Reliability and Validity of a German Standardized Diagnostic Interview Module for ICD-11 Adjustment Disorder.

The ICD-11 includes a new definition of adjustment disorder (AjD). The present study aimed to examine interrater reliability, internal consistency, and construct validity of a new diagnostic interview module to assess ICD-11 AjD. Data from two studies that used a standardized diagnostic interview assessment (i.e., DIA-X/M-CIDI and updated DIA-X-5) were used. For interrater reliability, agreement indicators (i.e., κ) were calculated using data from the DIA-X-5 test-retest study (N = 60). To examine internal consistency and construct validity, Cronbach's alpha values and the Kuder-Richardson correlation coefficient were computed along with confirmatory factor and latent class analyses (LCA), using data from the Zurich Adjustment Disorder Study (N = 330). Interrater reliability analyses found an adjusted kappa of 0.807 for the ICD-11 AjD diagnosis. Few items from the impairment criterion of the diagnostic algorithm performed poorly. The internal consistency was acceptable, Cronbach's αs = .43-.80; the lower-bound estimate resulted from the two-item preoccupation symptom pattern. However, both items were significantly associated, OR = 3.14, 95% CI [1.97, 4.99]. Regarding LCA results, a two-class model was favored. We found that 94.3% of all ICD-11 AjD cases belonged to Class 2, OR = 23.69, 95% CI [7.15, 79.54], which was associated with subjectively rated distress, OR = 2.18, 95% CI [1.57, 3.02], and the external measure of the Brief Symptom Inventory global severity index, OR = 2.18, 95% CI [1.57, 3.02]. Overall, the new AjD interview module provided a reliable, valid assessment of the ICD-11 diagnosis; confirmation by other studies is needed.

The 12-Month Course of ICD-11 Adjustment Disorder in the Context of Involuntary Job Loss.

Background: After its redefinition in ICD-11, adjustment disorder (AjD) comprises two core symptom clusters of preoccupations and failure to adapt to the stressor. Only a few studies investigate the course of AjD over time and the definition of six months until the remission of the disorder is based on little to no empirical evidence. The aim of the present study was to investigate the course of AjD symptoms and symptom clusters over time and to longitudinally evaluate predictors of AjD symptom severity. Method: A selective sample of the Zurich Adjustment Disorder Study, N = 105 individuals who experienced involuntary job loss and reported either high or low symptom severity at first assessment (t1), were assessed M = 3.4 (SD = 2.1) months after the last day at work, and followed up six (t2) and twelve months (t3) later. They completed a fully structured diagnostic interview for AjD and self-report questionnaires. Results: The prevalence of AjD was 21.9% at t1, 6.7% at t2, and dropped to 2.9% at t3. All individual symptoms and symptom clusters showed declines in prevalence rates across the three assessments. A hierarchical regression analysis of symptoms at t3 revealed that more symptoms at the first assessment (ß = 0.32, p = .002) and the number of new life events between the first assessment and t3 (ß = 0.29, p = .004) significantly predicted the number of AjD symptoms at t3. Conclusion: Although prevalence rates of AjD declined over time, a significant proportion of individuals still experienced AjD symptoms after six months. Future research should focus on the specific mechanisms underlying the course of AjD.

The Role of Religion in Buffering the Impact of Stressful Life Events on Depressive Symptoms in Patients with Depressive Episodes or Adjustment Disorder.

Most studies into the role of religiousness in relation to depression severity have mainly found an inverse relationship between greater religiousness and lower levels of depressive symptoms. There is reason to assume that religiousness has a buffering effect on the relationship between stressful life events and depressive symptoms. The aim of this study was to investigate the role of religiousness in moderating the impact of stressors on depressive symptoms. n = 348 patients with either a depressive episode or adjustment disorder were assessed at referral to the liaison psychiatry services in three Dublin hospitals and n = 132 patients were followed up six months later. We assessed depressive symptoms, life events, social support, and religiosity, and used hierarchical and multiple linear regression for data analysis. The interaction of organised religious activity and the amount of life events was significant (ß = -0.19, p = 0.001) in the cross-sectional prediction of depressive symptoms while non-organised religious activity (ß = -0.23, p = 0.001) and intrinsic religiousness (ß = -0.15, p = 0.033) interacted significantly with life events in the longitudinal analysis. This study demonstrated that various dimensions of religiousness buffered the impact of life events on outcome.

Sleep Disturbance in Adjustment Disorder and Depressive Episode.

Background: In this paper, we aimed to examine the patterns of sleep disturbance in adjustment disorder (AD) and depressive episode (DE), to examine the variables associated with sleep disturbance in AD and DE and associated impairment in functioning. Methods: This is a multi-centre case-control study of 370 patients: 185 patients with AD and 185 patients with a diagnosis of DE, recruited from the liaison psychiatry services of three Dublin hospitals. We examined the participants' sleep pathology using the sleep disturbance items on the Schedule for Clinical Assessment in Neuropsychiatry, and the Inventory of Depressive Symptoms-Clinician-rated-30. Results: Patients with a diagnosis of AD were less likely to report disturbed sleep than those with a diagnosis of DE (p = 0.002). On multivariate analysis, sleep disturbance was significantly associated with greater severity of certain depressive symptoms: decreased appetite (p < 0.001) and psychomotor agitation (p = 0.009). Decreased appetite, younger age and single marital status were significantly associated with sleep disturbance in male patients, and decreased appetite and psychomotor agitation were significantly associated with sleep disturbance in female participants. Conclusions: This is the largest study to date which has examined sleep disturbance in adjustment disorder. Disturbance of sleep is a significant symptom in AD and may represent a potential target for treatment. With further research, patterns of sleep disturbance may be useful in differentiating AD from DE.

Prolonged grief disorder: Its co-occurrence with adjustment disorder and post-traumatic stress disorder in a bereaved Israeli general-population sample.

BACKGROUND: Prolonged grief disorder (PGD) is a new disorder included in the WHO International Classification of Diseases 11th version (ICD-11). This study is the first to use these new ICD-11 PGD guidelines to examine prevalence rates, predictors of PGD and disorder co-occurrence with other stress-related disorders in a survey of 544 bereaved Israelis. METHODS: Descriptive statistics, correlation, linear regression and mediation analysis examined the validity of the ICD-11 diagnostic algorithm. RESULTS: Prevalence of PGD in the Israeli population sample is low (2%). The prevalence rate of post-traumatic stress disorder (PTSD) was 7.2% and for adjustment disorder (AjD) was 17.8%. A significant positive correlation found between scores on these measures indicates concurrent validity. Mediation analysis found that symptoms of PGD were predicted by serious life events, and significantly mediated by symptoms of PTSD and AjD. A regression analysis found significant predictors of PGD symptom severity, including socio-demographic and person-specific predictors. LIMITATIONS: This study did not assess the index-death of the grief questionnaire. No conclusions could be made regarding the relationship between the type of loss and grief severity. Furthermore, the time since loss (time criterion) was not assessed. CONCLUSIONS: This study is the first to examine prevalence rates of ICD-11 PGD in a population-based survey. The mediation relationship between serious life events, AjD, PTSD and PGD supports a vulnerability model of stress related disorders whereby the number of stressful life events may predict symptoms of stress related disorders.

Revalidation of Adjustment Disorder-New Module-4 screening of adjustment disorder in a non-clinical sample: Psychometric reevaluation and correlates with other ICD-11 mental disorders.

In line with the new conceptualization of adjustment disorder (AjD) in the 11th revision of the International Classification of Diseases (ICD-11), a new 20-item self-report questionnaire was developed and validated - the Adjustment Disorder-New Module (ADNM). However, such a long research tool has the potential to become problematic for use in epidemiological and clinical settings. Therefore, an ultra-brief measure for AjD (ADNM-4) was established and validated in a recent study conducted with a representative national sample. The aim of the present study was to revalidate the ultra-brief ADNM-4 Scale, as well as to reestablish cutoff scores for clinical use. An online survey was conducted with a convenience sample of 484 Israelis aged 18-65 years, who were recruited via social media. Participants filled out self-report questionnaires dealing with diagnostic criteria of stress-related disorders, that is, AjD (the original and ultra-brief modules), prolonged grief disorder, depression, anxiety, and hypochondriasis. Construct, discriminant, and convergent validity were assessed via confirmatory factor analysis and correlation coefficients, while cutoff scores were established through receiver-operating characteristic analysis. The findings confirmed the ultra-brief module's validity. The high fit indices indicated construct validity, and the correlations with the various stress-related disorders indicated good convergent and discriminant validity. Cutoff scores resembled earlier cutoff scores calculated with a representative national sample, indicating a consistent and accurate diagnostic ability. These findings provide additional evidence for the psychometric characteristics of the ADNM-4, which seems to be a suitable brief screening tool for assessing AjD symptoms according to the ICD-11 definition. Therefore, the ADNM-4 is recommended in cases where prompt screening is required, as well as for research purposes.

Adjustment disorder diagnosis: Improving clinical utility.

OBJECTIVES: Adjustment disorder (AD) is a frequent diagnosis in clinical practice worldwide. After long neglect in mental health research, the new DSM definition and in particular the ICD-11 model of AD is about to create a fresh impulse for research on AD and for refined clinical use of the diagnosis. METHODS: This paper outlines the clinical features of AD according to the ICD-10, ICD-11 and DSM-5 definitions, and provides case vignettes of patients with AD with clinical presentations of dominating anxiety, depressed mood or mixed symptom presentations. The available clinical assessments and diagnostic tools are described in detail, together with findings on their psychometric properties. RESULTS: The current AD definitions are consistent with a new nosological grouping of AD with posttraumatic stress disorder in the chapter on trauma- and stressor-related disorders, or stress response syndromes. CONCLUSIONS: This nosological specification opens new avenues for neurobiological and psychological research on AD and for developing novel therapies.

Prevalence and correlates of ICD-11 adjustment disorder: Findings from the Zurich Adjustment Disorder Study.

Background/Objective: The 11th revision of the International Classification of Diseases (ICD-11) will provide a new definition of adjustment disorder (AjD). The aim of the present study is to report on prevalence and correlates of ICD-11 AjD in a high-risk sample. Method: Three hundred thirty persons who had lost their job involuntarily were sampled by local job centres. The Munich Composite International Diagnostic Interview was administered with a new AjD module. Associations between AjD and correlates were investigated with logistic regression analyses. Results: 27.3% of the participants reported the AjD core symptom pattern. 13.8% men and 17.2% women met diagnostic guidelines of ICD-11 AjD. Prevalence increased with age and exposure to multiple stressors. The AjD core symptom pattern was associated with various sociodemographic correlates (e. g., lower financial household budget), whereas the full ICD-11 diagnosis including the exclusion algorithm was not. Regarding work-related factors, AjD occurred with a lower probability if the last job position had higher responsibilities and more general confidence for the future. Conclusions: ICD-11 AjD has a high prevalence among persons who lost their jobs involuntarily. Healthcare professionals should be aware of this problem. Research to investigate the ICD-11 AjD concept in the general populations and other subpopulations is needed.

Antecedentes/Objetivo: La versión beta de la undécima revisión de la Clasificación Internacional de Enfermedades (CIE-11) proporciona una nueva definición del trastorno de adaptación (TdA). Este estudio investiga la prevalencia y los correlatos del CIE-11 TdA en una muestra de personas de alto riesgo. Método: Se reclutaron trescientas treinta personas afectadas por una pérdida de trabajo involuntaria. Se aplicó la Munich Composite International Diagnostic Interview y un nuevo módulo del TdA. Se calcularon asociaciones entre TdA y correlatos mediante análisis de regresión logísticas. Resultados: El 27,3% de los participantes reportaron el patrón de síntomas principales de TdA. El 13,8% de los hombres y el 17,2% de las mujeres cumplieron con los criterios de diagnóstico del CIE-11 TdA. La prevalencia se relacionó con la edad y la exposición a múltiples estresores. Solamente el patrón de los síntomas principales, pero no el diagnóstico completo, correlacionó con factores socio-demográficos (e. g., presupuesto familiar). La probabilidad del TdA era más baja si el último puesto de trabajo fue de más responsabilidad y con más perspectivas de futuro. Conclusiones: Existe una prevalencia elevada del CIE-11 TdA en personas afectadas por una pérdida de trabajo involuntaria. Se precisa más investigación sobre el concepto del TdA en la CIE-11.

A socio-interpersonal approach to adjustment disorder: the example of involuntary job loss.

Background: Adjustment disorder (AjD) was redefined for ICD-11 with core symptoms of preoccupation with a stressor and failure to adapt. The socio-interpersonal framework model for stress-response syndromes suggests that interpersonal factors, besides intrapersonal processes, substantially contribute to the development of AjD. Objective: The current study aimed to identify predictive factors in the development of AjD symptoms by the application of a framework model for stress-response syndromes. Method: N = 321 recently laid-off participants (47.7% female) were assessed with a newly developed standardized clinical diagnostic interview section on ICD-11 AjD. Self-report questionnaires measured AjD symptom severity, and interpersonal and intrapersonal predictors. Path analysis was used to model the associations between AjD symptom severity and the predictor variables. We conducted logistic regression to identify associated characteristics of diagnostic status. Results: AjD symptoms were highly prevalent and 25.6% of participants met the diagnostic criteria. Higher loneliness, higher dysfunctional disclosure, and lower self-efficacy were associated with both higher symptom severity and higher likelihood of meeting the diagnostic criteria for AjD. Higher perceived social support was associated with higher likelihood for AjD diagnosis. Conclusions: Research on risk factors for AjD is still sparse. This study provided empirical evidence on the role of interpersonal factors supporting the socio-interpersonal model for stress-response syndromes.

Planteamiento: El trastorno de adaptación (TAd) se redefinió para la CIE-11 con síntomas centrales de preocupación por un factor estresante y falta de adaptación. El modelo de marco socio-interpersonal para los síndromes de respuesta ante el estrés sugiere que los factores interpersonales, además de los procesos intrapersonales, contribuyen sustancialmente al desarrollo del TAd. Objetivo: El presente estudio pretendía identificar los factores predictivos en el desarrollo de síntomas de TAd mediante la aplicación de un modelo de marco de trabajo para los síndromes de respuesta frente al estrés. Método: Se evaluaron N = 321 participantes recientemente despedidos (47,7% mujeres) con una sección de entrevista diagnóstica clínica estandarizada recientemente desarrollada para el TAd de la CIE-11. Los cuestionarios de autoinforme midieron la gravedad de los síntomas de TAd y los predictores interpersonales e intrapersonales. El análisis de ruta se utilizó para modelar las asociaciones entre la gravedad del síntoma de TAd y las variables predictoras. Realizamos una regresión logística para identificar las características asociadas del estatus del diagnóstico. Resultados: Los síntomas de TAd fueron altamente prevalentes y el 25.6% de los participantes cumplieron con los criterios diagnósticos. Una mayor soledad, una revelación personal más disfuncional y una menor autoeficacia se asociaron con una mayor gravedad de los síntomas y una mayor probabilidad de cumplir los criterios de diagnóstico para el TAd. Un mayor apoyo social percibido se asoció con una mayor probabilidad de diagnóstico de Tad. Conclusión: La investigación sobre los factores de riesgo para el TAd aún es escasa. Este estudio proporcionó evidencia empírica sobre el papel de los factores interpersonales que apoyan el modelo socio-interpersonal para los síndromes de respuesta frente al estrés.

Is adjustment disorder unidimensional or multidimensional? Implications for ICD-11.

In preparation for ICD-11, the adjustment disorder (AjD) diagnosis has undergone considerable revisions; however, the latent structure of AjD remains uncertain. It is unclear whether AjD is best represented as a unidimensional or multidimensional construct. This study performed a comprehensive assessment of the latent structure of AjD symptomatology and assessed its concurrent and discriminant validity. Individuals who experienced involuntary job loss (N = 333) completed a self-report measure of AjD symptoms. Seven alternative models of AjD were tested using confirmatory factor analysis. General psychological distress, impairment in social functioning, occupational self-efficacy, and sense of coherence were used as criterion variables for construct validity. In the confirmatory factor analysis, a bifactor solution with one dominant general AjD factor and 5 correlated group factors (preoccupation, failure-to-adapt, avoidance, affective reaction, and impulsivity) provided optimal fit. As expected, the AjD factor showed strong positive associations with general psychological distress and impairments in social functioning and moderately negative associations with occupational self-efficacy and sense of coherence. With regard to unidimensionality or multidimensionality of AjD symptoms, the current results indicate the plausibility of a unidimensional conceptualization. Future research should focus on essential key characteristics and a reduction of symptoms for the AjD definition.

An empirical assessment of adjustment disorder as proposed for ICD-11 in a general population sample of Israel.

BACKGROUND: A new diagnostic concept of Adjustment Disorder (AjD) was proposed for inclusion in the International Classification of Diseases, 11th version (ICD-11). However, the symptom structure of AjD is poorly understood. The aim of the present study was to investigate the dimensionality of AjD as a stress-response syndrome. METHODS: A general population sample of the Israeli population (N = 1003) completed the Adjustment Disorder - New Module 20 and the WHO-5 Wellbeing Scale. We compared seven alternative models of AjD using confirmatory factor analysis (CFA). A latent profile analysis (LPA) was performed to determine if subtypes of AjD were present. The performance of the unidimensional and multidimensional models of AjD were evaluated using regression analyses. RESULTS: CFA results supported a unidimensional model of AjD. The LPA identified three quantitatively distinct classes (low, medium, and high) with no evidence of any subtypes of AjD. The criterion validity of AjD was superior when treated as unidimensional. AjD was associated with lower levels of psychological wellbeing (ß = -.32, p < .001). CONCLUSIONS: Our results suggest that AjD is better conceptualised as a unidimensional construct. Future work should focus on a reduction of required symptoms in order to improve clinical utility and validity of the diagnosis.

Screening of adjustment disorder: Scale based on the ICD-11 and the Adjustment Disorder New Module.

In line with ICD-11 new conceptualization of Adjustment disorder (AjD), a self-report Adjustment Disorder-New Module (ADNM) was developed and validated. Nevertheless, the ADNM-20 is a long research tool and potentially problematic in the use in epidemiological and clinical studies. The present study introduces the brief ADNM-8 and the ultra-brief ADNM-4, examines their validity and establishes cut-off scores for their clinical use. The study used a representative national sample of 1003 Israelis who reported on the ICD-11 stress spectrum ranging from AjD, PTSD, complex PTSD and complicated grief. Construct validity was assessed via confirmatory factor analysis and cut-off scores were established through ROC analysis. The original and brief instruments were highly correlated (r > 0.918 or better). Cronbach's Alpha for the Brief ADNM-8 and the Ultra-Brief ADNM-4 were above 0.800. Correlations with stress related conditions indicated a good convergent and construct validity for both instruments as well. The ultra-brief ADNM-4 was found to have a very good fit with the data. These findings indicate that the brief ADNM-8 and the ultra-brief ADNM-4 can serve as a brief screening tools for assessing AjD symptoms according to the ICD-11 definition.

A scoping review of ICD-11 adjustment disorder research.

Background: Adjustment disorder (AjD) is one of the most used mental disorder diagnoses among mental health professionals. Important revisions of the AjD definition in the 11th edition of the International Classification of Diseases (ICD-11) are proposed. AjD is included in a chapter of disorders specifically associated with stress in ICD-11. Objective: This paper aims to review recent developments in ICD-11 AjD research, and to discuss the available ICD-11 AjD diagnosis validation studies, AjD measures, treatment studies, and outline the future perspectives for AjD research and clinical practice. Methods: In total, 10 empirical studies of AjD ICD-11 were identified and included in this review. We searched for studies in Embase, PubMed, PsycINFO, Scopus, PILOTS, SocINDEX, and via additional search by contacting authors of published empirical studies and reference screening. Results: Review of the studies revealed a lack of validation studies of the ICD-11 AjD symptom structure. AjD validation study findings are ambiguous, and there is still little support for the proposed two symptom structure of AjD for the ICD-11. A self-report AjD measure 'Adjustment Disorder New Module' (ADNM) based on the ICD-11 definition has been developed and used in all 10 reviewed studies. Two self-help interventions have been developed for the ICD-11 AjD, and findings from these studies indicate that self-help low-intensity cognitive-behavioural interventions, delivered via bibliography or internet-based, might be effective treatment of AjD. Conclusions: The AjD definition in ICD-11 with a description of a new symptom profile facilitates AjD measurement and AjD-focused treatment developments. More studies and insights from clinical practice are needed to move the field of AjD research and practice forward.

Contexto: El trastorno de adaptación o adaptativo (TA) se encuentra entre los diagnósticos de trastorno mental más usados entre los profesionales de la salud mental. Se proponen revisiones importantes de la definición de T. adaptativo de la 11ª edición de la Clasificación Internacional de Enfermedades (ICD 11). El T. adaptativo está incluido en la CIE 11 en un capitulo de trastornos específicamente asociados con el estrés. Objetivo: Este articulo pretende revisar desarrollos recientes sobre la investigación del T. adaptativo en la CIE 11 así como discutir los estudios de validación del diagnostico del mismo para la CIE 11. También medidas del T. adaptativo, estudios sobre tratamiento y la delineación de perspectivas futuras de la investigación sobre el T. adaptativo y la práctica clínica. Métodos: En total, fueron identificados e incluidos en esta revisión, 10 estudios empíricos sobre el T. adaptativo para la CIE 11. Revisamos la presencia de trabajos en las bases Embase, PubMed, PsycINFO, Scopus, PILOTS, SocINDEX y a través de una vía adicional contactando a los autores de estudios empíricos publicados. También se realizó una discriminación de referencias bibliográficas. Resultados: La revisión de los estudios revelaron una falta de estudios de validación de la estructura de síntomas para el T. adaptativo en la CIE 11. Los hallazgos de los estudios de validación son ambiguos, y todavía hay un soporte escaso para la propuesta estructura en dos síntomas del T. adaptativo en la CIE 11. Ha sido desarrollado un autoreporte de la medida del T. adaptativo denominada 'Nuevo modulo del T. adaptativo' (ADNM) basada en la definición de la CIE 11. Ha sido usada en todos los 10 trabajos revisados. Han sido desarrolladas dos intervenciones de autoayuda para el T. adaptativo de la CIE 11 y los hallazgos obtenidos por estos estudios indican que las intervenciones de autoayuda de baja intensidad, cognitivo ­ conductuales, administradas vía bibliografía o por Internet, pueden ser un tratamiento efectivo para el T. adaptativo. Conclusiones: La definición de T. adaptativo en la CIE 11, con la descripción de un nuevo perfil sintomatológico, facilita la medida del T. adaptativo y los desarrollos del tratamiento focalizado en el trastorno. Se necesitan más estudios y experiencias desde la práctica clínica para impulsar hacia delante el campo de la investigación y práctica del diagnóstico del T. adaptativo.

Adjustment Disorders Are Uniquely Suited for eHealth Interventions: Concept and Case Study.

BACKGROUND: Adjustment disorders (also known as mental distress in response to a stressor) are among the most frequently diagnosed mental disorders in psychiatry and clinical psychology worldwide. They are also commonly diagnosed in clients engaging in deliberate self-harm and in those consulting general practitioners. However, their reputation in research-oriented mental health remains weak since they are largely underresearched. This may change when the International Statistical Classification of Diseases-11 (ICD-11) by the World Health Organization is introduced, including a new conceptualization of adjustment disorders as a stress-response disorder with positively defined core symptoms. OBJECTIVE: This paper provides an overview of evidence-based interventions for adjustment disorders. METHODS: We reviewed the new ICD-11 concept of adjustment disorder and discuss the the rationale and case study of an unguided self-help protocol for burglary victims with adjustment disorder, and its possible implementation as an eHealth intervention. RESULTS: Overall, the treatment with the self-help manual reduced symptoms of adjustment disorder, namely preoccupation and failure to adapt, as well as symptoms of depression, anxiety, and stress. CONCLUSIONS: E-mental health options are considered uniquely suited for offering early intervention after the experiences of stressful life events that potentially trigger adjustment disorders.