Assessment of the Subtypes of Adjustment Disorder, Comorbidity and Diagnostic Boundaries
The diagnostic criteria for AD define the contextual and tempo-ral characteristics of a subthreshold response to a psychosocial stressor; the specific quality and nature of the resultant psycho-logical morbidity have been used as a means of subtyping.
DSM-IV-TR identifies six AD subtypes; two of the sub-types define discrete disturbances of mood (e.g., depressed, anxious); two describe mixed clinical presentations (e.g., mixed emotional features, mixed disturbance of emotions and conduct); one specifies disturbance of conduct; and the final subtype, un-specified, is a residual category.
Significant occurrence of comorbidity has been reported in studies of AD using structured diagnostic instruments. In a cohort of children, adolescents and adults, approximately 70% of AD patients had at least one additional Axis I diagnosis. In the study of correlates of depressive disorders in children, 45% of those with AD with depressed mood had another disorder. However, comorbidity in AD was less than in dysthymic disor-der or major depressive disorder, suggesting a “purer” or more encapsulated disturbance in AD.
Several studies reported an association of suicidal behav-ior in adolescents and young adults with AD. These studies un-derscore the seriousness of AD in a subset of individuals and suggest that although the diagnosis may be subthreshold, its morbidity can be serious and at times even fatal.
The issue of boundaries between the specific mood and anxiety disorders, depressive disorder or anxiety disorder NOS, and the AD remains problematic. The specific mood and anxi-ety disorders are often associated with and even precipitated by stress. Therefore, it is not always possible to say one group of diagnoses is accompanied by stress (the AD) and another (e.g., major depressive disorder) is not. Stress may accompany many of the psychiatric diagnoses, but it is not an essential component to make certain diagnoses (e.g., major depressive disorder).
More research is needed carefully to demarcate the bound-aries or the meaning of these boundaries among the problem-level, subthreshold and threshold disorders, in particular with regard to the role of stressors as etiological precipitants, con-comitants, or factors essentially unrelated to the occurrence of a particular psychiatric diagnosis. In reviewing the diagnosis of AD for DSM-IV, one issue emerges as fundamental. The effect of the imprecision of this diagnosis on reliability and validity, because of the lack of behavioral or operational criteria, must be determined.
Snyder and Strain (1989) observed that in the acute care inpatient hospital setting, many of the psychiatric consultation patients initially thought to have an AD did not maintain that diagnosis at the time of discharge. These same authors also ob-served that many patients initially diagnosed as having major depressive disorder were reclassified to AD at discharge. It re-mains to be seen if either the major depressive disorder or the AD diagnosis is significantly altered at a 6-week follow-up and, in particular, when the patient has left the hospital. This evolution of psychiatric morbidity within the acute care general medical setting cautions the psychiatrist to go slowly with treatment until there is a level of certainty to justify an intervention, in particular with a chemotherapeutic modality.
Attempting to diagnose disorders in an early state or be-fore there is a full-blown syndrome or disorder often means that a patient will qualify for the AD criteria or the subsyndromal con-dition. Just as it is difficult to know when a patient has crossed the diagnostic line (threshold) from normal to disturbed behavior, it is difficult to know how quickly the symptoms will remit with a remission of the stressor, which for the general medical–surgical inpatient include 1) acute hospitalization, 2) uncertain medical diagnosis, 3) pain, 4) medications, 5) separation and 6) lack of ability to function or contain emotions. The AD must be looked at as a transitory state for most patients, in that it may subside, respond with treatment, evolve to another diagnosis, or be main-tained as the stressor continues.
Furthermore, Monroe and associates (1992) pointed out that “stress does not credit a more favorable treatment course for patients with recurrent depression”. For these patients, stress oc-curring before treatment entry suggests the likelihood of a poorer early treatment response and a longer time to attain relief. Psychi-atrists working with recurrent depression should not expect more rapid recovery from patients reporting these types of stress and should not become discouraged if treatment progress is slower or more erratic than usual. The severity of the stressor should be studied as well as its recurrence and its meaning to the patient, all in conjunction with treatment outcome in those with AD.