International Journal of Methods in Psychiatric Research

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014)

Published online 30 January 2014 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/mpr.1418

Development and validation of the

Diagnostic Interview Adjustment
Disorder (DIAD)
L. R. CORNELIUS,1,2,4 S. BROUWER,1,2 M. R. DE BOER,1,2,3 J. W. GROOTHOFF2 & J. J. L. VAN DER KLINK1,2

1 Research Center for Insurance Medicine, The Netherlands

2 Department of Health Sciences, Community and Occupational Medicine, University Medical Center
Groningen, University of Groningen, Groningen, The Netherlands
3 Department of Health Sciences, VU University, Amsterdam, The Netherlands
4 Social Security Institute, The Netherlands

Key words Abstract

adjustment disorder,
Adjustment disorders (ADs) are under-researched due to the absence of a
development, validation, DSM-IV,
reliable and valid diagnostic tool. This paper describes the development and
structured interview
content/construct validation of a fully structured interview for the diagnosis of
AD, the Diagnostic Interview Adjustment Disorder (DIAD). We developed the
Correspondence
DIAD by partly adjusting and operationalizing DSM-IV criteria. Eleven experts
Bert Cornelius, Department of
were consulted on the content of the DIAD. In addition, the DIAD was
Health Sciences, Community and
administered by trained lay interviewers to a representative sample of disability
Occupational Medicine,
claimants (n = 323). To assess construct validity of the DIAD, we explored the
University Medical Center
associations between the AD classification by the DIAD and summary scores
Groningen, University of
of the Kessler Psychological Distress 10-item Scale (K10) and the World Health
Groningen, Antonius
Organization Disability Assessment Schedule (WHODAS) by linear regression.
Deusinglaan 1, Building 3217,
Expert agreement on content of the DIAD was moderate to good. The preva-
room 620, 9713 AV Groningen,
lence of AD using the DIAD with revised criteria for the diagnosis AD was
The Netherlands. Telephone:
7.4%. The associations of AD by the DIAD with average sum scores on the
(+31) 503-632-857/503-632-860
K10 and the WHODAS supported construct validity of the DIAD. The results
Email: l.r.cornelius@umcg.nl
provide a first indication that the DIAD is a valid instrument to diagnose AD.
Further studies on reliability and on other aspects of validity are needed.
Received 2 July 2012;
Copyright © 2014 John Wiley & Sons, Ltd.
revised 3 April 2013;
accepted 7 May 2013

Introduction self-limiting, AD is associated with long-term sickness

The term adjustment disorder (AD) is used to describe a absence and disability (van der Klink et al., 2003). In
condition where an individual reacts to a stressful event several countries, stress-related disorders are one of the
with disproportionate symptoms and behaviors. AD is most commonly reported types of work-related illness
considered to be a common mental health problem in (Health and Safety Executive, 2011; Knowledge Center
the general population, in primary and in secondary care UWV, 2007; National Institute for Occupational Safety
(Casey, 2009). Although usually believed to be mild and and Health, 2011). In the Netherlands, stress-related

192 Copyright © 2014 John Wiley & Sons, Ltd.

Cornelius et al. Diagnostic Interview Adjustment Disorder (DIAD)

disorders including AD are the second most important Fifth Edition (American Psychiatric Association, 2011) is
psychiatric diagnosis on certificates of benefit claimants, very similar to the DSM-IV.
with a prevalence of 6.7% after one year, and of 4.8% Recently, a questionnaire for the assessment of AD was
after two years of sickness absence (Knowledge Center developed and validated (Einsle et al., 2010). However, this
UWV, 2007). instrument is based on a new diagnostic proposal, that places
The diagnostic instrument most commonly used in psy- AD in a spectrum of stress-response syndromes, along with
chiatric epidemiological research, the Composite Interna- post-traumatic stress disorder (Maercker et al., 2007). As this
tional Diagnostic Interview (CIDI), lacks a section dealing questionnaire is not compatible with DSM-criteria, a valid
with AD (Kessler and Üstün, 2004). None of the large-scale diagnostic instrument that enables lay interviewers to assess
epidemiological surveys on mental health carried out in the AD based on DSM-IV criteria is still missing. The present
United States and in Europe included AD for consideration study is an attempt to make up for this deficiency by develop-
(Kessler et al., 2005; Bebbington et al., 2000; Vollebergh ing and validating a fully structured interview to diagnose AD,
et al., 2001; Wittchen and Jacobi, 2005). Only the Outcome the Diagnostic Interview Adjustment Disorder (DIAD), that
of Depression International Network (ODIN) study, a can be administered by lay interviewers, based on adjusted
general population survey carried out in five European DSM-IV criteria as recommended by Baumeister et al.
countries, assessed AD (Casey et al., 2006). In that study, (2009). We aimed to assess the content and the construct
the prevalence of AD was found to be extremely low: 0.0% validity of the DIAD. Regarding construct validity, distress
to 1.0%. Other studies that also incorporated the diagnosis and impairment are defined as core symptoms of AD. There-
of AD, used a variety of diagnostic methods and showed a fore, it can be expected that the diagnosis AD is associated
varying prevalence of AD (Casey, 2009). As a result, reliable with these symptoms. Therefore, we hypothesized that per-
information on the prevalence and course of AD is scarce, sons with AD have higher levels of distress and impairments
and few strategies for the treatment of AD are evidence- than persons without AD.
based (van der Klink et al., 2003).
Criteria for the diagnosis of AD are described in the Methods
Diagnostic and Statistical Manual of Mental Disorders,
Setting and participants
Fourth Edition (American Psychiatric Association, 1994),
see Table 1. The present study is part of a cohort study on prognostic
These criteria are generally considered to be vague and factors of long-term disability due to mental disorders,
ill-defined (Casey et al., 2001). In recent years, the non- Predicting Disability (PREDIS) (Cornelius et al., 2013).
specific classification of AD in the DSM-IV has been under Participants eligible for PREDIS were recruited using reg-
dispute (Baumeister and Kufner, 2009; Baumeister et al., istry data from the local office of the Social Security Insti-
2009; Casey and Bailey, 2011; Laugharne et al., 2008). tute (SSI) in the city of Groningen, servicing Groningen
Some critics argue that the concept AD medicalizes prob- and Drenthe, two northern provinces of the Netherlands.
lems of ordinary life, while others put forward that a rigid Recruitment started at October 1, 2008 and ended at
“cook-book” application of diagnostic criteria may result December 31, 2009. Included were persons claiming dis-
in an over diagnosis of other psychiatric disorders at the ability benefit after two years of sickness absence due to
cost of AD (Casey et al., 2006). More specifically, the any medical condition, whether somatic or mental. The
critique of the current DSM-IV conceptualization of AD SSI uses the International Classification of Diseases, 10th
concentrates upon the inadequate definition of clinical Revision (ICD-10) to certify diagnoses as cause of dis-
significance, the failure to distinguish AD from other Axis ability. The Medical Ethics committee of the University
I disorders and the neglect of contextual factors accounting Medical Center Groningen (UMCG) approved recruit-
for excess symptoms of AD (Baumeister et al., 2009). ment, consent and field procedures. Out of a total of
Therefore, Baumeister et al. (2009) recommended to 1544 eligible long-term sick listed workers, 375 persons
eliminate the criterion that requires the absence of another consented to participate (response rate = 24.3%), see
DSM-IV disorder, to define clinical significance with the Figure 1 for a flow chart of participants.
requirement that both distress and impairment are present At the first measurement, i.e. after two years of sickness
and to extend the bereavement exclusion criterion to other absence, respondents were sent a questionnaire on demo-
severe or uncommon stressful events (Baumeister et al., graphics, general and mental health, alcohol use, function-
2009). These recommendations are still worth considering, ing, health care use, coping behavior and social support.
since the proposed classification of AD in the upcoming After they completed and returned the questionnaire,
Diagnostic and Statistical Manual of Mental Disorders, respondents were interviewed at home by lay interviewers

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

Copyright © 2014 John Wiley & Sons, Ltd. 193
Diagnostic Interview Adjustment Disorder (DIAD) Cornelius et al.

Table 1. Criteria for adjustment disorder with diagnosis algorithm, specified according to the DSM-IV and adjusted/
operationalized for use in the present study

nr Criteria DSM-IV Adjusted/operationalized

1 Stressor identifiable stressor(s) cluster of identifiable stressors in

recall period of three years
2 First time limit occurring within three symptoms within three months
months of the onset after onset of stressor cluster
of stressor(s)
3 Distress clinically significant as 4DSQ distress scale scoring > 10
evidenced by marked
distress that is in excess
of what would be expected
4 Impairment clinically significant as SDS impairment scale scoring ≥ 4
evidenced by significant in at least two domains
impairment in social
or occupational (academic)
functioning
5 Second time limit once the stressor (or its not used
consequences) has terminated,
the symptoms do not persist for
more than an additional six months
6 DSM-IV Axis I/II the stress-related disturbance not used
does not meet the criteria for
another specific Axis I disorder
and is not merely an exacerbation
of a pre-existing Axis I or
Axis II disorder
7 Bereavement symptoms do not represent symptoms due to bereavement
bereavement or loss of health due to serious
illness/injury as single stressor
need to be present for longer
than 12 months.
Diagnosis algorithm 1 AND 2 AND (3 OR 4) AND 1 AND 2 AND 3 AND 4 AND 7
5 AND 6 AND 7

using the CIDI, supplemented by the DIAD. The median non-responders (p < 0.001; χ 2 = 60.022). Age categories
time between completing the questionnaire and the CIDI/ 45–54 years and 55–65 years are over-presented in the study
DIAD was four weeks (standard deviation [SD] five weeks). sample. We also compared the PREDIS cohort with a large
For the present study, we included only those participants national population (n = 56,267) of all persons claiming dis-
from whom we could obtain complete interview data, both ability benefit in the years 2006–2007 (Knowledge Center
from the CIDI and the DIAD. As a result, the study sample UWV, 2007). We found the sample not to differ significantly
consisted of 323 CIDI/DIAD completers. from this national population as to prevalence of ICD-10 so-
To assess generalizability, we compared PREDIS re- matic (p = 0.876; χ 2 = 1.214) and ICD-10 mental disorders,
sponders (n = 375) with non-responders (n = 1169) as to i.e. mood, anxiety and stress-related disorders (p = 0.344;
age, gender and ICD-10 diagnosis on SSI certificates as cause χ 2 = 7.870), certified by the SSI as primary cause of disability.
of disability. We found no significant differences between
responders and non-responders as to gender (p = 0.850;
Development
χ 2 = 0.036) and ICD-10 classifications of somatic and men-
tal disorder as cause of disability (p = 0.682; χ 2 = 1.500). As The DIAD was developed by two (BC, JvdK) of the authors
to age, we found responders to be significantly older than as a structured interview to diagnose AD based on DSM-IV

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

194 Copyright © 2014 John Wiley & Sons, Ltd.
Cornelius et al. Diagnostic Interview Adjustment Disorder (DIAD)

Figure 1. Flowchart of participants.

criteria and adjusted following the recommendations of of sickness absence, we chose a recall period to capture
Baumeister et al. (2009). Some of these adjusted criteria any stressor that may be related to the onset of sick-
needed further operationalization. The result was a set of ness absence. Therefore, we set the period of recall at
adjusted and operationalized criteria for the diagnosis three years.
AD, dealing with recall period, stressor(s), time relations
between stressor and complaints, clinical significance, co-
occurrence with other DSM-IV disorders and bereave- First time limit criterion
ment, see Table 1.
We expected respondents to probably report more than
one stressful life event, i.e. a cluster of stressors, to have
occurred in this recall period. Each stressor within a clus-
Recall period
ter may have different dates of onset and termination. We
The DSM-IV does not set a recall period for stressors to considered the first time limit criterion to be met, if the
have occurred. Since the DIAD was to be administered onset of symptoms occurred within three months of the
to persons claiming disability benefit after two years onset of at least one of the stressors within the cluster.

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

Copyright © 2014 John Wiley & Sons, Ltd. 195
Diagnostic Interview Adjustment Disorder (DIAD) Cornelius et al.

Clinical significance criterion Content of the DIAD

We revised the DSM-IV clinical significance criterion and We used the DIAD to diagnose AD in the study sample.
followed Baumeister et al. (2009), requiring that both The DIAD contains 29 questions, see Table 2.
marked distress and significant impairment are present. To The DIAD starts with three questions to identify and
operationalize distress and impairment, the DIAD incorpo- specify stressful live events that have occurred in the past
rates two reliable and valid scales: the distress subscale of the three years. Respondents were asked to select one or more
Four-dimensional Symptom Questionnaire (4DSQ) (Terluin stressor(s) from a list of stressors, followed by three ques-
et al., 2006) and the Sheehan Disability Scale (SDS) (Leon tions assessing the date at which the stressor(s) occurred
et al., 1997). Although these two scales are commonly for the first time, whether the stressor was still present at
employed as paper–pencil questionnaires, we used them as the moment of the interview and, if not, when the stressor
part of the DIAD. In accordance with existing scoring rules, ceased to exist. The DIAD then assesses levels of distress
we defined a sum score > 10 on the 4DSQ subscale distress caused by the reported stressor(s) with 16 questions, i.e.
as marked distress and a SDS sum score ≥ 4 in at least two the distress domain of the 4DSQ. The DIAD then asks
domains of the SDS as significant impairment. when distress symptoms have started and whether these
symptoms are a reaction to the stressful events mentioned
Second time limit criterion earlier on in the interview. Finally, the last five questions of
the DIAD focus on levels of impairment as a consequence
The DIAD does not assess the second time limit criterion of the reported distress symptoms, using the SDS. We
stated in the DSM-IV, i.e. the criterion that the symptoms have added a full transcript of the DIAD as an appendix
must have resolved within six months once the stressor to this paper.
has terminated.

DSM-IV exclusion criterion Content validation

By definition of DSM-IV, the diagnosis AD cannot be We developed the DIAD within the author group until we
made if the condition meets the criteria of an Axis I mood felt it to have sufficient face and content validity to be used
or anxiety disorder, or is merely an exacerbation of a pre- in the study. After the study started using this initial version
existing Axis I or Axis II disorder. We deleted this exclusion of the DIAD, we sought expert opinions on our choices and
criterion, following the recommendation of Baumeister decisions we had already made in the initial development of
et al. (2009). the DIAD. This means that our use of the DIAD in the
study population and our asking the opinion of selected
Bereavement exclusion criterion experts was a parallel process. To assess whether the DIAD

Normal sadness due to bereavement after the death of a

loved one, or similar types of loss should be excluded from
the diagnosis AD, while pathological or dysfunctional Table 2. Content of the Diagnostic Interview Adjustment
reactions should be included. We defined similar types of Disorder (DIAD)
loss as loss of health due to a serious illness or injury.
Element item Assessment of
According to the proposed classification of AD in the
DSM-V, reactions due to bereavement (or similar types
Stressor 1–3 identification of
of loss) are pathological or dysfunctional when they persist
stressor(s)
for more than 12 months after the event. Therefore, we 4–6 onset and duration
adjusted the DSM-IV bereavement criterion to only include of stressor(s)
persons with symptoms exclusively representing bereave- distress 7–22 distress domain
ment after the death of a loved one or similar types of loss (from 4DSQ 1)
and lasting longer than 12 months. 23 onset of distress
distress-stressor 24 relation distress –
AD subtypes stressor(s)
impairment 25–29 impairment (SDS 2)
We did not expand the DIAD with questions aiming to
subtype AD with depressed mood, anxiety, disturbance 1
Four-dimensional Symptom Questionnaire (Terluin et al., 2006).
2
of conduct or combinations thereof. Sheehan Disability Scale (Leon et al., 1997).

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

196 Copyright © 2014 John Wiley & Sons, Ltd.
Cornelius et al. Diagnostic Interview Adjustment Disorder (DIAD)

captured all essential aspects of AD, we asked 11 experts in Construct validation

relevant fields of psychiatry, psychiatric epidemiology,
Administration
primary, occupational and insurance health care, and
instrument development (see acknowledgments) to review We tested our hypotheses by administering the DIAD to
a written transcript of the DIAD (see Appendix) and to the PREDIS cohort. Twelve lay interviewers were trained
complete a 17-item questionnaire (see Table 3). by certified trainers from the Dutch CIDI Training Center

Table 3. Expert opinion (n = 11) on content validity of the DIAD1 for the diagnosis adjustment disorder (AD)

item What is your opinion on: Disagree Neutral Agree

1 our decision to set the recall period duration at three years? 1 (9.1) 5 (45.5) 5 (45.5)
2 our assumption that respondents are unable to attribute 5 (45.5) 2 (18.2) 4 (36.4)
complaints to separate stressors
with overlapping time frames?
3 our decision to consider stressors with overlapping time 1 (9.1) 1 (9.1) 9 (81.8)
frames as a single
problem cluster?
4 our assumption that respondents are able to attribute 1 (9.1) 1 (9.1) 9 (81.8)
complaints to a cluster of stressors xwith overlapping
time frames?
5 our decision to have the DIAD assess xdistress complaints only? 3 (27.3) 4 (36.4) 4 (36.4)
6 our choice for the Distress scale of the 4DSQ 1 (9.1) 0 (0.0) 10 (90.1)
to assess distress complaints?
7 our decision not to have the DIAD assess 4 (36.4) 4 (36.4) 3 (27.3)
depressed mood?
8 our decision not to have the DIAD 5 (45.5) 3 (27.3) 3 (27.3)
assess anxiety?
our decision not to have the DIAD assess 2 (18.2) 5 (45.5) 4 (36.4)
disturbance of conduct?
10 our decision not to have the DIAD assess 1 (9.1) 0 (0.0) 10 (90.1)
DSM-IV Axis II disorders?
11 our decision that the first time criterion is met, 1 (9.1) 0 (0.0) 10 (90.1)
if at least one stressor started within three
months preceding the onset of symptoms?
12 our decision not to have the DIAD assess 4 (36.4) 1 (9.1) 6 (54.5)
whether the second time criterion is met?
13 our assumption that respondents are well able 2 (18.2) 3 (27.3) 6 (54.5)
to self-assess whether their complaints are a
reaction to the stressor they experienced?
14 our choice for the Sheehan Disability Scale 0 (0.0) 5 (45.5) 6 (54.5)
to assess impairments?
15 our assumption that, in this specific population 7 (63.6) 3 (27.3) 1 (9.1)
of persons with long term disability, lay
interviewers are well able to assess whether
the distress is in excess of what would be
expected from exposure to the stressor?
16 the position that the DIAD covers essential 0 (0.0) 1 (9.1) 10 (90.1)
aspects of the DSM-IV diagnosis adjustment disorder?
17 the position that the DIAD as a supplement to the 1 (9.1) 1 (9.1) 9 (81.8)
CIDI has added value for the assessment of
adjustment disorder in psychiatric epidemiologic research?

1
Diagnostic Interview Adjustment Disorder.

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

Copyright © 2014 John Wiley & Sons, Ltd. 197
Diagnostic Interview Adjustment Disorder (DIAD) Cornelius et al.

in Groningen, the Netherlands and by the first author. scores, we performed simple linear regression analyses
Respondents were interviewed face-to-face at their home. with the diagnosis AD as an independent variable and
The DIAD was administered immediately after comple- the sum scores of the K10 and the WHODAS as dependent
tion of the CIDI. Interviewing was laptop assisted. Quality variables. The standardized coefficients provided by linear
of interviewing techniques was evaluated bimonthly in regression represent how many standard deviations the
training sessions. scale scores differed, depending on whether AD is present
or not. Calculation of the standardized coefficients enables
Measures ranking the effect of the presence of AD on the scores of
scales. We used a confidence interval of 95% and a level
To assess distress and impairment, the questionnaire admin-
of significance of 0.05. Data were statistically analysed with
istered to PREDIS respondents included the Kessler Psycho-
IBM SPSS version 19.0 for Windows.
logical Distress 10-item Scale (K10) (Kessler et al., 2002) and
the World Health Organization Disability Assessment
Schedule version 2.0 (WHODAS 2.0) (Üstün et al., 2010). Results
The K10 consists of 10 items with each five response
categories: “none of the time” (1), “a little of the time” (2), Content validity
“some of the time” (3), “most of the time” (4) and “all of The experts opinion on the content of the DIAD is
the time” (5). Sum scores range from 10 to 50. The K10 presented in Table 3. Good agreement (more than 80%)
has strong psychometric properties and is widely used as was reached on items 3, 4, 6, 10, 11, 16 and 17. The experts
screener for psychological distress (Kessler et al., 2002). were in moderate agreement (between 50% and 80%) on
With 36 questions, the WHODAS 2.0 captures levels of items 12, 13 and 14. Poor agreement (lower than 50%)
functioning in six domains of life: Understanding and was found on items 1, 2, 5, 7, 8, 9 and 15. Lowest agree-
Communicating (six items), Getting around (five items), ment was obtained on item 15.
Self-care (four items), Getting along with people (five
items), Life activities (household activities: four items;
work: four items) and Participation in society (eight Description of study sample
items). Answering options are “none” (1), “mild” (2),
Table 4 presents the prevalence of AD as measured with
“moderate” (3), “severe” (4) and “extreme/cannot do”
the DIAD, demographics (age, gender), DSM-IV comor-
(5). Sum scores run from 36 to 180. The WHODAS 2.0
bidity and number as well as nature of reported stressors
has excellent psychometric properties (Buist-Bouwman
for the total study sample, and the distribution of these
et al., 2008).
variables in two sub-samples, one sample with AD
The CIDI was used to assess other 12-month DSM-IV
(n = 24) and one sample without AD (n = 299).
disorders co-occurring with the diagnosis AD. The CIDI
We found 24 respondents (7.4%) to meet all our
is a laptop assisted fully-structured interview to be admin-
criteria for AD. In both sub-samples with and without
istered by lay interviewers. The validity of the CIDI in
AD, we found a high comorbidity of 12-month mood
assessing mental disorders is generally good, as compared
and anxiety disorders: 45.8% and 66.7% respectively
with structured diagnostic interviews administered by
(with AD) and 24.1% and 27.4%, respectively (without
clinicians (Haro et al., 2006).
AD). The prevalence of a mixed mood and anxiety dis-
order within the group diagnosed with AD was 41.7%,
Data analysis
and in the group without AD 12%. More than 90% of
For content validity, expert agreements greater than 80% respondents with AD reported more than one stressor
were considered good, between 50% and 80% moderate, to have occurred in the three year recall period. In
and lower than 50% poor (slightly adapted from Altman, the group without AD, multiple stressors were reported
1991). DIAD data were merged from the different laptops in 42% of cases. In both groups, stressors most often
used for the CIDI/DIAD interviews. With these data, we reported were those related to own illness, psychosocial
made the diagnosis AD post hoc with an algorithm, using factors and work. We found no respondents with be-
the criteria presented in Table 1, dividing the study popu- reavement or injury as single stressor while meeting
lation in a group with AD and a group without AD. For all other criteria for AD (not shown in table). Using
construct validity, we calculated sum scores of the K10 the DIAD, we classified two respondents with AD that
and the WHODAS. To evaluate our hypotheses on the reported sustained distress two years after they were
expected associations of the diagnosis AD with these sum diagnosed with a serious illness (not shown in table).

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

198 Copyright © 2014 John Wiley & Sons, Ltd.
Cornelius et al. Diagnostic Interview Adjustment Disorder (DIAD)

Table 4. Descriptive statistics (%) for the total sample, and for persons that fulfill (AD+) and not fulfill (AD ) the criteria for
adjustment disorder (AD) based on the DIAD1

Total (n = 323) AD + (n = 24) AD– (n = 299)

Prevalence AD 7.4 100.0 0.0

Mean age 49.9 41.6 50.3
Gender (female) 50.2 58.3 49.5
12-month DSM-IV comorbidity 2
any disorder 42.4 75.0 39.8
mood disorder 25.7 45.8 24.1
anxiety disorder 30.3 66.7 27.4
mood & anxiety disorder 12.2 41.7 12.0
Number of stressors
0 31.0 —3 33.4
1 22.9 8.3 24.1
2 11.8 20.8 11.0
>2 34.3 70.1 31.5
Nature of stressor
work 41.3 66.7 37.8
own illness 40.4 70.8 36.5
illness of other(s) 9.9 12.5 9.4
psychosocial 28.5 70.8 24.1

1
Diagnostic Interview Adjustment Disorder.
2
Assessed by the CIDI.
3
By definition.

Construct validity of distress and impairment, than persons not diagnosed

with AD.
In Table 5, we present the results of linear regression with
the K10 and the WHODAS scores as dependent variables
to explore associations with the diagnosis AD (AD+), Content validity
using the absence of the diagnosis AD (AD ) as reference
category. Good expert agreement
The unstandardized regression coefficients (B) shown in
Table 5 represent the mean differences in all scores between The experts were in good agreement on items 3, 4, 6, 10
groups with and without AD. For example, persons with AD and 11 and almost 90% of them felt that the DIAD covers
scored 7.26 points higher on the K10 than persons without essential aspects of the DSM-IV diagnosis AD.
AD. We found AD associated with statistically significant
higher scores on the K10 and the WHODAS subscales
Moderate expert agreement
Communication, Getting along, Household activities and
Participation, and the WHODAS Total. The differences we The experts were in moderate agreement on items 2, 12,
found in scores of other scales were not statistically signifi- 13 and 14. The expert opinion on item 2, i.e. our assump-
cant, although in the expected direction. tion that respondents would not be able to attribute any
distress symptoms to a separate stressor, when in a certain
period more than one stressor were present, was incon-
Discussion
clusive. However, they strongly agreed (81.1%) with our
The experts we consulted on content validity of the DIAD decision to consider stressors with overlapping time
were in moderate to good agreement on most items we frames as a single problem cluster (item 3) and our as-
used for the concept of AD. With regard to construct sumption that respondents are able to attribute com-
validity, our hypothesis was confirmed that persons plaints to such a cluster of stressors (item 4) and not to
diagnosed by the DIAD with AD score higher on levels each stressor separately.

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

Copyright © 2014 John Wiley & Sons, Ltd. 199
Diagnostic Interview Adjustment Disorder (DIAD) Cornelius et al.

Table 5. Associations of adjustment disorder (AD) based on the DIAD1 with the K102 and the WHODAS 2.03 sum scores for
groups classified with AD (AD+) and without AD (AD )

Unstandardized Standardized
Range Mean ± SD coefficient B (95% CI) coefficient Beta p-Value

AD + (n = 24) AD– (n = 299)

K10 10–50 28.17 ± 6.18 20.91 ± 7.37 7.26 (4.14 to 10.37) 0.26 <0.001*
WHODAS 2.0
communication 6–30 14.96 ± 5.99 11.37 ± 5.08 3.59 (1.39 to 5.79) 0.18 0.001*
getting around 5–25 11.48 ± 4.65 11.33 ± 5.03 0.15 (–1.98 to 2.29) 0.01 0.888
self-care 4–20 6.09 ± 2.76 5.53 ± 2.40 0.56 (–0.48 to 1.59) 0.06 0.289
getting along 5–25 11.35 ± 3.55 9.11 ± 3.76 2.23 (0.64 to 3.83) 0.16 0.006*
household 4–20 12.82 ± 4.68 10.39 ± 4.45 2.43 (0.48 to 4.38) 0.14 0.015*
work 4–20 13.86 ± 4.49 11.27 ± 4.91 2.59 (–0.10 to 5.28) 0.15 0.059
participation 8–40 24.39 ± 6.48 19.26 ± 6.04 5.13 (2.54 to 7.72) 0.22 <0.001*
total 36–180 94.08 ± 22.32 75.06 ± 22.27 19.02 (6.29 to 31.74) 0.23 0.004*

1
Diagnostic Interview Adjustment Disorder
2
Kessler Psychological Distress Scale 10-items.
3
World Health Organization Disability Assessment Scale version 2.0.
*p < 0.05.

Item 12 deals with our elimination of the second time long-term sick listed workers, the illness underlying the
limit criterion, i.e. that the symptoms must have resolved disability, is of a chronic nature with enduring conse-
within six months once the stressor has terminated. The quences. This implies that most AD found in the study
possibility that our elimination of this DSM-IV criterion sample can be specified as chronic and that the deletion
resulted in false-positive or false-negative diagnosis of of the second time criterion had no effect on the preva-
AD should be discussed. The first section of the DIAD asks lence of AD and our validity estimates.
whether a stressor has been present in the past three years With the moderate expert agreement on item 13, we
and, if so, at what date it started, if it is still present and, if are fairly confident that the reported symptoms were a
not, when it ended. The DIAD then asks about present reaction to the reported stressor.
state distress complaints. If distress is still present three Item 14 deals with our choice of the SDS to measure
possibilities exist – either the person has a chronic AD, impairment. We included the SDS predominantly for
or the person has developed a new condition or the diag- practical reasons. The CIDI administered immediately
nosis at the outset was not AD but some other disorder. If prior to the DIAD, contained the SDS as well. Having
distress is absent two possibilities exist – either AD has the DIAD assessing impairment using yet another scale,
resolved or some other disorder causing distress has would in our view have confused respondents, resulting
resolved. In our opinion, therefore, the elimination of in biased answers.
the second time limit was justified so as to avoid false
positive or false negative diagnoses. Strict application of
Poor expert agreement
the second time criterion would imply that a diagnosis of
present state AD is never possible and that the diagnosis We found the experts in poor agreement on five of the 14
AD can be made in retrospect only, when both stressor items we used: 1, 5, 7, 8, 9 and 15. Item 1 deals with our
and symptoms no longer exist. In our view and in line choice to set the recall period at three years. This particular
with that of other authors (van der Klink and Terluin, recall period was chosen to capture any stressor related to
2005), application of this second time criterion makes the onset of sickness absence, two years before the inter-
the diagnosis AD clinically less relevant. Furthermore, we view. As any other psychiatric diagnostic interview, the
found that more than 70% of respondents with AD DIAD is an instrument based on self-report. Due to the
reported their own illness as one of multiple stressors. It lengthy recall period, respondents may have been unable
is reasonable to assume that in this specific population of to reliably recollect dates of onset and termination of

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

200 Copyright © 2014 John Wiley & Sons, Ltd.
Cornelius et al. Diagnostic Interview Adjustment Disorder (DIAD)

stressing circumstances, resulting in biased assessment of whether criteria for AD should be adjusted in the upcoming
the first time limit criterion for the diagnosis AD. There DSM-V. The operationalization of the bereavement exclu-
is a very extensive body of knowledge on the relation sion criterion in particular is difficult, since it requires a
between stress and memory. It shows that stressful experi- normative discussion about the threshold between normal
ences may produce intense, long-lasting memories of the and pathological reactions to stressing events. Persons with
events themselves, while stress may also impair subsequent normal symptoms of distress and impairment due to be-
attention and memory and can even induce profound reavement or other uncommon/severe stressors, should
amnesia (Kim and Diamond, 2002). In general, with a be excluded from the diagnosis of AD, while those with
probing sequence of age-of-onset questions, individuals pathological or dysfunctional symptoms should not. It
are well able to recollect how old they were when certain seems reasonable to assume that our operationalization of
events occurred or when certain symptoms began (Kessler the bereavement criterion, following both Baumeister
et al., 2007; Knauper et al., 1999). However, reliable assess- et al. (2009) and the proposed classification of AD in the
ment of the AD time limit criterion requires precise recol- upcoming DSM-V, excluded respondents with normal reac-
lection in terms of days or weeks, making age-of-onset tions to a stressing event.
questions useless. This potential recall bias may be two-
sided, because respondents may erroneously indicate a Construct validity
date too early or too late. This will therefore most likely
not have influenced our estimate of the prevalence of Prevalence
AD, but will have underestimated the associations between
The prevalence of AD using the revised criteria was 7.4%.
the AD diagnosis and the other constructs in our construct
That is much higher than the prevalence of 0.0% to 1.0%
validity study.
found in the ODIN study (Casey et al., 2006). The expla-
Item 5 deals with our decision to have the DIAD assess
nation for this large prevalence difference may be that in
distress complaints only. Consistent with this, expert
the present study mood and anxiety disorders are allowed
agreement on our decision not to assess subtypes of AD,
to be comorbid with AD, while in the ODIN study using
i.e. depressed mood (item 7), anxiety (item 8) and disor-
strict ICD-10 criteria, they are not. This confirms the
der of conduct (item 9), were poor as well. We had several
assumption of DSM-IV critics that strict “cook-book”
reasons for not assessing these subtypes. First, since we
application of all diagnostic criteria for AD leads to over-
expected a relatively high prevalence of mental health
diagnosis of mood disorders at the expense of AD (Casey
problems in our study sample of long-term sick listed
et al., 2001; Baumeister et al., 2009; Taggart et al., 2006).
workers, resulting in a lengthy CIDI interview time, and
These mood disorders may in fact be self-limiting periods
since the DIAD was to be administered after completion
of low mood triggered by stressful events and be misdiag-
of the CIDI, it was important to balance interview burden
nosed as depression.
for respondents and DIAD performance. Therefore, we
In the present study we used the DIAD in combination
limited the DIAD to assess key symptoms of distress and
with the CIDI and found an AD prevalence of 7.4%.
impairment only. Second, strictly speaking, these subtypes
Therefore, we believe that the results of our validation
are not inclusive or exclusion criteria for the diagnosis of
study indicate that the DIAD is able to differentiate between
AD. Third, it is not yet certain how AD will be subtyped
AD and depression.
in the upcoming DSM-V. Had we included assessment
of DSM-IV subtypes, the DIAD would possibly have soon
Stressors
been outdated.
Regarding item 15, as we expected, most experts As we expected, a vast majority of persons diagnosed with
(9.1%) felt that lay interviewers are not able to assess AD reported multiple stressors, mostly related to work,
whether distress symptoms are in excess. This confirmed own illness and psychosocial factors. However, in the
our decision earlier in the developing process to assess sub-sample without AD, almost half of respondents also
clinical significance with the distress scale of the 4DSQ, reported multiple stressful life events. A post hoc analysis
instead of having the interviewer assess clinical significance. of the study sample showed that 15.2% (n = 49) of respon-
We did not specifically ask the experts opinion about dents reported one or more stressors in the past three
our adoption of the recommendations by Baumeister years, without meeting criteria for AD nor for any other
et al. (2009). These recommendations are subject to a lifetime DSM-IV classification. This illustrates that some
broader discussion (Baumeister and Kufner, 2009; Laugharne individuals react to stressors with clinically significant
et al., 2008) about the classification of AD in the DSM-IV and symptoms, while others do not.

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

Copyright © 2014 John Wiley & Sons, Ltd. 201
Diagnostic Interview Adjustment Disorder (DIAD) Cornelius et al.

K10 and WHODAS disability claimants as to the prevalence of somatic and

mental disorders, certified by the SSI. Therefore, we believe
On a scale of 10 to 50, we found the K10 score to differ
our results as to the construct validity of the DIAD to be
seven points (21 versus 28) between persons without and
externally valid. Fourth, the capability of the DIAD to differ-
with AD, respectively. On a scale of 36 to 180, the sum
entiate between persons with (n = 24) and without AD may
score of the total WHODAS 2.0 was found to differ 19
be compromised by the small sample size.
points (75 versus 94). Meaningful score differences should
have not only statistical significance, but clinical relevance
as well. To our knowledge, the smallest relevant difference Recommendations for future research
in K10 score is not known. However, based on K10 valid- The present study describes the development of a new
ity studies (Donker et al., 2003; Furukawa et al., 2003), we instrument and is a first effort to validate it. Further reli-
believe a seven point difference in K10 score to be clini- ability and validity studies are clearly needed. Guidance
cally meaningful. As to the clinical significance of the for this validation process is provided by the consensus
difference we found in WHODAS 2.0 score, also for this based standards for the selection of health status measure-
questionnaire a meaningful cutoff value is not known. In ment instruments, i.e. the COSMIN checklist (Mokkink
a group of persons with depression before and after reha- et al., 2010).
bilitation, a decrease of 13 points in WHODAS mean total
score was found (Pösl et al., 2007). Therefore, in our view, Content
the difference of 19 points we found in WHODAS 2.0 total
sum score between persons with and without AD, is The content of the DIAD should be further validated, with
clinically significant as well. regard to the inclusion of AD subtypes depressed mood
and anxiety, and recall bias. Allowing the DIAD to subtype
Limitations AD is clinically relevant for treatment purposes. If the
DIAD is aimed to be used as stand-alone instrument, ade-
Some limitations of this study must be taken into account. quate subtyping can be achieved by including not only the
First, the present study describes the development of a new 4DSQ subscale distress, but also the subscales depression
instrument and is a first effort to validate it. We did not yet and anxiety. If the DIAD is used in conjunction with a
assess the reproducibility of the DIAD. Therefore, pending more comprehensive interview capable of detecting other
further studies on interrater and intrarater reliability and mental disorders, e.g. the CIDI, then AD can be subtyped
on other aspects of validity, the DIAD can only be used based on the diagnosis of subthreshold mood and anxiety
with prudence. Second, it has been pointed out by others disorders, diagnosed by the larger interview. For a clear
that mood changes may occur on exposure to reminder differentiation between AD and depression the DIAD
of or discussion about the stressor referred to as “cognitive should be used in combination with a larger structured
engagement” (Casey and Bailey, 2011). Although the psychiatric interview, e.g. the CIDI, capable of detecting
DIAD questions on distress specifically ask to report other DSM-IV classifications.
symptoms present in the past seven days, it cannot be To minimize recall bias, almost inherent to strict time
excluded that cognitive engagement with stressing events limits in a diagnosis, in future versions of the DIAD, ques-
has biased responses. tions should be included about some other independent
Third, the PREDIS cohort study response rate was only dateable events, e.g. related to sick leave, school atten-
24.3%. This could have led to selection bias. We found dance, employment, marriage, child birth, moving house,
no significant differences between responders and non- etc., that can be linked to self-report dates of onset and
responders as to gender and prevalence of certified ICD-10 termination of stressing events and symptoms.
somatic and mental disorder. However, we found respon-
dents to be significantly older than than non-responders.
Reliability and validity
In general, poor mental health is prevalent at all ages with
the highest prevalence occurring in the youngest age groups Reliability of the DIAD should be assessed through test–
(WHO International Consortium in Psychiatric Epide- retest and interrater reliability studies. Concurrent validity
miology, 2000). Prevalence rates of mental disorders found should be assessed by comparing DIAD outcome with
in the present study may therefore be an underestimation those of clinical psychiatric interviews that include the
when compared with non-responders. However, we found diagnosis AD. The use of a clinical interview as gold stan-
no significant difference between the PREDIS cohort and dard is to be preferred above semi-structured psychiatric
the target population, i.e. the national population of interviews, such as the Schedules for Clinical Assessment

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

202 Copyright © 2014 John Wiley & Sons, Ltd.
Cornelius et al. Diagnostic Interview Adjustment Disorder (DIAD)

in Neuropsychiatry (SCAN), the Structured Clinical Inter- upcoming DSM-V. Further studies on criterion validity
view for DSM (SCID) or the Mini International Neuro- and reliability of the DIAD in other samples and settings
psychiatric Interview (MINI), since the capability of are clearly needed. With a reliable and valid diagnostic
these schedules to diagnose AD is limited (Casey, 2009). instrument, the epidemiology of AD can be better researched
Longitudinal studies are needed to evaluate the predictive and evidence-based strategies for therapy and intervention
validity of the DIAD, i.e. to assess whether the DIAD cor- can be developed.
relates with some relevant criterion measure. To further
investigate the capability of the DIAD to differentiate Acknowledgments
between persons with and without AD, future studies
The authors wish to thank the following: Professor Dr F.J. van
require clearly larger sample sizes. It is very important that
Dijk (MD; field: occupational health care); Professor Dr P. de
psychometric properties, i.e. internal consistency, sensi- Jonge (psychologist, WHO CIDI trainer; field: psychiatric
tivity, specificity, positive and negative predictive value, epidemiology); M. Loo (MD; field: occupational care, mental
of the DIAD are assessed in other settings and populations, health); F.J. Nienhuis (psychologist, WHO CIDI trainer,
using appropriate recall periods, e.g. in community sam- designer of the mini-version of the Schedules for Clinical
ples, primary care patients, psychiatric inpatients and out- Assessment in Neuropsychiatry (mini-SCAN); field: psychiat-
patients, consultation liaison psychiatry and other groups ric epidemiology); Professor Dr W. van Rhenen (MD; field:
of specific interest, such as those with deliberate self-harm, occupational care, mental health); Professor Dr A. Schene
sick listed or unemployed workers, high risk groups, or (MD; field: psychiatry); Dr J. Spanjer (MD, designer of the
other specific age groups. disability assessment structured interview [DASI]; field: insur-
ance medicine); Dr B. Terluin (MD, designer 4DSQ; field:
primary care, stress-related disorder); Professor Dr P.
Conclusion
Verhaak (sociologist; field: primary care, mental disorder); J.
The expert consultation group was in moderate to good H. Wijers (MD; field: insurance medicine, mental disorder);
agreement on the content of AD, although whether the Professor Dr H. Wind (MD; insurance medicine), for giving
DIAD covers all essential aspects of AD is still not fully their opinion on the content of the DIAD. The authors thank
Robbert de Bruin for translating the DIAD from Dutch to
clear. Our hypothesis regarding the construct validity of
English. Also, the authors wish to thank the reviewers for their
the DIAD, was confirmed. These results are a first indi-
valuable comment on an earlier draft of this article.
cation that the DIAD using adjusted DSM-IV criteria is
a valid, stand-alone instrument to diagnose AD, to be
Declaration of interest statement
administered by lay interviewers. With regard to the
bereavement criterion, the DIAD is compatible to the The authors have no competing interests.

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Appendix Text to read out 1

A the Diagnostic Interview Adjustment Disorder In their lives, people may experience events or circum-
(DIAD)1 stances that cause stress. I want to ask you now if such prob-
lem situations or events exist or have occurred in the past.
(When asking the questions the interviewer emphasizes This refers to the previous three years, including the year
the underlined words.) prior to your calling in sick. Take your time to reflect.

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204 Copyright © 2014 John Wiley & Sons, Ltd.
Cornelius et al. Diagnostic Interview Adjustment Disorder (DIAD)

1
Disclaimer: this transcript is a translation from the original Dutch version of the DIAD and presented here for the interested
reader. For further reliability and validity studies among English-speaking respondents, translation errors should be controlled
for by back translating this transcript into Dutch. Reliable administration of the DIAD in any language requires interview
training. Use of the DIAD is allowed only with permission from the authors of this paper.

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

Copyright © 2014 John Wiley & Sons, Ltd. 205
Diagnostic Interview Adjustment Disorder (DIAD) Cornelius et al.

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

206 Copyright © 2014 John Wiley & Sons, Ltd.
Cornelius et al. Diagnostic Interview Adjustment Disorder (DIAD)

Int. J. Methods Psychiatr. Res. 23(2): 192–207 (2014). DOI: 10.1002/mpr

Copyright © 2014 John Wiley & Sons, Ltd. 207