Original Paper

Psychopathology 2012;45:305309
DOI: 10.1159/000336048

Received: May 4, 2011

Accepted after revision: December 22, 2011
Published online: July 12, 2012

Diagnosis of Adjustment Disorder:

Reliability of Its Clinical Use and
Long-Term Stability
Markus Jger Daniel Burger Thomas Becker Karel Frasch
Department of Psychiatry II, Ulm University, Gnzburg, Germany

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.
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Introduction

Adjustment disorder is a common diagnosis in mental

health services [16]. The diagnostic category of adjustment disorder was introduced into the International
Classification of Diseases in 1978 (ICD-9) and into the
Diagnostic and Statistical Manual of Mental Disorders
in 1980 (DSM-III). ICD-10, DSM-III-R and DSM-IV
retained this diagnosis. Adjustment disorder replaced
nosological categories such as abnormal reactions or
transient situational disturbances. However, the historical roots of adjustment disorder can be traced back to K.
Schneiders [7] concept of abnormal reaction to experience (abnorme Erlebnisreaktion). The current ICD-10
diagnostic criteria (research criteria) [8] are summarized
in table1. The DSM-IV criteria are quite similar to those
of ICD-10. The symptoms of adjustment disorder can
vary in both severity and form. However, a specific psychiatric disorder such as depression, anxiety or somatoform disorder has to be excluded. Several authors have
criticized this subordination of adjustment disorder to
other mental disorders and the lack of more specific criteria [911]. Adjustment disorder has been described as a
marginal or transitional illness category [12] or cryptic
form of disease entity [3]. A diagnostic shift from adjustment disorder with depressed mood to major depressive
disorders has been reported from 1988 to 1997 [13]. Overall, there seems to be a lack of scientific interest in adjustPriv.-Doz. Dr. Markus Jger
Department of Psychiatry II, Ulm University
Ludwig-Heilmeyer-Strasse 2
DE89312 Gnzburg (Germany)
Tel. +49 822 196 2204, E-Mail Markus.Jaeger@bkh-guenzburg.de

Table 1. ICD-10 criteria for adjustment disorder [8]

Experience of an identifiable psychosocial stressor (not of an

unusual or catastrophic type) within 1 month before the onset
of symptoms
Symptoms or behavior disturbance of types found in any of
the affective disorders (except for delusions and
hallucinations) or neurotic, stress-related, somatoform and
conduct disorders, as long as the criteria of an individual
disorder are not fulfilled
The symptoms do not persist for more than 6 months after
the cessation of the stress or its consequences (except
prolonged depressive reaction)

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

The use of ICD-10 has been obligatory in Germany since 2000,

and psychiatrists are familiar with its use.
Diagnostic Assessment
The present study adopted the methodological approach of
Vollmer-Larsen et al. [16], who reviewed chart records of patients
with a clinical diagnosis of schizoaffective disorder. Two of the authors (M.J. and K.F.) reviewed the clinical chart material independently. Both raters were board-certified psychiatrists. They were
trained in using structured diagnostic instruments. On the basis of
a narrative summary of each chart record, the raters made diagnoses according to the research criteria of ICD-10 [8]. If there was a
diagnostic disagreement in the independent assessment, both raters discussed the case based on the narrative summary and the
original chart records. They brought forward arguments for and
against each diagnosis. After this process, a consensus diagnosis
was made. Only information available at the time of the index admission in 2005 was used for the diagnostic reassessment. Raters
were blinded to chart material of further admissions to the hospital.
In a further step, to examine the frequency of readmissions
and changes in diagnoses at readmission, both raters reviewed the
available chart material up to the end of 2010 for all patients with
a confirmed diagnosis of adjustment disorder at index admission.
This approach was adopted from the study of Greenberg et al. [3].
Analyses
The diagnostic agreement between the two independent raters
(M.J. and K.F.) was assessed by calculating the kappa value [17].
Descriptive statistical analyses were performed to describe diagnostic assessment, comorbidity, readmission rates and diagnostic
changes at readmission. All analyses were performed with the Statistical Package for Social Sciences (SPSS), version 19.1.

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).

Table 2. Diagnostic reassessment (ICD-10) of clinical chart diag-

noses

Adjustment disorder (F43.2)

Mood disorders (F3)
Psychoactive substance abuse disorder (F1)
Other neurotic, stress-related and somatoform
disorder (F4)
Personality disorders (F6)
Schizophrenia, schizotypal and delusional
disorder (F2)
Other diagnoses
Total

91
19
12

64.1
13.4
8.5

8
5

5.6
3.5

3
4

2.1
2.8

142

100

Diagnostic Reliability and Stability of Adjustment

Disorder
The present study revealed a satisfactory interrater reliability for ICD-10 adjustment disorder (kappa = 0.69).
A lower kappa value (0.54) was found in the WHO field
trial that accompanied the introduction of ICD-10 [18].
However, the field trial examined the clinical guidelines
of ICD-10, whereas the present study used the respective
criteria for research.
Agreement between clinical diagnoses and ICD-10
criteria was only 64.1%, meaning that many clinicians did
not make the diagnosis of adjustment disorder in accordance with the ICD-10 criteria. Similar results were reported for other diagnostic categories such as schizoaffective disorder [16]. In particular, the subordination of
adjustment disorder to specific mood disorders was not
adequately considered in clinical practice. The differences may partly be explained by the fact that clinicians usually use the more flexible clinical guidelines of ICD-10
[19] rather than the research criteria [8]. However, these
clinical guidelines for adjustment disorder also include
the exclusion criterion of other specific psychiatric disorders. A lower concordance between clinical and research
diagnoses for adjustment disorder (17%) was reported by

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-

Diagnosis of Adjustment Disorder

Psychopathology 2012;45:305309

Discussion

307

agnostic stability. Significantly lower stability rates were

reported for diagnostic groups such as somatoform, generalized anxiety or panic disorders [26]. Due to the absence of a systematic follow-up procedure these conclusions should be taken with caution.
Implications for Diagnostic Validity
Satisfactory interrater reliability and diagnostic stability of ICD-10 adjustment disorder, with only a few diagnostic changes within a 5-year period, lend support to the
validity of this diagnosis. This is in line with the results
of other studies which demonstrated that patients with
adjustment disorders have a rather favourable outcome:
Bronisch [27] reported that 82% of patients with adjustment reaction showed a favourable outcome within a
5-year follow-up period. Andreasen and Hoeck [28] also
found a favourable outcome without diagnostic change in
79% of patients. Jones et al. [25] reported that patients
with adjustment disorder have a better outcome than patients with major depression or dysthymia. However, the
comparability of these results is limited by the use of different diagnostic criteria and outcome measures.
Nevertheless, a diagnosis of adjustment disorder according to ICD-10 criteria appears to be effective in differentiating between minor disturbances following a
stressful life event and severe mental disorders such as
major depression or bipolar disorder. However, the high
comorbidity and diagnostic overlap with substance abuse
and personality disorders have to be considered. These
disorders might predispose patients to developing an adjustment disorder in the event of a stressful life event.
The low acceptance of the diagnostic criteria in clinical practice and the dramatic divergence between clinical
diagnosis and current operational criteria challenges the
validity and utility of the nosological concept of adjustment disorder. On the one hand, better training in the
correct use of the current diagnostic criteria is required.
The study by Malt et al. [29] showed that a specific training program for consultation-liaison psychiatrists and
psychologists can help to achieve satisfactory interrater
reliability for ICD-10 guidelines. On the other hand, the
diagnostic system should provide criteria that are accepted and used by the majority of clinicians; these criteria
should be based on clinical expertise, particularly in the
absence of clear empirical findings such as in the case of
adjustment disorder [9].
Considerations for ICD-11 and DSM-V
A crucial question is whether ICD-11 and DSM-V will
retain the current concept of adjustment disorder as a re308

Psychopathology 2012;45:305309

sidual diagnostic category for minor mental disturbances

or whether they will make important modifications.
Authors like Casey [30] have stated the case for rehabilitating adjustment disorder as a major diagnostic category without subordination to other mental disorders.
This would imply that the current overinclusive concept
of depression should be narrowed [9]. If a life event has
triggered depressive symptoms and there is a close temporal relationship between the event and the onset of
symptoms, a diagnosis of adjustment disorder should be
given priority [10, 30]. Thus, an overdiagnosing of affective disorders should be avoided [31]. In line with such an
approach, Maercker et al. [32] proposed a diagnostic
model that describes adjustment disorder as a stress response syndrome. They provided specific diagnostic criteria comprising intrusive symptoms, avoidance and
failure to adapt [32].
In contrast, if ICD-11 and DSM-V introduce a dimensional diagnostic approach, as suggested by several authors [33, 34], adjustment disorder will disappear from
the psychiatric nomenclature. As a result, reactions to
stressful life events could be described by using psychopathological syndrome scores for dimensions such as depression or anxiety. In 2010, the American Psychiatric
Association published the first draft for DSM-V, which
retained the current concept of adjustment disorders
with only minor modifications [35]. If this is the case in
the final version, however, a method must be found to
ensure correct use of the respective criteria.

Limitations and Conclusions

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 diagnostic stability should be regarded with caution.

However, the Department of Psychiatry II, Ulm University, has a defined catchment area in a rural region in
Southern Germany. Therefore, a high probability of readmission to the sample hospital in case of renewed need for
inpatient treatment can be assumed.
To summarize, in spite of satisfactory interrater reliability and diagnostic stability, the dramatic divergence
between clinical diagnosis and ICD-10 criteria challenges

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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