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Psychopathology 2012;45:305309
DOI: 10.1159/000336048
Key Words
Adjustment disorder ICD-10 Diagnostic stability
Reliability Nosology Life events
Abstract
Background: Adjustment disorder is a common diagnosis in
mental health services. However, the diagnostic reliability
and stability of this nosological construct are unclear. Sampling and Methods: Clinical chart records of patients who
had been discharged with a clinical diagnosis of adjustment
disorder were re-evaluated by two independent raters using
ICD-10 criteria. On the basis of the chart material, the frequency of readmissions and diagnostic changes were recorded. Results: Of 142 patients with a clinical diagnosis of
adjustment disorder, only 91 (64.1%) retrospectively met
ICD-10 criteria for this diagnosis. Eighteen of these 91 patients (19.8%) were readmitted to a mental health hospital
within a 5-year period and 9 (9.9%) showed a diagnostic
change at readmission, 5 of them to substance use disorders
(5.5%). Conclusions: The dramatic divergence between the
clinical diagnosis and ICD-10 criteria challenges the validity
and usefulness of the current nosological concept of adjustment disorder.
Copyright 2012 S. Karger AG, Basel
Introduction
ment disorder. Authors like Casey et al. [9] have even referred to an academic neglect.
As yet, the diagnostic reliability and validity of the nosological construct of adjustment disorder are dubious.
For example, Shear et al. [14] used the Structured Clinical
Interview for DSM-IV (SCID) to examine patients with a
clinical diagnosis of adjustment disorder. They found
poor agreement between the clinical and SCID diagnoses: only 17% of the patients with a clinical diagnosis of
adjustment disorder fulfilled the respective DSM-IV criteria. Similar results were reported by Taggart et al. [15].
Greenberg et al. [3] found low diagnostic stability of adjustment disorder according to DSM-III-R criteria: only
60% of patients with an adjustment disorder on admission to inpatient treatment were discharged with this diagnosis. Furthermore, only 18% of patients who were rehospitalized retained the diagnosis at readmission [3].
Against this background, the present study attempted
to explore diagnostic reliability and long-term stability of
ICD-10 adjustment disorder. The aims were to examine
(i) the accordance of the daily use of the clinical diagnosis
adjustment disorder in a German mental health hospital
with the operational criteria of ICD-10, and (ii) the stability of the diagnosis adjustment disorder in patients who
were rehospitalized within 5 years after index admission.
Methods
Sampling
Chart records of inpatients with a clinical diagnosis of adjustment disorder at discharge were reviewed. The clinical documentation system was used to identify all patients who were admitted
to the Department of Psychiatry II, Ulm University, Germany,
between 1st January 2005 and 31st December 2005 and diagnosed
at discharge as having an adjustment disorder (ICD-10: F43.2).
The sample hospital has a catchment area with 660,000 inhabitants. The diagnoses were made by senior physicians (Oberrzte).
306
Psychopathology 2012;45:305309
Results
Diagnostic Reliability
One hundred and forty-two chart records of patients
with a clinical diagnosis of adjustment disorder were reviewed. A satisfactory interrater reliability between the
two research psychiatrists was achieved (kappa = 0.69).
The results of the diagnostic reassessment are shown in
table2. Only 64.1% of the sample retrospectively fulfilled
the ICD-10 criteria for adjustment disorder.
Patients did not fulfil criteria for different reasons: 27
met the criteria for a mood or anxiety disorder, so that in
accordance with the ICD-10 criteria the diagnosis of an
adjustment disorder had to be excluded; 17 fulfilled the
criteria for a personality disorder or a substance use disorder, and the diagnosis of an adjustment disorder had to
be abandoned because of the absence of an identifiable
psychosocial stressor in the month before the onset of
symptoms; in 3 the symptoms or behavior disturbances
could be attributed to a schizophrenic disorder, and in 4
the diagnostic disagreement resulted from other reasons.
Jger/Burger/Becker/Frasch
In the patients with a confirmed diagnosis of an adjustment disorder (n = 91), 47.3% (n = 43) also fulfilled the
ICD-10 criteria for one or more comorbid mental disorders: 27 (29.6%) had a mental disorder resulting from psychotropic substance use; 14 (15.3%) from a personality
disorder, and 4 from another mental disorder (4.3%).
Five-Year Rehospitalization Outcome
The majority of patients with a confirmed diagnosis of
adjustment disorder at index admission were not readmitted to hospital (n = 73, 80.2%). Ten patients (11.0%)
were rehospitalized once and 8 patients (8.8%) two or
more times.
In 9 patients (9.9% of the total sample), the diagnosis
of adjustment disorder was maintained in further admissions. The remaining patients were diagnosed with a different disorder: 5 with a mental disorder due to psychotropic substance use (5.5%), 2 with a depressive disorder
(2.2%), 1 with a personality disorder (1.1%) and 1 with
schizophrenia (1.1%). Therefore, a diagnostic change was
found in 9 patients (9.9% of the total sample and 50% of
the rehospitalized patients).
noses
91
19
12
64.1
13.4
8.5
8
5
5.6
3.5
3
4
2.1
2.8
142
100
Shear et al. [14], who used the SCID in face-to-face interviews to reassess clinical diagnoses. Similar results were
reported by Taggart et al. [15]. However, this study indicates that the divergence between everyday clinical diagnoses and the stringency of research criteria is not limited to adjustment disorders [15].
Our study found a high comorbidity rate of adjustment disorder with other mental disorders (47.3%), which
is in agreement with findings of previous studies [3, 20
24]. However, the frequency of comorbid mental disorders due to psychoactive substances (29.6%) was about
twice that described elsewhere [20, 21].
The present study found a 5-year readmission rate of
19.8% for patients with an ICD-10 adjustment disorder at
index admission, but Jones et al. [25] reported a lower readmission rate (6.9%) for DSM-IV adjustment disorder.
These divergent findings can possibly be explained by
different thresholds for inpatient treatment in Germany
and the United States. In the present study, diagnostic
change was observed in 50% of patients with readmissions. These results are in contrast to those of Greenberg
et al. [3], who reported that only 18% of the readmitted
patients retained the diagnosis of adjustment disorder.
However, the sample of Greenberg et al. [3] included all
patients with an admission diagnosis of adjustment disorder, and a diagnostic change took place during the index episode in 40% of the patients.
Of the total sample with a confirmed diagnosis of adjustment disorder at index admission, we observed a diagnostic change in only 9.9%. Assuming that patients
without a readmission had no further episode of severe
mental illness and therefore retained the initial diagnosis
of adjustment disorder, this finding would imply high di-
Psychopathology 2012;45:305309
Discussion
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Psychopathology 2012;45:305309
The present study adopted the methodological approaches of Vollmer-Larsen et al. [16] and Greenberg et
al. [3] and was thus limited by the sole use of clinical chart
records to re-evaluate the clinical diagnoses and lack of
face-to-face interviews. Therefore, the study might have
over- or underestimated the divergence between clinical
diagnoses and ICD-10 criteria. Nevertheless, our study
shows a low reliability of the clinical diagnosis adjustment disorder because many clinicians did not use the
ICD-10 criteria properly in accordance with their own
chart records.
The frequency of rehospitalizations as a proxy measure of an episode of severe mental illness was derived
from the clinical chart records without a systematic follow-up assessment. The use of outpatient treatment, potential readmissions to other hospitals and suicides were
not assessed. Therefore, all conclusions with respect to
Jger/Burger/Becker/Frasch
the validity of the nosological concept of adjustment disorder. As yet, the future classification of reactions to
stressful life events in ICD-11 and DSM-V is unclear.
Acknowledgement
The authors thank Jacquie Klesing, ELS, for editing assistance
with the manuscript.
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