Adjustment Disorder vs Major Depressive Disorder

Med students are often asked to distinguish between Major Depressive Disorder (296.xx) and Adjustment Disorder with depressed mood (309.xx)… Both are characteristically different groups of conditions that although are categorically distinct, sometimes present with similar symptoms…

Adjustment disorder is a major depressive episode that occurs in response to a psychosocial stressor (e.g. losing a family member or loved one, major disaster, loss of job etc). Depression is distinguished fro adjustment disorder by the fact that the full criteria for MDD are not met in adjustment disorder…

As stated in the DSM V, MDD can be diagnosed based on criteria A-E.
Criteria A. Key Signs and Symptoms.
– >5 or more of the following during a 2 week period and represent a change from previous functioning; 1. Depressed mood, 2. Markedly diminished interest or pleasure in all or almost all activities most f the day, nearly every day, 3. Significant weight loss (not through intentional dieting/exercise), 4. Insomnia or hypersomnia nearly every day, 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy, 7. Feelings of worthlessness or excessive or inappropriate guilt, 8. Diminished ability to think or concentrate, being indecisive, 9. Recurrent thought of death (not just fear of dying), recurring suicidal ideation without specific plan, or suicide attempt…
– AT LEAST ONE of the symptoms should be either 1. Depressed mood OR 2. Loss of interest in pleasure.

Criteria B; Significance
– the symptoms cause considerable distress or impairment in social, occupational or other important areas of functioning.

Criteria C; No attributes
– the episode cannot be attributed to substance use or any other medical condition.

Criteria D. No better explaination
– The occurrence of DD is not better explained by any other psychological condition (e.g. schizoaffective disorder, schizophrenia, schizopreniform, delusional disorder)

Criteria E; No previous manic episode..
– this is similar to criteria D as it may indicate bipolar disorder…

The above are better memorised with the mnemonic SADAFACES (Sleep Disturbance, Anhedonia, Depressed mood, Appetite loss, Fatigue, Aggitation, Concentration loss, Esteem loss, Suicidality)

It is important to note that MDD has many other differential diagnoses including…

– Manic episodes with irritable mood or mixed episodes
– Mood disorder due to another medical condition
– Substance/medication induced depression
– Bipolar disorder (I/II)
– Dysthymia
– ADHD (via manifestations of distractibility and low frustration tolerance)
– Plain ‘Sadness’ – the human experience

But the distinction should be somewhat more obvious..

An adjustment disorder with depressed mood may also present with clinically significant (i.e. marked distress, significant impairment) elements of low mood, tearfullness and feelings of hopelessness – but are frequently precipitated by an identifiabe stressor, within 3 months of the onset. This can be considered if a bereavement process is not seen to represent normal social/cultural practices or if symptoms persist an additional 6 months after that stressor has been terminated.

The key differential diagnoses for adjustment disorder include
– MDD
– PTSD
– Personality disorder
– Psychological factors from other medical conditions
– Normative stress reactions

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