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Although the diagnosis of AD requires evidence of maladapat-tion, it is notable that no specific requirement for functional im-pairment has been included (e.g., there is no requirement for a certain decrement in the Global Assessment of Functioning Scale score in order to make the diagnosis). Fabrega and colleagues (1986) stated that both subjective symptoms and decrement in social function can be considered maladaptive and that the se-verity of either of these is subject to great individual variation. However, they could not conclude that the level of severity of psychiatric illness observed correlates with impaired functioning in three areas: occupational status, family, or other individuals.
The psychiatrist needs to examine the patient’s behavior to see whether it is beyond what is expected in a particular situation, and for that patient. In order to do this, the psychiatrist needs to take into account the patient’s cultural beliefs and practices, his or her developmental age and the transient nature of the behavior. If the behavior lasts a few moments or is an impulsive outburst, it would not qualify for a maladaptive response to justify the di-agnosis of AD. The behavior in question should be maladaptive for that patient, in his/her culture and sufficiently persistent to qualify for the maladaptation attribute of the AD diagnosis.
No criteria or guidelines are offered in DSM-IV-TR to quantify the degree of stress required for the diagnosis of AD or assess its effect or meaning for a particular individual at a given time. Many of the statements regarding the problem of assessing mal-adaptation described above apply equally well to the assessment of stressors. The measurement of the severity of the stressor and its temporal and causal relationship to demonstrable symptoms are often uncertain.
According to DSM-IV-TR, even if a specific and presum-ably causal stressor is identified, if enough symptoms develop so that diagnostic criteria are met for a specific disorder, then that diagnosis should be made instead of a diagnosis of AD (American Psychiatric Association, 1980, 1987, 2000). Therefore, the pres-ence of stressors does not automatically signify a diagnosis ofAD, and conversely, a diagnosis of a specific disorder (e.g., ma-jor depressive or anxiety disorder) does not imply the absence of concomitant or concurrent stressful events.
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