43
CATEGORY SPONSORED BY CME LLC • PSYCHIATRIC TIMES • JANUARY 2012
Adjustment Disorder: Diagnostic and
Treatment Issues
by Patricia Casey, FRCPI, FRCPsych, MD
and Anne Doherty, MBBCh, MedS,
MRCPsych
T
he diagnostic category of adjustment dis-
order (AD) made its first appearance in
DSM-III in 1968. It replaced the previ-
ous “transient situational disturbance” of
DSM-II, and shortly after was included in ICD-9.
It has persisted into the current versions of both
DSM-IV and ICD-10. The inclusion of AD rec-
ognizes that people can often develop symptoms
or exhibit behaviors in response to stressful
events that are in excess of normal reactions.
Resolution with the minimum of intervention,
CREDITS: 1.5
RELEASE DATE: January 20, 2012
EXPIRATION DATE: January 20, 2013
FACULTY
Patricia Casey, FRCPI, FRCPsych, MD, Professor of
Psychiatry, University College, Dublin; Consultant
Psychiatrist, Mater Misericordiae University Hospital
Anne Doherty, MBBCh, MedS, MRCPsych, Senior Registrar
in Psychiatry, St James Hospital, Dublin
DISCLOSURES
Professor Casey and Dr Doherty have no relationships to
disclose relating to the subject matter of this article.
Applicable CME LLC staff have no relationships to disclose
relating to the subject matter of this activity.
This activity has been independently reviewed for balance.
TARGET AUDIENCE
This continuing medical education activity is intended for
psychiatrists, psychologists, primary care physicians,
physician assistants, nurse practitioners, and other health
care professionals who seek to improve their care for
patients with mental health disorders.
GOAL STATEMENT
This activity will provide participants with a better
understanding of adjustment disorders, which will enable
them to assess symptoms and make treatment decisions.
ESTIMATED TIME TO COMPLETE
The activity in its entirety should take approximately 90
minutes to complete.
To earn credit online, go to www.PsychiatricTimes.com/cme.
apart from general supportive measures, is fre-
quent either when the stressor is removed or as
new levels of adaptation are reached. Manage-
ment of anxiety or insomnia symptoms, or brief
psychological treatments are sometimes used to
shorten the duration or reduce the intensity of AD
episodes. In patients with AD, both emotional
and behavioral disturbances are present and in-
clude low mood, tearfulness, anxiety, self-harm,
withdrawal, anger, and irritability.
Definition
AD is defined in DSM-IV as:
. . . emotional or behavioral symptoms in re-
sponse to an identifiable stressor(s) occurring
LEARNING OBJECTIVES
After completing this activity, participants should be able to:
• Understand the diagnostic issues associated with
adjustment disorders
• Recognize the most useful screening tools for adjustment
disorders
• Implement a differential diagnosis
• Understand the psychotherapeutic and
psychopharmacological treatment options
• Better appreciate the implications for adjustment
disorders in regard to DSM-5
COMPLIANCE STATEMENT
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the direction of CME LLC. The activity was planned and
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Code on Interactions with Healthcare Professionals, thus
assuring the highest degree of independence, fair
balance, scientific rigor, and objectivity.
ACCREDITATION STATEMENT
This activity has been planned and implemented in accor-
dance with the Essential Areas and policies of the ACCME
through the joint sponsorship of CME LLC and Psychiatric
Times. CME LLC is accredited by the ACCME to provide
continuing medical education for physicians.
CREDIT DESIGNATION
CME LLC designates this enduring material for a maximum
of 1.5 AMA PRA Category 1 Credits™. Physicians should
claim only the credit commensurate with the extent of their
participation in the activity.
within 3 months of the onset of the stressor(s).
These symptoms or behaviors are clinically
significant as evidenced by either . . . marked
distress that is in excess of what would be ex-
pected from the stressor [or] significant im-
pairment of social or occupational (academic)
functioning.
This definition excludes the diagnosis if there
is another Axis I or II disorder to which the symp-
toms may be attributed or if the symptoms are
due to bereavement (Table). AD is classified as
either acute or chronic, and within each form
there are subtypes with depressed mood, with
anxiety, with mixed anxiety and depressed mood,
(Please see Adjustment Disorder, page 44)
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and other experts whose input is included in this activity
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44 PSYCHIATRIC TIMES
Adjustment Disorder
Continued from page 43
with disturbance of conduct, with mixed distur-
bance of emotions and conduct, and not other-
wise specified.
ICD-10 limits the time frame of onset of the
symptoms to within 1 month of the causative
stressor and, as with DSM-IV, it categorizes AD
as one of exclusion, specifying that the criteria
for an affective disorder must not be met. The
categories in ICD-10 are brief depressive reac-
tion, prolonged depressive reaction, mixed anxi-
ety and depressive reaction, with predominant
disturbance of other emotions, with predominant
disturbance of conduct, with mixed disturbance
of emotions and conduct, and with other speci-
fied predominant symptoms.
While DSM-IV states that the symptoms
should resolve within 6 months, it also recog­
nizes a chronic form if exposure to the stressor is
long-term or the consequences of exposure to the
stressor are prolonged. For example, the loss of a
job may lead to the loss of the home, thereby
causing marital problems. So the diagnosis can
be made even when the index event has resolved
or the 6-month time frame has been reached if
consequences continue. ICD-10 is silent on the
knock-on effect of stressors but allows a 2-year
period of symptoms in the prolonged depressive
subtype.
Symptoms caused by mood fluctuations in
response to day-to-day stressful events that occur
in persons with borderline (emotionally unstable)
personality disorder are not classified as AD.
AD is one of the few psychiatric diagnoses for
which the etiology, symptoms, and course, rather
than symptoms alone, are central to making the
diagnosis.1
Controversies and dilemmas
A diagnosis of AD raises a number of dilemmas.
The first is the distinction from normal reactions
to stress, a separation that is important so as not
to pathologize the day-to-day travails of life.
There is nothing to assist the clinician in making
this distinction except that ICD-10 requires both
functional impairment and symptoms to make
the diagnosis, while DSM requires symptoms or
impairment. Thus, ICD is more stringent and has
a higher threshold than DSM. Arguably, a deci-
sion on whether a reaction is pathological should
take account of a number of factors, including:
• C ultural differences in the expression of
Table DSM-IV criteria for adjustment disorder
• Occurs within 3 months of the onset of a stressor
•M
 arked by distress that is in excess of what would be expected, given the nature of the stressor, or by
significant impairment in social or occupational functioning
• S hould not be diagnosed if the disturbance meets the criteria for another Axis I disorder or if it is an
exacerbation of a preexisting Axis I or II condition
• Should not be diagnosed when the symptoms represent bereavement
• T he symptoms must resolve within 6 months of the termination of the stressor but may persist for a
prolonged period (longer than 6 months) if they occur in response to long-term exposure to a stressor or to a
stressor that has enduring consequences
CATEGORY 1
emotion
• Individual circumstances (eg, the loss of a job
may render a person homeless, which is appro-
priately associated with high levels of distress)
• The mere fact of visiting a doctor or being re-
ferred to a mental health professional should not
inevitably be regarded as indicative of disorder
• The level of functional impairment as a result of
the symptoms (ICD-10 only)
The second dilemma is the differentiation of
AD from other Axis I disorders, such as general-
ized anxiety disorder (GAD) and major depres-
sive disorder (MDD). Simply on the basis of
symptom numbers and duration of more than 2
weeks, AD would be relabeled as MDD after the
time threshold has been crossed, even though the
onset of symptoms was temporally close to the
stressor. Thus, a young woman with children who
had received a diagnosis of stage IV cancer 3
weeks earlier and now has low mood, is not
sleeping, is unable to get pleasure from life, has
recurrent thoughts of dying, and has poor concen-
tration might variously be thought to be experi-
encing an appropriate reaction, an AD, or MDD.
Examples such as this highlight the need for con-
tinued monitoring.
Ordinarily, one would expect the symptoms to
resolve when the stressor diminished or was re-
moved. At other times, notwithstanding the per-
sistence of the stressor or its ramifications, the
person adapts. A diagnostic conundrum arises,
however, when the symptoms and the stressor
persist in tandem—is the appropriate diagnosis
chronic AD, MDD, or appropriate sadness? In
general, normal reactions to events resolve
quickly and do not persist, hence the time frames
specified in DSM-IV and ICD-10. A further rea-
son for monitoring is that the symptoms may rep-
resent a disorder, such as evolving MDD that
emerges more clearly over time.
Another controversy stems from the subsyn-
dromal nature of AD. It may be that allowing
MDD to override a diagnosis of AD is a clinical
mistake, since there is little to distinguish one
from the other in terms of symptoms, although
the course of each is different.2 In addition, doing
so is illogical because the diagnosis of MDD is
cross-sectional and is based on symptom num-
bers and duration; the course of AD is longitudi-
nal and is based on etiology and duration. Thus,
MDD and AD represent conceptually different,
nonoverlapping dimensions.
This suggests that the current diagnostic sys-
tem based on symptom thresholds is limited and
JANUARY 2012
that in DSM-5, more emphasis should be placed
on the specific symptom clusters and their quali-
ty. Moreover, the longitudinal course of AD
should receive more attention. Since, currently, a
diagnosis of AD cannot be made when the thresh-
old for another condition is met, it is regarded as
a subsyndromal rather than a full Axis I disorder.1
However, its clinical importance may be such
that it should be accorded full syndromal status
with its own diagnostic criteria.3
Prevalence
AD is underresearched, and most of the large
epidemiological surveys of the general popula-
tion lack any prevalence data for AD, including
the Epidemiological Catchment Area study, the
US National Comorbidity Survey, and the Na-
tional Psychiatric Morbidity surveys of Great
Britain.4-6 As a result, the diagnostic category of
AD has not received the attention that it warrants
and most of the scientific data are derived from
smaller studies made up of particular clinical
groups.
The prevalence of AD has been found to be
11% to 18% in primary care.7,8 In consultation-
liaison, where the diagnosis is most often made,
the rates are similar: 7.1% to 18.4%.9-11 This,
however, is in a state of flux, and it may be that
the “culture of prescription” drives the “culture of
diagnosis.”1 The diagnosis of AD has declined
from 28% in 1988 to 14.7% in 1997, while the
diagnosis of MDD has increased (6.4% to 14.7%)
over the same 10 years.12
A major problem in studying AD is the ab-
sence of any specific diagnostic criteria with
which to make the diagnosis. (Instruments such
as the Structured Clinical Interview for DSM
[SCID] and the Schedules for Clinical Assess-
ment in Neuropsychiatry [SCAN] include the
criteria for AD, albeit in a cursory manner.) So it
is not possible to achieve a gold standard measure
on the basis of the current criteria in DSM-IV and
ICD-10. For this reason, clinical diagnosis with
all its associated problems is the only standard
currently available.
Structured diagnostic and
screening instruments for AD
Structured interviews are frequently considered
the gold standard in psychiatric research because
they eliminate the subjective element of the diag-
nostic process; however, for purposes of diagnos-
ing AD, there are problems. Some of the most
widely used structured interviews in research,
such as the Clinical Interview Schedule and the
Composite International Diagnostic Interview,
fail to include AD.13,14 Others, such as SCID,
SCAN, and the Mini International Neuropsychi-
atric Interview, include AD but regard it as a sub-
syndromal diagnosis.15-17 This commonly leads to
AD being ignored or conflated with and sub-
sumed by MDD.2,18
Screening instruments have likewise met with
little success in distinguishing between AD and
MDD. The Zung Depression Scale, the One-
Question Interview, the Impact Thermometer,
and the Hospital Anxiety and Depression Scale,
although helpful in identifying possible mood
disorders, are of little use in differentiating AD
from MDD.19-21
JANUARY 2012
Since diagnostic interviews and screening in-
struments either fail to distinguish between AD
and MDD or entirely omit AD, their utility is lim-
ited when applied to AD. Thus, the diagnosis of
AD relies on the traditional medical skills of care-
ful history taking and clinical judgment in assess-
ing the presenting symptoms, the context in which
the symptoms arise, and the likely course of the
condition.
Diagnosis
The presence of a stressor is central to the diagno-
sis of AD, and this is the consideration that most
sets AD apart from other disorders in DSM-IV
and ICD-10. This makes AD similar to PTSD and
to acute stress disorder, which also require a
stressor—the symptoms would not have devel-
oped if there had been no stressor. This differs
from MDD, which does not require a stressor, al-
though many episodes of MDD are preceded by a
life event.
AD is more strongly associated with marital
problems and less with family-related or occupa-
tional stressors than MDD.22 Clinically, this is un-
likely to be helpful because the types of events are
not specific and even traumatic events can trigger
AD as well as PTSD.
Symptoms are important to any clinical diag-
nosis, but they are not sufficiently specific to
allow a distinction to be made between AD and
MDD.10,23 While neither of the classifications
specifies the symptoms required for a diagnosis of
AD, there are some symptoms that may be indica-
tive of AD. Yates and colleagues24 found that diur-
nal mood variation, the loss of mood reactivity, a
distinct quality to the mood, and a family history
of MDD were predictive of a diagnosis of MDD
rather than AD. Further studies are needed to
demonstrate whether these symptoms have suffi-
cient specificity.
The mood state of those with AD often de-
pends on the cognitive presence of the stressor so
that immediate impairment of mood is observed
when the stressor is discussed, with more obvious
mood recovery when the patient is distracted.
Thus, removing the person from the stressful situ-
ation will lead to a reduction in symptoms that
would otherwise persist.
Because of the limitations in the criteria for di-
agnosing AD, the diagnosis is based on the pres-
ence of a precipitating stressor and on a clinical
evaluation of the likelihood of symptom resolu-
tion on removal of the stressor. For those exposed
to stressors long-term, the diagnosis of AD is less
clear because this type of exposure can be associ-
ated with MDD, GAD, or AD.
Depending on the predominant symptoms, the
differential diagnosis may be MDD, GAD, or
evolving MDD. When the person exhibits behav-
ioral disturbance such as self-harm or anger, bor-
derline personality disorder must be excluded. For
those who have experienced a traumatic event,
PTSD must be considered; however, PTSD does
not develop in all persons who have been exposed
to a traumatic event, and therefore AD may be a
more appropriate diagnosis. Unlike most other
disorders in DSM, AD must be distinguished from
a normal homeostatic reaction to stress. Failure to
consider this could lead to normal distress being
miscategorized as a psychiatric disorder.25
CATEGORY 1
Treatment
AD is largely short-lived and generally resolves
spontaneously, which may account for the paucity
of studies on the treatment of this common condi-
tion. Yet treatment cannot be disregarded, since,
despite its brevity, symptoms may be severe and
are associated with a risk of suicide.26 In addition,
the effect on quality of life and functioning means
that there are social and even economic reasons
why interventions are worthy of further study.26
In clinical practice, 3 approaches to treatment
deserve consideration on the basis of the stress
response model:
• Modifying or removing the stressor
• Facilitating adaptation to the stressor using
various psychological therapies
• Altering the symptomatic response to the
stressor with medication or behavioral
approaches
Brief psychotherapy has been identified as the
treatment of choice for AD.27 Approaches using
ego strengthening and mirror therapy have shown
some success in specific groups, such as the el-
derly during transition phases and those recover-
ing from myocardial infracts.28,29 For patients who
have experienced work-related stress, cognitive
interventions have been effective.30
Most randomized controlled trials have focussed
on pharmacotherapy for AD with anxiety subtypes.
In a study that compared a benzodiazepine with a
nonbenzodiazepine anxiolytic, more patients re-
sponded to the nonbenzodiazepine, although the
reduction in symptom severity was the same by day
28 of the study. Fewer patients who received the
nonbenzodiazepine experienced rebound anxiety
when medication was discontinued.31
Two randomized placebo-controlled studies
that examined symptom response in patients with
AD with anxiety subtypes showed a positive ef-
fect with kava-kava and valerian extracts.32,33 Ans-
seau and colleagues34 found that anxiolytics and
antidepressants were equally effective in patients
with AD and anxiety. Results from a randomized
controlled trial of pharmacological and psycho-
therapeutic interventions that included supportive
psychotherapy, an antidepressant, a benzodiaze-
pine, and placebo showed significant improve-
ments regardless of the intervention.35
There have been no randomized clinical trials
that compared antidepressants with placebo or
other pharmacological treatments for AD with the
depression subtype. Evidence for the use of med-
ications, especially antidepressants, is lacking,
and further studies are required.
Prognostic considerations
The most common comorbidities with AD are
personality disorder and substance abuse disor-
ders, which have been associated with poor out-
come.36-39 Patients with AD are at increased risk
for suicide. Psychological autopsy studies have
shown that between 6% and 25% of patients who
die by suicide have received a diagnosis of AD.26,40
The rates of AD in patients who present after an
act of self-harm range from 4% to 10%.41,42 Sui-
cidal ideation has been found to be of a more rapid
onset and resolution in patients with AD than in
patients with other disorders.41
The definition of AD in both DSM-IV and
ICD-10 conveys an expectation of good outcome,
PSYCHIATRIC TIMES 45
with the spontaneous resolution of symptoms.
This has been borne out in follow-up studies that
found that patients who received a diagnosis of
AD on admission had shorter index admissions
and fewer psychiatric readmissions than those
who received another diagnosis.38
DSM-5 and beyond
The problems concerning the absence of specific
diagnostic criteria for AD and the relegation of
AD to subsyndromal status are significant con-
cerns that should be taken into account during the
framing of DSM-5. Suggestions for new criteria
for AD include the following3:
• Terminating the subsyndromal status of AD
and according it full diagnostic criteria along-
side MDD and GAD
• Extending the bereavement exclusion to other
events
• Recognizing that AD may be conflated with
MDD, the following wording is suggested:
“Stressors may also trigger adverse reactions
that symptomatically resemble major depres-
sion, anxiety or conduct disorders but are bet-
ter classified as AD, particularly when there
is a close temporal relationship between the
event and the onset of symptoms and sponta-
neous recovery is anticipated after a period of
adaptation or when the stressor is removed.”
• Associating the condition with symptoms
and impairment
Currently, the broad criteria for MDD have the
unintended consequence of drawing self-limited
conditions, such as AD, into their net, simply be-
cause they reach the threshold in terms of duration
or symptom numbers, leading to a mistaken belief
that the prevalence of MDD is increasing. Devel-
oping criteria for AD in DSM-5 will also affect
the criteria for MDD. The requirement for func-
tional difficulties as well as symptoms reduces the
likelihood that normal adaptive reactions are
deemed pathological and corresponds with ICD-
10 and ICD-11.
AD should also be considered in a separate cat-
egory of stress-related disorders together with
PTSD, acute stress reactions and, possibly, dis-
sociation, because all are triggered by a stressful
event. The continuing interest in PTSD will in-
evitably help direct research endeavors to the as-
sociated categories. This change would lead to
greater harmonization between DSM-5 and ICD-
11, in which AD is classified in the stress-related
group.
The classification of AD is of more than theo-
retical interest, since it has implications for how
normal stress responses are distinguished from
those that are pathological on the one hand and
how pathological responses are distinguished
from other psychiatric disorders such as MDD
and GAD, on the other.
This also has financial implications because
antidepressants are now the most commonly pre-
scribed medications in the United States.43 The
proportion of the general population for whom
antidepressants are prescribed almost doubled
from 5.84% in 1996 to 10.12% in 2005. During
this time, the use of antidepressants for “depres-
sion,” anxiety, and AD increased significantly.
The biggest increase was seen in patients with
(Please see Adjustment Disorder, page 46)
46 PSYCHIATRIC TIMES
Adjustment Disorder
Continued from page 45
AD—22.3% to 39.4% annually, and this increase
is set against a backdrop of a near total absence
of scientific evidence for their benefit. Thus,
the public is paying for pharmacological treat-
ments that are not necessary and not supported
by evidence.
References
1. Strain JJ, Diefenbacher A. The adjustment disorders: the conun-
drums of the diagnoses. Compr Psychiatry. 2008;49:121-130.
2. Casey P, Maracy M, Kelly BD, et al. Can adjustment disorder and
depressive episode be distinguished? Results from ODIN. J Affect Dis-
ord. 2006;92:291-297.
3. Baumeister H, Maercker A, Casey P. Adjustment disorder with de-
pressed mood: a critique of its DSM-IV and ICD-10 conceptualisations
and recommendations for the future. Psychopathology. 2009;42:139-
147.
4. Myers JK, Weissman MM, Tischler GL, et al. Six-month prevalence of
psychiatric disorders in three communities 1980 to 1982. Arch Gen
Psychiatry. 1984;41:959-967.
5. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder
in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-
1060.
6. Jenkins R, Lewis G, Bebbington P, et al. The National Psychiatric
Morbidity surveys of Great Britain—initial findings from the household
survey. Psychol Med. 1997;27:775-789.
7. Casey PR, Dillon S, Tyrer PJ. The diagnostic status of patients with
conspicuous psychiatric morbidity in primary care. Psychol Med.
1984;14:673-681.
8. Blacker CVR, Clare AW. The prevalence and treatment of depression
in general practice. Psychopharmacology. 1988;95:14-17.
9. Strain JJ, Smith GC, Hammer JS. Adjustment disorder: a multisite
study of its utilization and interventions in the consultation-liaison psy-
chiatry setting. Gen Hosp Psychiatry. 1998;20:139-149.
10. Taggart C, O’Grady J, Stevenson M, et al. Accuracy of diagnosis at
routine psychiatric assessment in patients presenting to an accident
and emergency department. Gen Hosp Psychiatry. 2006;28:330-335.
11. Bakr A, Amr M, Sarhan A, et al. Psychiatric disorders in children with
chronic renal failure. Pediatr Nephrol. 2007;22:128-131.
12. Diefenbacher A, Strain JJ. Consultation-liaison psychiatry: stability
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Participants are allowed 2 attempts to successfully complete the activity.
To speak to a customer service representative, call (800) 447-4474 or (201) 984-6278 (M - F, 9 am to 6 pm Eastern Time).
1. Which of the following is not considered relevant in making
a diagnosis of adjustment disorder (AD)?
A. A stressful event
B. Exclusion of any other Axis I or II disorder
C. Symptoms due to mood fluctuations in response to
day-to-day stresses
D. Etiology, symptoms, and course
2. To make a diagnosis of AD, DSM requires both symptoms and
impairment.
A. True
B. False
3. Which of the following statements is true?
A. The diagnosis of AD is cross-sectional and based on
symptom numbers and duration.
B. The course of AD is longitudinal and based on etiology and
duration.
C. MDD and AD are conceptually similar with overlapping
dimensions.
CATEGORY 1
and change over a 10-year period. Gen Hosp Psychiatry. 2002;24:249-
256.
13. Lewis G, Pelosi AJ, Araya R, Dunn G. Measuring psychiatric disorder
in the community: a standardized assessment for use by lay interview-
ers. Psychol Med. 1992;22:465-486.
14. Kessler RC, Üstün TB. The World Mental Health (WMH) Survey Ini-
tiative Version of the World Health Organization (WHO) Composite Inter-
national Diagnostic Interview (CIDI). Int J Methods Psychiatr Res.
2004;13:93-121.
15. First MB, Gibbon M, Spitzer RL, Williams JBW. Structured Clinical
Interview for DSM-IV Axis I Disorders (SCID 1). New York: New York State
Psychiatric Institute Biometric Research Department; 1996.
16. Wing JK, Babor T, Brugha T, et al. SCAN. Schedules for Clinical As-
sessment in Neuropsychiatry. Arch Gen Psychiatry. 1990;47:589-593.
17. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International
Neuropsychiatric Interview (M.I.N.I.): the development and validation
of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.
J Clin Psychiatry. 1998;59(suppl 20):22-33.
18. Parker G. Beyond major depression. Psychol Med. 2005;35:467-
474.
19. Gawronski I, Privette G. Empathy and reactive depression. Psychol
Rep. 1997;80(3, pt 1):1043-1049.
20. Akizuki N, Akechi T, Nakanishi T, et al. Development of a brief
screening interview for adjustment disorder and major depression in
patients with cancer. Cancer. 2003;97:2605-2613.
21. Akechi T, Okuyama T, Sugawara Y, et al. Major depression, adjust-
ment disorders, and post-traumatic stress disorder in terminally ill
cancer patients: associated and predictive factors. J Clin Oncol.
2004;22:1957-1965.
22. Despland JN, Monod L, Ferrero F. Clinical relevance of adjustment
disorder in DSM-III-R and DSM-IV. Compr Psychiatry. 1995;36:454-
460.
23. Shear MK, Greeno C, Kang J, et al. Diagnosis of nonpsychotic pa-
tients in community clinics. Am J Psychiatry. 2000;157:581-587.
24. Yates WR, Mitchell J, Rush AJ, et al. Clinical features of depressed
outpatients with and without co-occurring general medical conditions
in STAR*D. Gen Hosp Psychiatry. 2004;26:421-429.
25. Maj M. Are we able to differentiate between true mental disorders
and homeostatic reactions to adverse life events. Psychother Psycho-
som. 2007;76:257-259.
26. Foster T, Gillespie K, McClelland R. Mental disorders and suicide in
Northern Ireland. Br J Psychiatry. 1997;170:447-452.
27. Kaplan HI, Sadock BJ. Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry. 8th ed. Baltimore: Williams &
Wilkins; 1998.
28. Frankel M. Ego enhancing treatment of adjustment disorders of
later life. J Geriatr Psychiatry. 2001;34:221-223.
CATEGORY 1 POSTTEST
4. Which of the following may easily be misdiagnosed for AD?
A. Major depressive disorder (MDD)
B. Bipolar disorder
C. Borderline personality disorder
5. Structured diagnostic and screening instruments such as the
Clinical Interview Schedule have well-developed criteria for
assessing and diagnosing AD.
A. True
B. False
6. One study found that diurnal mood variation, the loss of
mood reactivity, and a distinct quality to the mood were
predictive of
A. MDD
B. AD with depressed mood
7. Most randomized controlled trials have focused on
pharmacotherapy for AD with anxiety subtypes.
A. True
B. False
JANUARY 2012
29. González-Jaimes EI, Turnbull-Plaza B. Selection of psychotherapeu-
tic treatment for adjustment disorder with depressive mood due to
acute myocardial infarction. Arch Med Res. 2003;34:298-304.
30. van der Klink JJ, Blonk RW, Schene AH, Dijk FJ. Reducing long term
sickness absence by an activating intervention in adjustment disorders:
a cluster randomised controlled design. Occup Environ Med. 2003;
60:429-437.
31. Nguyen N, Fakra E, Pradel V, et al. Efficacy of etifoxine compared to
lorazepam monotherapy in the treatment of patients with adjustment
disorders with anxiety: a double-blind controlled study in general prac-
tice [published correction appears in Hum Psychopharmacol. 2006;
21:562]. Hum Psychopharmacol. 2006;21:139-149.
32. Volz HP, Kieser M. Kava-kava extract WS 1490 versus placebo in
anxiety disorders—a randomized placebo-controlled 25-week outpa-
tient trial. Pharmacopsychiatry. 1997;30:1-5.
33. Bourin M, Bougerol T, Guitton B, Broutin E. A combination of plant
extracts in the treatment of outpatients with adjustment disorder with
anxious mood: controlled study versus placebo. Fundam Clin Pharma-
col. 1997;11:127-132.
34. Ansseau M, Bataille M, Briole G, et al. Controlled comparison of
tianeptine, alprazolam and mianserin in the treatment of adjustment
disorders with anxiety and depression. Hum Psychopharmacol. 1996;
11:293-298.
35. De Leo D. Treatment of adjustment disorders: a comparative evalu-
ation. Psychol Rep. 1989;64:51-54.
36. Rundell JR. Demographics of and diagnosis in Operation Enduring
Freedom and Operation Iraqi Freedom personnel who were psychiatri-
cally evacuated from the theatre of operations. Gen Hosp Psychiatry.
2006;28:352-356.
37. Looney JG, Gunderson EK. Transient situational disturbances:
course and outcome. Am J Psychiatry. 1978;135:660-663.
38. Greenberg WM, Rosenfeld DN, Ortega EA. Adjustment disorder as
an admission diagnosis. Am J Psychiatry. 1995;152:459-461.
39. Al-Turkait FA, Ohaeri JU. Post-traumatic stress disorder among
wives of Kuwaiti veterans of the first Gulf War. J Anxiety Disord.
2008;22:18-31.
40. Marttunen MJ, Aro HM, Henriksson MM, Lönnqvist JK. Adolescent
suicides with adjustment disorders or no psychiatric diagnosis. Eur
Child Adolesc Psychiatry. 1994;3:101-110.
41. Polyakova I, Knobler HY, Ambrumova A, Lerner V. Characteristics
of suicidal attempts in major depression versus adjustment reactions.
J Affect Disord. 1998;47:159-167.
42. Chiou PN, Chen YS, Lee YC. Characteristics of adolescent suicide
attempters admitted to an acute psychiatric ward in Taiwan. J Chin Med
Assoc. 2006;69:428-435.
43. Olfson M, Marcus SC. National patterns in antidepressant medica-
tion treatment. Arch Gen Psychiatry. 2009;66:848-856. r
8. Which of the following is essential to the diagnosis of AD in
DSM-IV?
A. Functional impairment
B. At least 1 psychotic episode
C. The presence of a stressor
9. According to psychological autopsy studies, what percentage
of persons who die by suicide have previously received a
diagnosis of AD?
A. 4% to 10%
B. 7% to 12%
C. 6% to 25%
10. In framing DSM-5, which of the following might be
considered?
A. Changing the status of AD from subsyndromal to full
diagnostic criteria
B. Removing AD from DSM altogether
C. Combining AD and complicated grief under one
diagnostic entity
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