Adjustment Disorder

Definition

Adjustment Disorder is a condition in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) category of Trauma- and Stressor-Related Disorders.

The essential feature of an Adjustment Disorder is the presence of emotional or behavioural symptoms in response to an identifiable stressor.

The stressor(s) may be of any severity (e.g., retirement or traumatic loss of a significant other).

The stressors may be a single event (e.g., loss of a job) or there may be multiple events (e.g., a divorce, custody issues and financial difficulties).

Stressors may be recurrent (e.g., seasonal business difficulties) or ongoing/continuous (e.g., a persistent painful illness with increasing disability).

By definition, the symptoms of an Adjustment Disorder begin within three months of the onset of the identifiable stressor(s) and last no longer than six months after the stressor, or its consequences, have ceased.

If the stressor(s), or its consequences, are ongoing/ continuous the Adjustment Disorder may become persistent.

Only Adjustment Disorder which has become persistent may be granted entitlement.

Criteria Set for Adjustment Disorder

The Adjustment Disorder criteria set is derived from the DSM-5. The diagnosis of an Adjustment Disorder may include a specifier which characterizes the predominant symptoms.

Adjustment Disorder:

Criterion A

The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).

Criterion B

These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:

1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
2. Significant impairment in social, or occupational, or other important areas of functioning.

Criterion C

The stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.

Criterion D

The symptoms do not represent normal bereavement.

Criterion E

Once the stressor or its consequences has terminated, the symptoms do not persist for more than an additional 6 months.

Diagnostic Standard

A diagnosis from a qualified medical practitioner (family physician or psychiatrist) or a registered/licensed psychologist is required.

The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible.

NOTE: Entitlement should be granted for a chronic condition only. For VAC purposes, "chronic" means the signs and symptoms of the condition have existed for at least six months. Signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane over the six month period and thereafter.

Entitlement Considerations

A. Causes And/Or Aggravation

Causal or Aggravating Factors versus Predisposing Factors

Causal or aggravating factors directly result in the onset or aggravation of the claimed psychiatric condition.

Predisposing factors do not cause a claimed condition. Predisposing factors are experiences or exposures which affect the individual's ability to cope with stress. Predisposing factors makes an individual more susceptible to developing the claimed condition. For example, the presence of a remote history of severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life.

Partial entitlement should only be considered for non-service related causal or aggravating factors.

Partial entitlement should not be considered for predisposing factors.

If it is unclear if a factor is a causal or aggravating factor versus a predisposing factor consultation with Medical Advisory is strongly recommended.

NOTE: The onset of symptoms of an Adjustment Disorder occurs within three months of an identifiable stressor(s). The documentation of the symptoms and/or the formal diagnosis of an Adjustment Disorder may not occur until after the three month period has elapsed. Each case should be adjudicated on the medical evidence provided and its own merits.

NOTE: The following list of factors is not all inclusive. Factors, other than those listed in Section A, may be claimed to cause or aggravate an Adjustment Disorder. Other factors may be considered based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

1. Directly experiencing a traumatic event(s) within the three months before the clinical onset or aggravation of Adjustment Disorder
   
   Traumatic events include, but are not limited to:
   1. exposure to military combat
   2. threatened physical assault or being physically assaulted
   3. threatened sexual assault or being sexually assaulted
   4. being kidnapped
   5. being taken hostage
   6. being in a terrorist attack
   7. being tortured
   8. incarceration as a prisoner of war
   9. being in a natural or human-made disaster
   10. being in a severe motor vehicle accident
   11. killing or injuring a person in a non-criminal act
   12. experiencing a sudden, catastrophic medical incident
2. Witnessing, in person, a traumatic event(s) as it occurred to another person(s) within the three months before the clinical onset or aggravation of Adjustment Disorder
   
   Witnessed traumatic events include, but are not limited to:
   1. threatened or serious injury to another person
   2. an unnatural death
   3. physical or sexual abuse of another person
   4. a medical catastrophe in a close family member or close friend
3. Learning a close family member or close friend experienced a violent or accidental traumatic event(s) within the three months before the clinical onset or aggravation of Adjustment Disorder
   
   Traumatic events include, but are not limited to:
   1. physical assault
   2. sexual assault
   3. serious accident
   4. serious injury
4. Experiencing repeated or extreme exposure to aversive details of a traumatic event(s) within the three months before the clinical onset or aggravation of Adjustment Disorder
   
   Exposures include, but are not limited to:
   1. viewing and/or collecting human remains
   2. viewing and/or participating in the clearance of critically injured casualties
   3. repeated exposure to the details of abuse and/or atrocities inflicted on another person(s)
   4. dispatch operators exposed to violent or accidental traumatic event(s)

   Note: Factor 4 applies to exposure through electronic media, television, movies and pictures only if the exposure is work related.

5. Living or working in a hostile or life-threatening environment for a period of at least four weeks before the clinical onset or aggravation of Adjustment Disorder
   
   Situations or settings which have a pervasive threat to life or bodily integrity including but not limited to:
   1. being under threat of artillery, missile, rocket, mine or bomb attack
   2. being under threat of nuclear, biologic or chemical agent attack
   3. being involved in combat or going on combat patrols
6. Experiencing the death of a close family member or close friend within the three months before the clinical onset or aggravation of Adjustment Disorder
7. Experiencing a stressful life event within the three months before the clinical onset or aggravation of Adjustment Disorder
   
   Events which qualify as stressful life events include, but are not limited to:
   1. being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness
   2. experiencing a problem with a long-term relationship including: the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce
   3. having concerns in the work or school environment including: on-going disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment
   4. experiencing serious legal issues including: being detained or held in custody, on-going involvement with law enforcement concerning violations of the law, or court appearances associated with personal legal problems
   5. having severe financial hardship including: loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy
   6. having a close family member or close friend experience a major deterioration in their health
   7. being a full-time caregiver to a family member or close friend with a severe physical, mental or developmental disability
8. Having a clinically significant psychiatric condition within the three months before the clinical onset or aggravation of Adjustment Disorder
   
   A clinically significant psychiatric condition is a mental disorder as defined in the DSM-5.
9. Having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability within the three months before the clinical onset or aggravation of Adjustment Disorder
10. Having chronic pain of at least three months duration at the time of clinical onset or aggravation of Adjustment Disorder
11. Having a miscarriage, fetal death in-utero or stillbirth, within the three months before the clinical onset or aggravation of Adjustment Disorder
12. Inability to obtain appropriate clinical management of Adjustment Disorder

B. Medical Conditions Which Are To Be Included In Entitlement/Assessment

NOTE: If specific conditions are listed for a category, only these conditions are included in the entitlement and assessment of Adjustment Disorder.

If no conditions are listed for a category, all conditions within the category are included in the entitlement and assessment of Adjustment Disorder.

• Other Trauma- and Stressor-Related Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Depressive Disorders
• Bipolar and Related Disorders
• Schizophrenia Spectrum and other Psychotic Disorders
• Personality Disorders
• Feeding and Eating Disorders
• Substance-Related and Addictive Disorders
• Dissociative Disorders
• Somatic Symptom and Related Disorder
  • Somatic Symptom Disorder
  • Illness Anxiety Disorder
  • Conversion Disorder
• Pain Disorders/Chronic Pain Syndrome (DSM-IV-TR Axis I Diagnosis)
• Sleep-Wake Disorders
  • Insomnia Disorder
  • Hypersomnolence Disorder
• Neurodevelopmental Disorders
  • Attention-Deficit/Hyperactivity Disorder
• Decreased Libido - if the medical information indicates decreased libido is a symptom of a psychiatric condition.

Separate entitlement is required for a DSM-5 condition not included in Section B of the Adjustment Disorder Entitlement Eligibility Guideline.

C. Common Medical Conditions Which May Result In Whole Or In Part From Adjustment Disorder And/Or Its Treatment

Section C medical conditions may result in whole or in part as a direct result of Adjustment Disorder, from the treatment of Adjustment Disorder or the combined effects of Adjustment Disorder and its treatment.

Conditions listed in Section C of the Entitlement Considerations are only granted entitlement if the individual merits and medical evidence of the case determines a consequential relationship exists. Consultation with Medical Advisory is strongly recommended.

If it is claimed a medication required to treat Adjustment Disorder resulted in whole, or in part, in the clinical onset or aggravation of a medical condition the following must be established:

1. The individual was receiving the medication at the time of the clinical onset or aggravation of the medical condition.
2. The medication was used for the treatment of the Adjustment Disorder.
3. The medication is unlikely to be discontinued or the medication is known to have enduring effects after discontinuation.
4. The individual's medical information and the current medical literature support the medication can result in the clinical onset or aggravation of the medical condition.
5. Note: Individual medications may belong to a class, or grouping, of medications. The effects of a specific medication may vary from the grouping. The effects of the specific medication should be considered and not the effects of the group.

The list of Section C conditions is not all inclusive. Conditions, other than those listed in Section C, may be claimed to have a consequential relationship to an Adjustment Disorder and/or its treatment. Other conditions may be considered for entitlement based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

• Sexual Dysfunction (e.g., Erectile Dysfunction)
• Irritable Bowel Syndrome
• Bruxism
• Xerostomia
• Periodic Limb Movement Disorder
• Restless Leg Syndrome
• Obstructive Sleep Apnea

References For Adjustment Disorder

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4^th ed. Text Revision ( DSM-IV-TR ) Washington: American Psychiatric Association, 2000.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5^th ed. ( DSM-5 ) Washington: American Psychiatric Association, 2013.
3. Australia. (2008). Statement of principles concerning adjustment disorder. No. 37 of 2008.
4. Australia. (2008). Statement of principles concerning adjustment disorder. No. 38 of 2008.
5. Sadock B.J., Sadock V.A. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 8^th ed. Philadephia: Lippincott Williams & Wilkins, 2005.