Adjustment Disorders: Diagnosis and Differential Diagnosis

Diagnosis and Differential Diagnosis

Each of the diagnostic constructs required for the diagnosis of AD is difficult to assess and measure: 1) the stressor, 2) the mal-adaptive reaction to the stressor, and 3) the time and relationship between the stressor and the psychological response. None of these three components has been operationalized for a diagnostic decision tree, which consequently plagues the AD diagnosis with limited reliability.

In contrast to other DSM-IV-TR disorders, the diagnostic criteria for AD include no clear and specific symptoms (or check-list) that collectively compose a psychiatric (medical) syndrome or disorder.

First, with regard to the maladaptive reaction, it is unclear how this concept can or should be operationalized. The social, vocational and relationship dysfunctions, which are unspecified qualitatively or quantitatively, do not lend themselves to reliable or to valid assessment. The elements of culture (i.e., the expect-able reactions within a specific cultural environment), differ-ences in gender responses, developmental level differences and differences in the “meaning” of events and reactions to them by a specific individual further confound it.

The concepts of “average expectable environment” (e.g., the expectation of adequate food in a household in an industrial so-ciety) and “patient’s explanatory belief model” are examples of an attempt to weigh cultural and subjective differences in the assess-ment of an individual’s mental state and reaction. Such individual cultural–social considerations often require an understanding on the part of the psychiatrist and thereby often render the assessment of whether a reaction is excessive or maladaptive a judgment call.

The criterion and predictive validity of the diagnosis of AD in 92 children who had new onset insulin-dependent diabetes mellitus were examined. DSM-III criteria were employed plus requiring four clinically significant signs or symptoms, and the time frame extended to 6 months (instead of the 3 months speci-fied in the definition) after the diagnosis of diabetes. Thirty-three percent of the cohort developed AD (mean 29 days after the med-ical diagnosis) and the average episode length was 3 months with a recovery rate of 100%. The five-year cumulative probability of a new psychiatric disorder was 0.48 in comparison to 0.16 for the nonAD subjects. The findings support the criterion validity of the AD diagnosis using the criterion of predicting the future development of psychiatric disorder.