percentage showing severe symptoms account for a significant portion of suicides (see later discussion). An absence of major mood or other major disorder does not rule out acute suicide risk. Although such extreme outcomes are extraordinarily rare compared to the frequency of these disorders, they are noted here to emphasize the essential nature of making adjustment disorder diagnoses, educating patients about responses to stress, and justifying recommendations and reimbursements for treatment.

Adjustments to the normal challenges of the life cycle are usually taken in stride with socially and culturally prescribed ranges of expected responses. However, even commonly encountered events can disrupt an unusually crucial part of an individual's self-view (Table 28–1) and provoke symptoms outside of expected norms. Stressors leading to adjustment disorders are often termed "problems in coping." Among adolescents, adjustment disorders frequently emerge following disappointment(s) in relationships with family members or friends. Especially complex difficulties may be encountered among homosexual teens. Interventions matter: in adult crime victims, early detection of adverse responses has been shown to improve outcome.

Table 28–1Commonly Observed Precipitants for Adjustment Disorders

Individuals of all ages may encounter adjustment disorders following psychiatric hospitalization, or in the course of treatment for another, otherwise unrelated, psychiatric disorder. For example, after being hospitalized for severe obsessive–compulsive disorder (OCD), a patient may express a conduct disturbance that is otherwise atypical for OCD. It may then ...

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