The psychiatric diagnoses that arise between normal behaviour and the major psychiatric morbidities constitute the problematic subthreshold disorders. These subthreshold entities are also juxtaposed between problem-level diagnoses and more clearly defined disorders. They present major taxonomical and diagnostic dilemmas in that they are often poorly defined, overlap with other diagnostic groupings, and have indefinite symptomatology. It is therefore not surprising that issues of reliability and validity prevail. One of the most commonly employed subthreshold diagnosis that has undergone a major evolution since 1952 is adjustment disorder
(AD) (Table 1). The advantage of the indefiniteness of these subthreshold disorders is that they permit the classification of early or prodromal states when the clinical picture is vague and indistinct, and yet the morbid state is in excess of that expected in a normal reaction and this morbidity needs to be identified. Therefore AD has an essential place in the psychiatric taxonomy:
Table 1 DSM-IV criteria for adjustment disorders
1. normal state
2. problem-level diagnoses (V Codes)
3. adjustment disorders
4. disorders not otherwise specified (NOS)
Adjustment disorder would 'trump' problem-level disorders, but would be 'trumped' by a specific diagnosis even if it were in the NOS category. The aetiological and dynamic attributes of the diagnosis of AD make it an important diagnostic category that bridges normality and pathology.
Many questions prevail with regard to the concept of the adjustment disorder diagnosis: the role of stressors and the place of specific stressors; the importance of age; the role of concurrent medical morbidity, for example comorbidity of Axis I and Axis III morbidity; the specificity of the diagnostic criteria; the unavailability of a list of symptoms; uncertainty as to optimal treatment protocols; undocumented outcomes or prognosis. Research data regarding these questions will be examined.
AD is a stress-related phenomenon in which the stressor precipitates maladaptation and symptoms that are time limited until the stressor is attenuated or a new state of adaptation occurs (Table. .2). At the same time that AD was evolving, other stress-related disorders, for example post-traumatic stress disorder and acute stress disorder, have been described. (Acute stress disorders were formulated by Spiegel during the development of the DSM-IV. (1..,2)) Acute stress reactions could result from involvement in a natural disaster such as a flood, or an avalanche, or a cataclysmic personal event, for example loss of a body part. The stress-related disorders are unique in that they are psychiatric diagnoses with a known aetiology—the stressor—and this aetiology is central to the diagnosis. (Three other diagnostic categories also invoke aetiology in their diagnostic criteria: organic mental disorders (aetiology—physical abnormality); substance abuse disorders (aetiology—ingestion of substances); post-traumatic and acute stress disorders (aetiology—an identifiable stressor).) The DSM was conceptually designed with an atheoretical framework to encourage psychiatric diagnoses to be derived on phenomenological grounds with an avowed dismissal of pathogenesis or aetiology as diagnostic imperatives. In frank contradiction of this atheoretical algorithm, the stress-induced disorders require the inclusion of an aetiological significance to a life event—a stressor—and the need to relate the stressor's effect on the patient in clinical terms.
Table 2 ICD-10 definition of adjustment disorder
The diagnosis of AD also requires a careful titration of the timing of the stressor in relation to the adverse psychological sequelae that ensued. Maladaptation and disturbance of mood should obtain within 3 months of the patient experiencing the stressor. Until the DSM-IV criteria, the ADs were regarded as transitory diagnoses that should not exceed 6 months in duration. Thereafter, that appellation could not be employed and the diagnosis had to be changed to a major psychiatric disorder or dropped.
In summary, AD is a diagnosis that has been insufficiently researched but is, however, commonly employed in clinical practice. The utilization of the AD diagnosis is attributable to several issues:
1. in a diagnostic system that is principally atheoretical, AD remains one of the few conditions which is linked to an aetiologic event;
2. the concept that adjustment problems stem from stressful events has been a precept of psychodynamic thinking, and often underlies the approach of psychotherapeutic treatment;
3. because the development of transient psychiatric symptoms in the context of stress is virtually a universal experience, AD is considered by many to be a non-stigmatizing diagnosis to assign when making a patient's psychiatric status public.
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