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Adjustment disorder: An occupational perspective (with particular focus on the military) 

Adjustment disorder: An occupational perspective (with particular focus on the military)
Adjustment disorder: An occupational perspective (with particular focus on the military)

Geoffrey Reid

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date: 22 September 2018

The diagnostic concept of adjustment disorder (AD), a disturbance of mental state arising specifically as a contingent response to an external psycho-social stressor and relieved on resolution of the stressor, is an apparently simple idea; individuals develop disturbances in mental state in association with psycho-social stressors. However, whilst widely employed as a diagnosis, the evidence base is surprisingly sparse.

AD is a common condition and may impact upon occupational psychiatry either as a direct consequence of the occupation (especially in those occupations exposed to hazardous activities, e.g. the armed forces) or as a result of the associated impairment of AD originating elsewhere impacting upon employability.

AD is associated with both recurrent absence (1) and long-term absence (2), and around 20% never return to work (3). The diagnosis plays an important role in the field of occupational psychiatry, and in particular in the field of military occupational psychiatry, and stress-related disorders are often seen as the particular focus of military psychiatry. AD was the most prevalent mental disorder among UK armed forces personnel in 2015–16, accounting for 35% of all mental disorders in the UK armed forces (4). A study in the Sri Lanka Air Force (5) showed, in a survey of 78 Sri Lankan Air Force personnel referred to psychiatric services, that 25% had a diagnosis of AD, using DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria. In one UK study (6), the single most commonly diagnosed psychiatric disorder was moderate-to-severe AD in 38.8% of 1,405 personnel seen at a military Department of Community Mental Health (DCMH).

Case vignette 1

Cpl AW was referred to mental health services having been posted from front-line weapons engineering duties on fast jets to weapons instructor duties. He was looking forward to the posting. He had enjoyed his 8 years of Royal Air Force duties and had no previous history of mental health concerns. Although aware that he was never comfortable in front of groups, he had chosen these duties, highly valuing his role as a father and looking for some stability for his family. Unfortunately, he found himself becoming increasingly anxious in the performance of his instructional duties. The posting was for 5 years. His mood deteriorated and he presented to primary care and was referred to the DCMH. At initial CMHN (Community Mental Health Nurse) assessment, he was tearful and low in mood, scoring in the moderately depressed range on the Patient Health Questionnaire (PHQ)-9, and highly anxious. He was avoiding social contact, his affect was flattened, and he was lethargic. His appetite was variably poor but he had not lost weight. He did not have any suicidal thoughts. Antidepressant medication was recommended and commenced in primary care. A consultant psychiatrist review was requested. At consultant review 3 weeks later, he presented as well. He described having developed incapacitating headaches on the medication and he had stopped it after 9 days. The executive had taken action. He had been categorized as unsuited to instructional duties and had been removed from teaching. Action was under way to find him a new posting, returning to his primary weapons engineering task. At further review, he remained well.

The managerial problem-solving was welcome. Medical occupational management would have probably involved a medical recommendation that he was unfit for instructor duties, with an associated medical downgrading. The use of antidepressant medication and the medical downgrading would have precluded a return to front-line weapons engineering duties in the medium term.

Despite being the single most common diagnostic category, there is a remarkable paucity of research into the aetiology and treatment of the disorder, as noted by the various authors of this book. Many community mental health surveys omit AD, and the overall quality of epidemiological studies in either the military or civilian population is poor. The evidence base is not only poor, but almost entirely lacking. Confusion continues to reign in professional and lay circles on the distinction, if any, between depressive and anxiety symptoms arising in association with psycho-social stressors and other forms of anxiety and depressive disorders. Common contemporary treatments seem to focus upon symptom relief, with variable degrees of success, whether by cognitive–behavioural strategies or by medication. Largely, this reflects the current state of psychiatric understanding, where underlying structures and mechanisms remain very incompletely understood. Unlike much of contemporary medicine, where substantial gains have been made in the understanding of mechanisms, psychiatry remains the last ‘clinical art’, unsullied by tests and imaging at this point. The attempts to understand and classify psychiatric disorders have been, of necessity, observational and therefore subject to limitations. The use of diagnostic criteria held the hope that discrete categorical disorders would have distinct boundaries, despite the recognition that such boundaries were not reliably determinable for the depressive disorders, resulting in the unitary category of major depression in DSM-III. The situation is neatly summarized by Parker (7): the concept of major depression is analogous to ‘major breathlessness’. Breathlessness may arise as a consequence of strong exertion, or disorders such as asthma, emphysema, pneumonia, heart failure, and pulmonary embolus. The classification hides a number of distinct entities, awaiting further knowledge.

Unfortunately, the boundaries within and between diagnostic categories remain fuzzy, and the latest iteration of the DSM classification, DSM-5 (8), remains a symptom-based descriptive system. The inability to clearly identify the nature and mechanisms of psychiatric disorders, how these may operate in ‘normality’, and the way in which disturbance or decompensation may arise has led to renewed criticism of the validity of psychiatric diagnosis previously seen in the ‘anti-psychiatry’ days of Thomas Szasz (9). For example, the critique of the DSM operationalization of the diagnosis of depression with inadequate attention to the context has resulted in ‘normal sadness’ being seen as pathological by Horwitz & Wakefield (10). The deficiencies of symptom-based categorization should be clear: in this, psychiatry remains at the level of physical medicine before the full clarification of physiology, biochemistry, etc. Given these limits in understanding, Spitzer (11) recognized the pragmatic need that expressed disorder needed to be associated with ‘clinically significant distress or impairment in social, occupational or other important areas of functioning’. This has remained a feature of the DSM classifications, although it has been weakened in DSM-5 by the statement that ‘Mental disorders are usually associated with significant distress or disability in social, occupational or other important activities’ (italics added) (8). The constraint of functional impairment is central to the practice of military psychiatry.

Military psychiatry is closely integrated with the day-to-day functioning of the armed forces and, as part of a comprehensive military occupational medical service, is required to assess fitness to perform safety-critical tasks and to maintain the workforce. In the UK, mental health care is delivered to the military population from Departments of Community Mental Health, comprising multidisciplinary teams of consultant psychiatrists, clinical psychologists, community mental health nurses (CMHNs), and mental health social workers (MHSWs). The focus on function and fitness for task and the expectation of fitness for task (and the particular safety-critical aspects) have historically been associated with a familiarity with disturbances of mental state arising in association with stressors—most dramatically, of course, in association with operational events, but more mundanely in association with the day-to-day strains of personal and Service life. These circumstances are many and varied. They can include the impact of marital disharmony and family issues, bullying from within the organization, disenchantment with the service, mismatches between individuals and task, separation from families, the growth of single-parent families, and many more aspects of life. A particular issue within the armed forces can be the lack of access to a confidant, arising from the separation of young people from their families. Access to live weapons, the operation of safety-critical equipment, and the high expectation of personnel reliability are intrinsic aspects of the military environment. The identification of disturbances of mental state that arise in association with particular circumstances is critical to the performance of this role in that such identification offers the prospect of ready resolution, whether this is by the process of resolution of stressors or by a specific change in the working environment. Function is the keystone of military occupational psychiatry. For these reasons, adjustment issues have historically played a major role in the day-to-day provision of military mental health services. Military psychiatry was the seedbed for the development of social psychiatry (12) and remains closely embedded with the environmental context of the armed forces.

Disturbances of mental state developing within the operational environment have been widely recognized and have led to a substantial literature on acute stress sisorder (ASD) and post-traumatic stress disorder (PTSD).

ASD has been characterized as an incapacitating disturbance of mental state arising in direct association with operational stressors, and is considered to be commonly transient (80% recovery rate within 72 hours). The symptoms show a typically mixed and changing pattern and can include an initial ‘dazed’ state, with some constriction of the field of consciousness, and narrowing of attention with an inability to comprehend stimuli and with disorientation. It may be followed by further withdrawal from the surrounding situation (even to the extent of a dissociative stupor) or by agitation and over-reactivity. Although the short-term prognosis is good, it carries an increased risk of PTSD. The disorder is seen as more severe than AD (13).

PTSD is characterized as a long-term chronic disorder with the features of intrusive memories, avoidance, and chronic hyper-arousal. The term post-traumatic stress reaction (PTSR) has been used to identify the development of PTSD-like symptoms in the immediate aftermath of a major stressor, carrying a very high spontaneous recovery rate. PTSR overlaps with the concept of ASD and AD. Most personnel who develop PTSR do not progress to PTSD (14). The NICE (National Institute for Health and Care Excellence) guidelines for PTSD, recognizing the high degree of spontaneous recovery, recommend intervention 3 months after the precipitating event where symptoms persist (15). Within the UK military, the diagnosis of ASD and PTSR within the first 3 months of exposure to a traumatic event is coded as AD, reflecting the use of a computerized, limited diagnostic list. This will inflate the UK military diagnosis of AD, although the major proportion of AD diagnoses are not operationally related.

It has been suggested that AD requires only limited treatment because of a tendency to be short-lived and to resolve spontaneously (16). However, although resolution of symptoms may develop through the process of habituation or by resolution of the precipitating stressor, recovery may be delayed or abolished if the precipitant stressor is maintained or the cognitive appraisal of threat continues. If the stressor persists, the disorder may become persistent (17). However, ICD-10 and DSM-5 require a change of diagnosis where the disorder is persistent, irrespective of the persistence of a precipitating stressor. Such diagnostic practices, whereby the diagnosis may change to major depression where the disorder persists, are a further source of confusion.

A common criticism of the concept of AD is that it is essentially a normal human response to various stressors and therefore not pathological. Horwitz & Wakefield (10), in their critique of ‘how psychiatry transformed normal sorrow into depressive disorder’, dismiss the concept of AD on the basis that the criterion of impairment of social or occupational functioning fails to exclude large numbers of normal loss response conditions and that virtually any low mood may involve some loss of motivation and interest. They conclude that the flaws in the concept of AD ‘are so apparent that researchers and epidemiologists have largely ignored it’, the diagnosis suffering from such glaring problems in distinguishing normal from disordered conditions that it has collapsed as a serious target for research under the weight of its own invalidity. Within military psychiatry, function rather than diagnosis remains the prime determinant of occupational intervention and limitations. The determination of fitness to carry out safety-critical tasks is a requirement placed upon military psychiatry. Access to weapons is a common component of military duties, as is the performance of tasks requiring a high level of attention and concentration (e.g. piloting a fast jet), and the presence of any self-harmful thoughts or the extent of actual and anticipated impairment of concentration and attention is an essential component of military psychiatric assessment. The specific diagnosis is a secondary issue.

Case vignette 2

LCpl AB, a Royal Signals operator, was referred after having presented with poor sleep, distress, and low mood. His girlfriend had been raped. She had developed PTSD, for which she was receiving treatment. He described taking hours to get to sleep, being subject to ruminative thoughts. His appetite was good, and his libido variable. Concentration was variable. He did not understand what was happening to his girlfriend. At CMHN assessment, he scored within the moderately severely depressed range on the PHQ-9. A high-achiever at school, he had been the victim of bullying and had been expelled from school for poor behaviour but had enjoyed his army career. He had no previous psychiatric history. He had served for 4 years; he had not been on any operational deployments. He did not have routine access to weapons and he was not involved in safety-critical activities. He did not have any self-harmful thoughts or wish to be dead. He was not considered to require any medical functional limitations. CMHN management included psycho-education on PTSD and the introduction of coping strategies for ruminative thoughts. He settled, his mood improved, and the ruminative thoughts receded. He remained well at follow up.

Development of the concept

The concept of AD is closely related to wider concepts of stress and has deep historical roots.

An early understanding derives from the work of Yerkes & Dodson (18) in 1908, describing the relationship between arousal and performance: the human performance curve (or ‘Yerkes–Dodson curve’). As arousal increases, performance (both physical and mental) increases. However, when arousal becomes too high, performance is impaired. Different tasks require different levels of arousal for optimum performance, with difficult cognitive tasks requiring lower levels of arousal than those demanding stamina or persistence. Diamond et al. (19) showed that there was a relationship with circulating levels of stress hormones which showed an inverted-U relationship with memory performance.

The original Yerkes–Dodson curve is shown below (see Fig. 11.1).

Fig. 11.1 The Yerkes–Dodson curve.

Fig. 11.1 The Yerkes–Dodson curve.

Reproduced from Journal of Comparative Neurology and Psychology, 18(5), Yerkes RM, Dodson JD, The relation of strength of stimulus to rapidity of habit-formation, pp. 459–482, Copyright 1908, with permission from The Wistar Institute of Anatomy and Biology.

During the World War I, the symptoms of shell shock and flying stress were identified in terms of the fear and fatigue associated with prolonged exposure to operational environments. The concepts of stability of the internal environment deriving from Claude Bernard in the nineteenth century, and the work of Walter Cannon (20) and others during the 1920s and 1930s, in turn led to the concept of the preservation of homeostasis. From 1936 onwards, and predominantly after the World War II, Hans Selye (21, 22) was responsible for developing his concept of the general adaptation syndrome and the understanding of the activity of the hypothalamic-pituitary-adrenal axis. The discovery that rats responded to various forms of damaging stimuli with a general response that involved alarm, resistance, and exhaustion led to the formulation of the general adaptation syndrome, which was said to consist of the following three stages: an initial alarm or shock phase, a stage of adaptation to injury in which physiological resistance allowed normal function, and a final stage of exhaustion when adaptive mechanism failed.

The role of stressors in the development of illness was pursued. Holmes & Rahe (23) developed the Social Adjustment Rating Scale, attempting to quantify stressful life events such as bereavement, divorce, and illness and to provide a means of predicting the development of illness. In 1970, Rahe tested the validity of the scale in a study of 2,500 US sailors. They were asked to rate scores of ‘life events’ over the previous 6 months. Over the next 6 months, detailed records were kept of the sailors’ health. There was a +0.118 correlation between stress scale scores and illness. In 1978, Brown & Harris (24) identified three factors that affected the development of depressive mood in women: protective factors, vulnerability factors, and provoking agents in women. Protective factors (e.g. high levels of intimacy with one’s husband) were found to protect against development of depression in spite of stressors. These factors lead to higher levels of self-esteem and the possibility of finding other sources of meaning in life. Vulnerability factors were found to increase the risk of depression in combination with particularly stressful life events—called ‘provoking agents’ in the study. The most significant vulnerability factors were:

  1. 1. Loss of one’s mother before the age of 11

  2. 2. Lack of a confiding relationship

  3. 3. More than three children under the age of 14 at home

  4. 4. Unemployment. Provoking agents were found to contribute to acute and ongoing stress.

These stressors could result in grief and hopelessness in vulnerable women with no social support. In 1988, Bebbington et al. (25), in the Camberwell Collaborative Depression Study, showed that the onset of depressive symptoms was associated with life stressors; the hypothesis that the ‘endogenous’ group of disorders would be relatively independent of prior life stress was not confirmed. Mazure (26) summarized the findings, noting that stressors were 2.5 times more likely in depressed patients than in controls, and that in community samples 80% of depressed cases had preceding major life events, and Hammen (27) noted that there was an established, robust, and causal association between stressful life events and major depressive episodes.

Stress has now long been identified as a risk factor for major depressive disorder, and a large body of evidence is implicating a dysregulated endocrine and inflammatory response system in its pathogenesis. Hughes et al. (28) provide a review of the role of the immune system and stressors in the onset of major depression. The desire to be free of the aetiological considerations inherent in the older concepts of reactive or neurotic depression and endogenous depression concept led to the use of the term ‘major depression’ and a general perception that depression was a unitary phenomenon. However, Goldberg (29) reiterated that major depression is not a homogeneous entity. He noted that depression could arise as a toxic reaction to drugs or could result from endocrine disorders such as myxoedema or Cushing’s syndrome, and that the depressed phase of bi-polar illness could be indistinguishable from unipolar depression. He discussed five subtypes and notes that many milder cases of depression remit without specific treatment, suggesting that they are ‘homeostatic responses to stress’. The biological mechanisms remain unclear, but it is this variety that is encompassed in the category of depressive adjustment disorder. Evidence is beginning to emerge on the differences between AD and major depression. Lindqvist et al. (30) showed that in individuals with suicidal ideation, post-dexamethasone suppression of cortisol levels was negatively correlated with symptom scores only in those with a clinical diagnosis of major depression. There was no correlation in those diagnosed with AD. Individuals developing AD in the context of workplace bullying did not develop abnormal dexamethasone suppression test results (31). For further information on the psychobiology of AD, see Chapter 5.

Occupational stressors

In the occupational field, the armed forces environment is characterized not only by the risk of exposure to the challenging circumstances of operational deployments, but also by a disciplined, structured environment in which individuals surrender some of their abilities to make environmental choices. Moreover, the services are also characterized by stoical attitudes, forged in the heat of operational demands, whereby intolerance of physical and mental hardship is discouraged, both by training and custom (32). Within this environment, the possibility of changes in circumstances, either geographically or socially, is surrounded by constraints and limitations. Individuals cannot easily remove themselves from an environment or make changes in their social milieu. Young people, removed from the buffering effects of social support in their home environment, may not find alternative sources of confiding support readily available. The capacity to resolve stressful circumstances may be constrained.

In operational deployments, armed forces personnel may be overwhelmed by the intrinsic challenges or develop stress reactions that may be best categorized as AD, prompting psychiatric aeromedical evacuation. AD is a common cause of psychiatric aeromedical evacuation. These post-trauma stress reactions have a high spontaneous recovery rate; the diagnostic category of PTSD would not generally be applied until 3 months after the incident, although this does not preclude early treatment.

It has been suggested that the great advantage of occupational psychiatry in the armed forces is the ability to make changes to the working environment. In the day-to-day working situation, where local environmental problems are not resolvable and it is judged that re-location of the individual is likely to result in a sustained improvement (e.g. in cases of personality clashes, bullying), there is the possibility of a geographical move. In the UK armed forces there are restricted opportunities for such moves within the organization of the Royal Navy and the Army, but more opportunities within the Royal Air Force, reflecting its more homogeneous corporate structure. This is recognized in the specific provision of a psychiatric recommendation for a geographical posting to enable effective psychiatric management. This would be for a maximum of 12 months and carries a requirement for a return to full effectiveness.

Controversy has arisen in the USA with the discharge of personnel from the military with a diagnosis of AD, with allegations of it being used to get rid of ‘troublemakers, whistle-blowers, sexual assault complainants, and ill or injured service members’. In many cases this reflects disaffection and demotivation with the military working environment—a mismatch between the individual and the conditions of the military environment, a stressor resulting in the appearance of adjustment features—rather than formal psychiatric disorder arising from operational experiences. In the UK, policies to address this issue remain from the days of conscription. These were developed prior to the inclusion of AD in the classification systems and are couched in terms of ‘temperamental unsuitability’. Each service has its own Temperamental Unsuitability Policy, with no identified common ground other than the need to expedite the discharge of a disaffected individual. Although a managerial and not a medical discharge, each policy requires individuals to be seen by a psychiatrist who then recommends discharge under the relevant policy. The Royal Navy requires the psychiatrist to classify the sailor according to a system of establishing the severity of personality traits and the potential for intervention. The Army requires the psychiatrist to state that the individual is ‘temperamentally unsuitable’ Finally, the Royal Air Force requires the psychiatrist to certificate that the individual is not suffering from any remedial psychiatric disorder. These policies may be seen as historical artefacts, serving to facilitate the discharge of those who no longer wish to serve in the military. The prospects for approaching these policies in terms of AD with poor prognosis in the military setting are probably unlikely.


Outside the military environment, while AD is widely recognized as highly prevalent, there remains remarkably little research on the course, outcomes, or treatment. Guidelines have been developed in the Netherlands (3) recommending treatment based on cognitive–behavioural principles, predominantly stress inoculation training and graded activity, aiming to enhance problem-solving capacity.

Historically, management of AD in the workplace has focused pragmatically on a combination of problem-solving and stress management techniques. A meta-analysis (33) of relaxation training (Jacobson’s progressive relaxation, autogenic training, applied relaxation, and meditation) has shown consistent and significant efficacy in reducing anxiety. The Cochrane Database (34) has published a meta-analysis, finding moderate-quality evidence that cognitive–behavioural therapy did not significantly reduce time until partial return to work, and low-quality evidence that it did not significantly reduce time to full return to work, compared with no treatment. Moderate-quality evidence showed that problem-solving therapy significantly enhanced partial return to work at 1-year follow up compared to non-guideline-based care, but did not significantly enhance time to full return to work at 1-year follow up. An important limitation was the small number of studies included in the meta-analyses and the small number of participants, which lowered the power of the analyses.

The configuration of UK military psychiatry into 15 Departments of Community Mental Health, facilitating local access, and the delivery of front-line psychiatric care by uniformed community mental health nurses, encourages the acquisition of familiarity with the military environment and the development of knowledge of the availability of problem-solving solutions (35) within the structured military environment.

Symptomatic treatment of anxiety and insomnia with benzodiazepines and hypnotics is often used, but in 1988 the Committee on Safety of Medicines (36) responded to the widespread misuse of benzodiazepines and concerns over the development of pharmacological dependence by issuing guidelines that they should be used for short-term use for 2–4 weeks only. The guidelines were reinforced in 2012 (37). Antidepressant medication may have benefits by virtue of sedative and anxiolytic properties. Such drugs may also have a direct effect on reducing ruminative thought. There has been no published evidence on which antidepressant drugs might be most helpful in treating AD, but a protocol for a Cochrane systematic review of pharmacological interventions in AD in adults has been published and the work is ongoing (38).

Patients with a clinical diagnosis of AD are likely to overlap with individuals seen by other agencies, including social work. Task-centred casework is a well-established treatment model in social work (39).

A systematic review (40) of the quantitative and qualitative literature on workplace-based return-to-work interventions, albeit not addressed to AD but limited to patients with pain-related conditions, recommended that workplace-based return-to-work interventions included the following core disability management strategies: early supportive contact with the worker, the offer of work accommodation, and contact between the healthcare provider and the workplace. There was moderate evidence that interventions which include these three components lead to important reductions in work disability duration and in associated costs. There is mixed evidence that these programmes lead to improvements in quality-of-life outcomes. Such conditions are met by effective occupational health departments and personnel. This model could potentially be applied to and tested in those with AD in occupational settings.

Occupational prognosis

In a study (41) of 328 young military conscripts with a DSM-IV diagnosis of AD secondary to non-combat military stress, the diagnosis was closely associated with undisturbed psycho-social function outside military life. A further study (42) of over 2,000 US naval personnel found that AD was less severe and less disabling than other psychiatric conditions, being shorter and with higher levels of subsequent return to effective work. In the Sri Lankan study (2), four-fifths returned to work within 6 months.

Individuals may be able to continue at work, with restrictions in place reflecting their capacity to work and the need for safety. The armed forces have a comprehensive fitness-for-work medical grading system that allows workplace restrictions to be put in place by the medical services without communicating confidential medical information. It is preferable to retain an individual in work where possible, albeit in a restricted role, thereby minimizing the hurdles of a return to work. However, where an individual is unable to work, sickness absence may become inevitable, though effective management is likely to reduce the period away from work.

Developments in classification

The establishment of a working group for disorders specifically associated with stress for ICD-11 has resulted in the proposed cluster under a single category of ‘Disorders Specifically Associated with Stress’. These comprise post-traumatic stress disorder, complex post-traumatic stress disorder, adjustment disorder, and prolonged grief disorder (43).

The symptom pattern for AD is characterized by ‘preoccupation with the stressor and failure to adapt’. Subtypes of AD have not been shown to have any clinical utility and have been abandoned. Acute stress reaction is not included, being moved to ‘Conditions Associated with Psychosocial Circumstances’ because of perceptions of ambiguity of definition and its transient time course. Until ICD-11 is published, the ICD-10 definition remains in place. It is unclear whether the new definition of AD will identify the same group as do the current criteria. This is particularly important in the context of defence forces, where the symptom overlap between the proposed ICD-11 criteria for AD (preoccupation and avoidance are among the core and secondary symptoms, respectively) and PTSD may cause diagnostic confusion. Alternatively, AD may be seen as a subthreshold form of PTSD. The defence forces will be a crucial population in which to clarify the utility and validity of the proposed new criteria.


The diagnosis of AD forms a substantial proportion of the clinical diagnoses in the field of armed forces occupational psychiatry. To a large degree, this is likely to reflect the functional orientation of military psychiatry, where the impact on performance and safety-critical tasks has a high priority. The concept has developed against the background of almost a century’s work on the role of stressors on mental states. While it is now generally accepted that a robust relationship exists between the development of major depression and stressors, it is being recognized that major depression is not a homogeneous entity and that there is a variety of depressive disorders that may remit without specific treatment. Evidence is beginning to develop of biological differences between major depression and depressive adjustment disorder. Problem-solving and stress management strategies are the current main ingredients of the management of AD, and the condition carries a good prognosis for a return to work, but there is a paucity of treatment and outcome studies. Developments in classification are to be incorporated in ICD-11, which may help to operationalize the diagnosis.


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