Adjustment Disorders Diagnostic and Treatment IssuesPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

Adjustment Disorders Diagnostic and Treatment IssuesMarch 18 2013 | Personality Disorders [1]By Patricia Casey FRCPI FRCPsych MD [2] and Anne Doherty MBBCh MedS MRCPsych [3]

Adjustment disorder is one of the few psychiatric diagnoses for which the etiology symptoms andcourse rather than symptoms alone are central to making the diagnosis Both emotional andbehavioral disturbances are present and include low mood tearfulness anxiety self-harmwithdrawal anger and irritability

The diagnostic category of adjustment disorder (AD) made its firstappearance in DSM-III in 1968 replacing the previous ldquotransient situational disturbancerdquo of DSM-IIand shortly after was included in ICD-9 It has persisted into the current versions of both DSM-IV and ICD-10 The inclusion of AD recognizes that people can often develop symptoms or exhibit behaviorsin response to stressful events that are in excess of normal reactions Resolution with the minimumof intervention apart from general supportive measures is frequent either when the stressor isremoved or as new levels of adaptation are reached Management of anxiety or insomniasymptoms or brief psychological treatments are sometimes used to shorten the duration or reducethe intensity of AD episodes In patients with AD both emotional and behavioral disturbances arepresent and include low mood tearfulness anxiety self-harm withdrawal anger and irritability

DefinitionAD is defined in DSM-IV as emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3months of the onset of the stressor(s) These symptoms or behaviors are clinically significant asevidenced by either marked distress that is in excess of what would be expected from thestressor [or] significant impairment of social or occupational (academic) functioningThis definition excludes the diagnosis if there is another Axis I or II disorder to which the symptomsmay be attributed or if the symptoms are due to bereavement (Table) AD is classified as eitheracute or chronic and within each form there are subtypes with depressed mood with anxiety withmixed anxiety and depressed mood with disturbance of conduct with mixed disturbance ofemotions and conduct and not otherwise specifiedICD-10 limits the time frame of onset to within 1 month of the causative stressor and as withDSM-IV categorizes it as one of exclusion specifying that the criteria for an affective disorder mustnot be met The categories in ICD-10 are brief depressive reaction prolonged depressive reactionmixed anxiety and depressive reaction with predominant disturbance of other emotions withpredominant disturbance of conduct with mixed disturbance of emotions and conduct and with

Page 1 of 7

Adjustment Disorders Diagnostic and Treatment IssuesPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

other specified predominant symptomsWhile DSM-IV states that the symptoms should resolve within 6 months it also recognizes a chronicform if exposure to the stressor is long-term or the consequences of exposure to the stressor areprolonged For example the loss of a job may lead to the loss of the home thereby causing maritalproblems So the diagnosis can be made even when the index event has resolved or the 6-monthtime frame has been reached if consequences continue ICD-10 is silent on the knock-on effect ofstressors but allows a 2-year period of symptoms in the prolonged depressive subtypeSymptoms caused by mood fluctuations in response to day-to-day stressful events that occur inpersons with borderline (emotionally unstable) personality disorder are not classified as AD AD isone of the few psychiatric diagnoses for which the etiology symptoms and course rather thansymptoms alone are central to making the diagnosis1

Table ndash DSM-IV criteria for adjustment disorder bull Occurs within 3 months of the onset of a stressorbull Marked by distress that is in excess of what would be expected given the nature of the stressor or by

significant impairment in social or occupational functioningbull Should not be diagnosed if the disturbance meets the criteria for another Axis I disorder or if it is an

exacerbation of a preexisting Axis I or II conditionbull Should not be diagnosed when the symptoms represent bereavementbull The symptoms must resolve within 6 months of the termination of the stressor but may persist for a

prolonged period (longer than 6 months) if they occur in response to long-term exposure to a stressor or to astressor that has enduring consequences

Controversies and dilemmasA diagnosis of AD raises a number of dilemmas The first is the distinction from normal reactions tostress a separation that is important so as not to pathologize the day-to-day travails of life There isnothing to assist the clinician in making this distinction except that ICD-10 requires both functionalimpairment and symptoms to make the diagnosis while DSM requires symptoms or impairmentThus ICD is more stringent and has a higher threshold than DSM Arguably a decision on whether areaction is pathological should take account of a number of factors includingbull Cultural differences in the expression of emotionbull Individual circumstances (eg the loss of a job may render a person homeless which isappropriately associated with high levels of distress)bull The mere fact of visiting a doctor or being referred to a mental health professional should notinevitably be regarded as indicative of disorderbull The level of functional impairment as a result of the symptoms (ICD-10 only)The second dilemma is the differentiation of AD from other Axis I disorders such as generalizedanxiety disorder (GAD) and major depression disorder (MDD) Simply on the basis of symptomnumbers and duration of more than 2 weeks AD would be relabeled as MDD after the time thresholdhas been crossed even though the onset of symptoms was temporally close to the stressor Thus ayoung woman with children who had received a diagnosis of stage IV cancer 3 weeks earlier and nowhas low mood is not sleeping is unable to get pleasure from life has recurrent thoughts of dyingand has poor concentration might variously be thought to be experiencing an appropriate reactionan AD or MDD Examples such as this highlight the need for continued monitoringOrdinarily one would expect the symptoms to resolve when the stressor diminished or was removedAt other times notwithstanding the persistence of the stressor or its ramifications the personadapts A diagnostic conundrum arises however when the symptoms and the stressor persist intandemmdashis the appropriate diagnosis chronic AD MDD or appropriate sadness In general normalreactions to events resolve quickly and do not persist hence the time frames specified in DSM-IVand ICD-10 A further reason for monitoring is that the symptoms may represent a disorder such asevolving MDD that emerges more clearly over timeAnother controversy stems from the subsyndromal nature of AD It may be that allowing MDD tooverride a diagnosis of AD is a clinical mistake since there is little to distinguish one from the otherin terms of symptoms although the course of each is different2 In addition doing so is illogicalbecause the diagnosis of MDD is cross-sectional and is based on symptom numbers and durationthe course of AD is longitudinal and is based on etiology and duration Thus MDD and AD representconceptually different nonoverlapping dimensionsThis suggests that the current diagnostic system based on symptom thresholds is limited and that inDSM-5 more emphasis should be placed on the specific symptom clusters and their quality

Page 2 of 7

Adjustment Disorders Diagnostic and Treatment IssuesPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

Moreover the longitudinal course of AD should receive more attention Since a diagnosis of ADcannot be made at present when the threshold for another condition is met it is currently regardedas a subsyndromal rather than a full Axis I disorder1 However its clinical importance may be suchthat it should be accorded full syndromal status with its own diagnostic criteria3PrevalenceAD is underresearched and most of the large epidemiological surveys of the general population lackany prevalence data for AD including the Epidemiological Catchment Area study the US NationalComorbidity Survey and the National Psychiatric Morbidity surveys of Great Britain4-6 As a resultthe diagnostic category of AD has not received the attention that it warrants and most of thescientific data are derived from smaller studies made up of particular clinical groupsThe prevalence of AD has been found to be 11 to 18 in primary care78 In consultation-liaisonwhere the diagnosis is most often made the rates are similar 71 to 1849-11 This however is ina state of flux and it may be that the ldquoculture of prescriptionrdquo drives the ldquoculture of diagnosisrdquo1 Thediagnosis of AD has declined from 28 in 1988 to 147 in 1997 while the diagnosis of MDD hasincreased (64 to 147) over the same 10 years12

A major problem in studying AD is the absence of any specific diagnostic criteria with which to makethe diagnosis Instruments such as the Structured Clinical Interview for DSM (SCID) and theSchedules for Clinical Assessment in Neuropsychiatry (SCAN) include the criteria for AD albeit in acursory manner So it is not possible to achieve a gold standard measure based on the currentcriteria in DSM-IV and ICD-10 For this reason clinical diagnosis with all its associated problems isthe only standard currently availableStructured diagnostic and screening instruments for ADStructured interviews are frequently considered the gold standard in psychiatric research becausethey eliminate the subjective element of the diagnostic process however for purposes of diagnosingAD there are problems Some of the most widely used structured interviews in research such as theClinical Interview Schedule and the Composite International Diagnostic Interview fail to includeAD1314 Others such as SCID SCAN and the Mini International Neuropsychiatric Interview includeAD but regard it as a subsyndromal diagnosis15-17 This commonly leads to AD being ignored orconflated with and subsumed by MDD218

Screening instruments have likewise met with little success in distinguishing between AD and MDDThe Zung Depression Scale the One-Question Interview the Impact Thermometer and the HospitalAnxiety and Depression Scale although helpful in identifying possible mood disorders are of littleuse in differentiating AD from MDD19-21

Since diagnostic interviews and screening instruments either fail to distinguish between AD and MDDor entirely omit AD their utility is limited when applied to AD Thus the diagnosis of AD relies on thetraditional medical skills of careful history taking and clinical judgment in assessing the presentingsymptoms the context in which the symptoms arise and the likely course of the conditionDiagnosisThe presence of a stressor is central to the diagnosis of AD and this is the consideration that mostsets AD apart from other disorders in DSM-IV and ICD-10 This makes AD similar to PTSD and toacute stress disorder which also require a stressormdashthe symptoms would not have developed ifthere had been no stressor This differs from MDD which does not require a stressor although manyepisodes of MDD are preceded by a life eventAD is more strongly associated with marital problems and less with family-related or occupationalstressors than MDD22 Clinically this is unlikely to be helpful because the types of events are notspecific and even traumatic events can trigger AD as well as PTSDSymptoms are important to any clinical diagnosis but they are not sufficiently specific to allow adistinction to be made between AD and MDD1023 While neither of the classifications specifies thesymptoms required for a diagnosis of AD there are some symptoms that may be indicative of ADYates and colleagues24 found that diurnal mood variation the loss of mood reactivity a distinctquality to the mood and a family history of MDD were predictive of a diagnosis of MDD rather thanAD Further studies are needed to demonstrate whether these symptoms have sufficient specificityThe mood state of those with AD often depends on the cognitive presence of the stressor so thatimmediate impairment of mood is observed when the stressor is discussed with more obvious moodrecovery when the patient is distracted Thus removing the person from the stressful situation willlead to a reduction in symptoms that would otherwise persistBecause of the limitations in the criteria for diagnosing AD the diagnosis is based on the presence ofa precipitating stressor and on a clinical evaluation of the likelihood of symptom resolution onremoval of the stressor For those exposed to stressors long-term the diagnosis of AD is less clear

Page 3 of 7

Adjustment Disorders Diagnostic and Treatment IssuesPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

because this type of exposure can be associated with MDD GAD or ADDepending on the predominant symptoms the differential diagnosis may be MDD GAD or evolvingMDD When the person exhibits behavioral disturbance such as self-harm or anger borderlinepersonality disorder must be excluded For those who have experienced a traumatic event PTSDmust be considered however PTSD does not develop in all persons who have been exposed to a traumatic event and therefore AD may be a more appropriate diagnosis Unlike most other disordersin DSM AD must be distinguished from a normal homeostatic reaction to stress Failure to considerthis could lead to normal distress being miscategorized as a psychiatric disorder25

TreatmentAD is largely short-lived and generally resolves spontaneously which may account for the paucity ofstudies on the treatment of this common condition Yet treatment cannot be disregarded sincedespite its brevity symptoms may be severe and are associated with a risk of suicide26 In additionthe effect on quality of life and functioning means that there are social and even economic reasonswhy interventions are worthy of further study26

In clinical practice 3 approaches to treatment deserve consideration on the basis of the stressresponse modelbull Modifying or removing the stressorbull Facilitating adaptation to the stressor using various psychological therapiesbull Altering the symptomatic response to the stressor with medication or behavioral approachesBrief psychotherapy has been identified as the treatment of choice for AD27 Approaches using egostrengthening and mirror therapy have shown some success in specific groups such as the elderlyduring transition phases and those recovering from myocardial infracts2829 For patients who haveexperienced work-related stress cognitive interventions have been effective30

Most randomized controlled trials have focussed on pharmacotherapy for AD with anxiety subtypesIn a study that compared a benzodiazepine with a nonbenzodiazepine anxiolytic more patientsresponded to the nonbenzodiazepine although the reduction in symptom severity was the same byday 28 of the study Fewer patients who received the nonbenzodiazepine experienced reboundanxiety when medication was discontinued31

Two randomized placebo-controlled studies that examined symptom response in patients with ADwith anxiety subtypes showed a positive effect with kava-kava and valerian extracts3233 Ansseauand colleagues34 found that anxiolytics and antidepressants were equally effective in patients withAD and anxiety Results from a randomized controlled trial of pharmacological andpsychotherapeutic interventions that included supportive psychotherapy an antidepressant abenzodiazepine and placebo showed significant improvements regardless of the intervention35

There have been no randomized clinical trials that compared antidepressants with placebo or otherpharmacological treatments for AD with the depression subtype Evidence for the use ofmedications especially antidepressants is lacking and further studies are requiredPrognostic considerationsThe most common comorbidities with AD are personality disorder and substance abuse disorderswhich have been associated with poor outcome36-39 Patients with AD are at increased risk forsuicide Psychological autopsy studies have shown that between 6 and 25 of patients who die bysuicide have received a diagnosis of AD2640 The rates of AD in patients who present after an act ofself-harm range from 4 to 104142 Suicidal ideation has been found to be of a more rapid onsetand resolution in patients with AD than in patients with other disorders41

The definition of AD in both DSM-IV and ICD-10 conveys an expectation of good outcome with thespontaneous resolution of symptoms This has been borne out in follow-up studies that found thatpatients who received a diagnosis of AD on admission had shorter index admissions and fewerpsychiatric readmissions than those who received another diagnosis38

DSM-5 and beyondThe problems concerning the absence of specific diagnostic criteria for AD and the relegation of ADto subsyndromal status are significant concerns that should be taken into account during the framingof DSM-5 Suggestions for new criteria for AD include the following3bull Terminating the subsyndromal status of AD and according it full diagnostic criteria alongside MDDand GADbull Extending of the bereavement exclusion to other eventsbull Recognizing that AD may be conflated with MDD the following wording is suggested ldquoStressorsmay also trigger adverse reactions that symptomatically resemble major depression anxiety orconduct disorders but are better classified as AD particularly when there is a close temporalrelationship between the event and the onset of symptoms and spontaneous recovery is anticipated

Page 4 of 7

Adjustment Disorders Diagnostic and Treatment IssuesPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

after a period of adaptation or when the stressor is removedrdquobull Associating the condition with symptoms and impairmentCurrently the broad criteria for MDD have the unintended consequence of drawing self-limitedconditions such as AD into their net simply because they reach the threshold in terms of durationor symptom numbers leading to a mistaken belief that the prevalence of MDD is increasingDeveloping criteria for AD in DSM-5 will also affect the criteria for MDD The requirement forfunctional difficulties as well as symptoms reduces the likelihood that normal adaptive reactions aredeemed pathological and corresponds with ICD-10 and ICD-11AD should also be considered in a separate category of stress-related disorders together with PTSDacute stress reactions and possibly dissociation because all are triggered by a stressful event Thecontinuing interest in PTSD will inevitably help direct research endeavors to the associatedcategories This change would lead to greater harmonization between DSM-5 and ICD-11 in whichAD is classified in the stress-related groupThe classification of AD is of more than theoretical interest since it has implications for how normalstress responses are distinguished from those that are pathological on the one hand and howpathological responses are distinguished from other psychiatric disorders such as MDD and GAD onthe otherThis also has financial implications because antidepressants are now the most commonly prescribedmedications in the United States43 The proportion of the general population for whomantidepressants are prescribed almost doubled from 584 in 1996 to 1012 in 2005 During thistime the use of antidepressants for ldquodepressionrdquo anxiety and AD increased significantly Thebiggest increase was seen in patients with ADmdash223 to 394 annually and this increase is setagainst a backdrop of a near total absence of scientific evidence for their benefit Thus the public ispaying for pharmacological treatments that are not necessary and not supported by evidence[Editors note This article was originally published as a CME in January 2012 Now expired as a CMEactivity it is published here for educational purposes only] References References1 Strain JJ Diefenbacher A The adjustment disorders the conundrums of the diagnoses ComprPsychiatry 200849121-1302 Casey P Maracy M Kelly BD et al Can adjustment disorder and depressive episode bedistinguished Results from ODIN J Affect Disord 200692291-2973 Baumeister H Maercker A Casey P Adjustment disorder with depressed mood a critique of itsDSM-IV and ICD-10 conceptualisations and recommendations for the future Psychopathology200942139-1474 Myers JK Weissman MM Tischler GL et al Six-month prevalence of psychiatric disorders in threecommunities 1980 to 1982 Arch Gen Psychiatry 198441959-9675 Kessler RC Sonnega A Bromet E et al Posttraumatic stress disorder in the National ComorbiditySurvey Arch Gen Psychiatry 1995521048-10606 Jenkins R Lewis G Bebbington P et al The National Psychiatric Morbidity surveys of GreatBritainmdashinitial findings from the household survey Psychol Med 199727775-7897 Casey PR Dillon S Tyrer PJ The diagnostic status of patients with conspicuous psychiatricmorbidity in primary care Psychol Med 198414673-6818 Blacker CVR Clare AW The prevalence and treatment of depression in general practice Psychopharmacology 19889514-179 Strain JJ Smith GC Hammer JS Adjustment disorder a multisite study of its utilization andinterventions in the consultation-liaison psychiatry setting Gen Hosp Psychiatry 199820139-14910 Taggart C OrsquoGrady J Stevenson M et al Accuracy of diagnosis at routine psychiatricassessment in patients presenting to an accident and emergency department Gen Hosp Psychiatry200628330-33511 Bakr A Amr M Sarhan A et al Psychiatric disorders in children with chronic renal failure PediatrNephrol 200722128-13112 Diefenbacher A Strain JJ Consultation-liaison psychiatry stability and change over a 10-yearperiod Gen Hosp Psychiatry 200224249-25613 Lewis G Pelosi AJ Araya R Dunn G Measuring psychiatric disorder in the community astandardized assessment for use by lay interviewers Psychol Med 199222465-48614 Kessler RC Uumlstuumln TB The World Mental Health (WMH) Survey Initiative Version of the World

Page 5 of 7

Adjustment Disorders Diagnostic and Treatment IssuesPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

Health Organization (WHO) Composite International Diagnostic Interview (CIDI) Int J MethodsPsychiatr Res 20041393-12115 First MB Gibbon M Spitzer RL Williams JBW Structured Clinical Interview for DSM-IV Axis IDisorders (SCID 1) New York New York State Psychiatric Institute Biometric Research Department199616 Wing JK Babor T Brugha T et al SCAN Schedules for Clinical Assessment in Neuropsychiatry Arch Gen Psychiatry 199047589-59317 Sheehan DV Lecrubier Y Sheehan KH et al The Mini-International Neuropsychiatric Interview(MINI) the development and validation of a structured diagnostic psychiatric interview for DSM-IVand ICD-10 J Clin Psychiatry 199859(suppl 20)22-3318 Parker G Beyond major depression Psychol Med 200535467-47419 Gawronski I Privette G Empathy and reactive depression Psychol Rep 199780(3 pt1)1043-104920 Akizuki N Akechi T Nakanishi T et al Development of a brief screening interview for adjustmentdisorder and major depression in patients with cancer Cancer 2003972605-261321 Akechi T Okuyama T Sugawara Y et al Major depression adjustment disorders andpost-traumatic stress disorder in terminally ill cancer patients associated and predictive factors JClin Oncol 2004221957-196522 Despland JN Monod L Ferrero F Clinical relevance of adjustment disorder in DSM-III-R andDSM-IV Compr Psychiatry 199536454-46023 Shear MK Greeno C Kang J et al Diagnosis of nonpsychotic patients in community clinics Am JPsychiatry 2000157581-58724 Yates WR Mitchell J Rush AJ et al Clinical features of depressed outpatients with and withoutco-occurring general medical conditions in STARD Gen Hosp Psychiatry 200426421-42925 Maj M Are we able to differentiate between true mental disorders and homeostatic reactions toadverse life events Psychother Psychosom 200776257-25926 Foster T Gillespie K McClelland R Mental disorders and suicide in Northern Ireland Br JPsychiatry 1997170447-45227 Kaplan HI Sadock BJ Kaplan and Sadockrsquos Synopsis of Psychiatry Behavioral SciencesClinicalPsychiatry 8th ed Baltimore Williams amp Wilkins 199828 Frankel M Ego enhancing treatment of adjustment disorders of later life J Geriatr Psychiatry200134221-22329 Gonzaacutelez-Jaimes EI Turnbull-Plaza B Selection of psychotherapeutic treatment for adjustmentdisorder with depressive mood due to acute myocardial infarction Arch Med Res 200334298-30430 van der Klink JJ Blonk RW Schene AH Dijk FJ Reducing long term sickness absence by anactivating intervention in adjustment disorders a cluster randomised controlled design OccupEnviron Med 200360429-43731 Nguyen N Fakra E Pradel V et al Efficacy of etifoxine compared to lorazepam monotherapy inthe treatment of patients with adjustment disorders with anxiety a double-blind controlled study ingeneral practice [published correction appears in Hum Psychopharmacol 200621562] HumPsychopharmacol 200621139-14932 Volz HP Kieser M Kava-kava extract WS 1490 versus placebo in anxiety disordersmdasharandomized placebo-controlled 25-week outpatient trial Pharmacopsychiatry 1997301-533 Bourin M Bougerol T Guitton B Broutin E A combination of plant extracts in the treatment ofoutpatients with adjustment disorder with anxious mood controlled study versus placebo FundamClin Pharmacol 199711127-13234 Ansseau M Bataille M Briole G et al Controlled comparison of tianeptine alprazolam andmianserin in the treatment of adjustment disorders with anxiety and depression HumPsychopharmacol 199611293-29835 De Leo D Treatment of adjustment disorders a comparative evaluation Psychol Rep19896451-5436 Rundell JR Demographics of and diagnosis in Operation Enduring Freedom and Operation IraqiFreedom personnel who were psychiatrically evacuated from the theatre of operations Gen HospPsychiatry 200628352-35637 Looney JG Gunderson EK Transient situational disturbances course and outcome Am JPsychiatry 1978135660-66338 Greenberg WM Rosenfeld DN Ortega EA Adjustment disorder as an admission diagnosis Am JPsychiatry 1995152459-46139 Al-Turkait FA Ohaeri JU Post-traumatic stress disorder among wives of Kuwaiti veterans of the

Page 6 of 7

Adjustment Disorders Diagnostic and Treatment IssuesPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

first Gulf War J Anxiety Disord 20082218-3140 Marttunen MJ Aro HM Henriksson MM Loumlnnqvist JK Adolescent suicides with adjustmentdisorders or no psychiatric diagnosis Eur Child Adolesc Psychiatry 19943101-11041 Polyakova I Knobler HY Ambrumova A Lerner V Characteristics of suicidal attempts in majordepression versus adjustment reactions J Affect Disord 199847159-16742 Chiou PN Chen YS Lee YC Characteristics of adolescent suicide attempters admitted to anacute psychiatric ward in Taiwan J Chin Med Assoc 200669428-43543 Olfson M Marcus SC National patterns in antidepressant medication treatment Arch GenPsychiatry 200966848-856 Source URL httpwwwpsychiatrictimescompersonality-disordersadjustment-disorders-diagnostic-and-treatment-issues

Links[1] httpwwwpsychiatrictimescompersonality-disorders[2] httpwwwpsychiatrictimescomauthorspatricia-casey-frcpi-frcpsych-md[3] httpwwwpsychiatrictimescomauthorsanne-doherty-mbbch-meds-mrcpsych

Page 7 of 7

Adjustment Disorders Diagnostic and Treatment IssuesPublished on Psychiatric Times(httpwwwpsychiatrictimescom)

first Gulf War J Anxiety Disord 20082218-3140 Marttunen MJ Aro HM Henriksson MM Loumlnnqvist JK Adolescent suicides with adjustmentdisorders or no psychiatric diagnosis Eur Child Adolesc Psychiatry 19943101-11041 Polyakova I Knobler HY Ambrumova A Lerner V Characteristics of suicidal attempts in majordepression versus adjustment reactions J Affect Disord 199847159-16742 Chiou PN Chen YS Lee YC Characteristics of adolescent suicide attempters admitted to anacute psychiatric ward in Taiwan J Chin Med Assoc 200669428-43543 Olfson M Marcus SC National patterns in antidepressant medication treatment Arch GenPsychiatry 200966848-856 Source URL httpwwwpsychiatrictimescompersonality-disordersadjustment-disorders-diagnostic-and-treatment-issues

Links[1] httpwwwpsychiatrictimescompersonality-disorders[2] httpwwwpsychiatrictimescomauthorspatricia-casey-frcpi-frcpsych-md[3] httpwwwpsychiatrictimescomauthorsanne-doherty-mbbch-meds-mrcpsych

Page 7 of 7