Chapter 29

The diagnosis of adjustment disorder would seem relatively straightforward, provided the clinician considers a wide range of stressors and other Axis I diagnoses, but it can present a number of pitfalls. Challenging diagnostic situations can arise when the stressor is subtle, for example, in a change of a previously stable life situation without any 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, if a discrete recent stressor has been identified, an adjustment disorder diagnosis may be more appropriate than, for example, anxiety disorder not otherwise specified or depressive disorder not otherwise specified.

The normal challenges of a life cycle are usually taken in stride with socially and culturally prescribed ranges of expected responses. However, commonly encountered events can disrupt an unusually crucial part of an individual's self-view (Table 29–1), 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. In adult crime victims, early detection of adverse responses was shown to improve outcome.

Table 29–1. Commonly Observed Precipitants for Adjustment Disorders

Individuals of all ages may encounter adjustment disorders following psychiatric hospitalization, or after 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 be appropriate to add the diagnosis of adjustment disorder. Exceptionally severe or extreme stressors may precipitate maladaptive responses. Retirement and aging can bring feelings of loss, depleted health and vigor, and fear of the future. If the symptoms and gravity of the stressor are less than those required for acute stress disorder, the diagnosis of adjustment disorder may be appropriate.

Lacking clear behavioral or emotional symptom criteria, the validity of the diagnostic label of adjustment disorder is sometimes questioned. Diagnostic recording allows communication with patients, insurers, and other clinicians. It assists in disease control by focusing research and guiding therapeutic selection. Contemporary knowledge of differential diagnosis, prognosis, course, and future risks may be illuminated by naming a disorder. Even though more studies are needed, the adjustment disorder diagnosis fulfills these expectations. The therapist will find criteria easily met, defensible, and practical. However, the adjustment disorder diagnosis must not become a conciliatory label aimed ...

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