When the Diagnosis Does Not Fit: Workplace Trauma, PTSD, and the Overuse of Adjustment Disorder
In brief: Adjustment disorder is the most common diagnosis attached to Victorian workers' compensation claims for psychological injury, and in many cases it is the wrong one. Sustained workplace bullying, harassment and discrimination produce symptom profiles that are often indistinguishable from post-traumatic stress disorder (PTSD). DSM-5-TR treats adjustment disorder as a diagnosis of exclusion, so it should not be retained once a person meets criteria for PTSD, major depressive disorder or another specified disorder. This article sets out the evidence, the diagnostic rules that apply, the reasons the mismatch happens, and what a structured assessment involves.
Many of the people I see through WorkCover arrive with a Certificate of Capacity that names adjustment disorder. By the time they reach a psychologist they have often been unwell for months. They describe intrusive memories of specific incidents, a physical reaction to the sight of a work email, sleep broken by nightmares about a former manager, and a belief that no workplace will ever be safe again. What happened to them was not a difficult period of change. It was harm, and their nervous system has responded to it as harm.
The scale of the problem is now well documented. Safe Work Australia's Key Work Health and Safety Statistics Australia 2025 report shows that mental health conditions accounted for 12 per cent of all serious workers' compensation claims in 2023–24, a 14.7 per cent increase on the previous year and a 161 per cent increase over ten years (Safe Work Australia, 2025). In 2022–23, the most recent year for which the report gives duration and cost figures, the median time lost for a serious mental health claim was 35.7 working weeks, against 7.4 weeks across all serious claims, and the median compensation paid was $67,400 (Safe Work Australia, 2025). These are long, expensive claims involving people who stay unwell for a long time. Getting the diagnosis right at the outset is one of the few things within a clinician's control.
What adjustment disorder is, and what DSM-5-TR actually allows
Adjustment disorder sits within the Trauma- and Stressor-Related Disorders chapter of DSM-5-TR (American Psychiatric Association, 2022). It describes emotional or behavioural symptoms that develop within three months of an identifiable stressor, involve either marked distress out of proportion to the stressor (taking context and culture into account) or significant impairment in functioning, and do not persist for more than a further six months once the stressor or its consequences have ended. Where the stressor or its consequences continue, DSM-5-TR permits a persistent (chronic) specifier, so duration alone does not rule the diagnosis out.
Two features of the DSM-5-TR text matter for this discussion and are frequently misunderstood.
The first is that adjustment disorder is a diagnosis of exclusion. The stress-related disturbance must not meet criteria for another mental disorder and must not be merely an exacerbation of a pre-existing one (American Psychiatric Association, 2022). If a person meets full criteria for PTSD, major depressive disorder or generalised anxiety disorder, adjustment disorder is not available as a diagnosis, whatever the Certificate of Capacity says.
The second is that the stressor for adjustment disorder can be of any type or severity. DSM-5-TR explicitly allows adjustment disorder to be diagnosed after a traumatic event where the full criteria for PTSD or acute stress disorder are not met. In other words, adjustment disorder is not reserved for ordinary life stressors, and its presence on a certificate does not by itself mean the assessor concluded the event was minor. What it should mean is that a structured assessment for PTSD was carried out and the person fell short of criteria. In practice, that assessment has often not happened. Bachem and Casey (2018) describe adjustment disorder's long history as a residual category, applied when the clinician is uncertain rather than when the presentation has been positively matched to the criteria, and O'Donnell and colleagues (2016), in an Australian longitudinal study of adjustment disorder after injury, found substantial symptom overlap between adjustment disorder and PTSD in the months following trauma exposure.
What counts as a traumatic event in the workplace?
DSM-5-TR Criterion A for PTSD requires exposure to actual or threatened death, serious injury or sexual violence, through direct experience, witnessing in person, learning that it happened to a close family member or friend, or repeated or extreme exposure to aversive details in the course of professional duties (American Psychiatric Association, 2022). In a workplace, events that clearly satisfy Criterion A include serious accidents, physical or sexual assault, credible threats of harm, armed robbery, and the repeated exposure to traumatic material that police, paramedics, child protection workers and similar occupations carry as part of their role.
Sustained bullying, harassment and discrimination sit in a more contested position. Some episodes clearly meet Criterion A, for example where there has been a threat of violence, physical intimidation or sexual harassment involving assault. Many do not, at least not on a strict reading. Whether Criterion A should be widened to include chronic interpersonal harm has been debated since DSM-5 was drafted, and Pai, Suris and North (2017) review that debate and the reasons the American Psychiatric Association retained a narrower definition.
The empirical picture is less ambiguous than the definitional one. In a meta-analysis of 29 studies of bullying at work and at school, Nielsen and colleagues (2015) reported that, on average, 57 per cent of people exposed to bullying scored above the screening threshold on self-report PTSD measures, and that bullying exposure correlated at r = .42 with overall symptom scores. Those are symptom scores rather than clinician-confirmed diagnoses, and the review pooled workplace and school samples, so the figure describes symptom burden rather than the prevalence of diagnosable PTSD. Even read conservatively, it shows that a majority of people exposed to sustained bullying carry a trauma-symptom load that would ordinarily prompt a full PTSD assessment. Verkuil, Atasayi and Molendijk (2015), in a separate meta-analysis of cross-sectional and longitudinal studies, found that workplace bullying is associated with subsequent mental health symptoms, which supports a causal reading of the relationship rather than one driven purely by prior vulnerability.
The theoretical account fits the data. Janoff-Bulman (1992) proposed that an event becomes traumatic when it shatters a person's core assumptions that the world is benevolent, that events are meaningful, and that the self is worthy. Workplace bullying by a manager, or by an institution that fails to act on a complaint, undermines all three, and it does so repeatedly, from within a relationship the person cannot easily leave because their income depends on it. Herman (1992) described the syndrome that follows prolonged, repeated trauma in conditions of captivity or coercive control, and that description became the basis for complex PTSD in ICD-11 (World Health Organization, 2019). ICD-11 complex PTSD comprises the three core PTSD clusters of re-experiencing, avoidance and a persistent sense of current threat, together with three disturbances in self-organisation, namely affect dysregulation, negative self-concept and difficulties in relationships (Cloitre et al., 2013; Brewin et al., 2017). People who have been through years of workplace harm often present with exactly that profile.
How WorkSafe Victoria defines a traumatic workplace event
For claims arising on or after 31 March 2024, WorkSafe Victoria's Practice Directive on mental injury eligibility offers a working definition that is broader than DSM-5-TR Criterion A. The Directive states that ‘Traumatic events in the workplace may involve exposure to abuse, bullying, harassment, the threat of harm or actual harm’ and that vicarious trauma ‘is likely to be considered a traumatic event’ (WorkSafe Victoria, 2024). On interpersonal conflict, it distinguishes ordinary friction from harm. In its words, ‘unreasonable behaviour including bullying, harassment, and discrimination, are not considered to be events that are reasonably expected to occur in the course of a worker's usual or typical duties and may be considered traumatic’ (WorkSafe Victoria, 2024).
Two further points in the Directive shape how a psychologist should think about diagnosis in this scheme. The first is that a compensable mental injury under section 3 of the Workplace Injury Rehabilitation and Compensation Act 2013 must cause ‘significant behavioural, cognitive or psychological dysfunction’ and be ‘diagnosed by a medical practitioner in accordance with the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM)’ (WorkSafe Victoria, 2024). The Directive is explicit that ‘Psychologists cannot provide a diagnosis of a mental injury for the purposes of the WIRC Act’. As a result, the diagnosis on the certificate belongs to the general practitioner or psychiatrist, and the psychologist's contribution is the structured assessment and report that informs it. The second point is that ICD-11 complex PTSD is not a DSM diagnosis, so it cannot serve as the compensable diagnosis in Victoria, even where it is the most accurate clinical description.
Where the diagnostic question actually sits
Putting the evidence and the rules together produces a clearer decision structure than the usual ‘adjustment disorder or PTSD’ framing.
Where the workplace events meet Criterion A and the person meets criteria B to E for at least one month with clinically significant distress or impairment, the diagnosis is PTSD (309.81 / F43.10). Adjustment disorder is excluded.
Where the events meet Criterion A but the person falls short of full PTSD criteria, DSM-5-TR offers adjustment disorder, or Other Specified Trauma- and Stressor-Related Disorder (309.89 / F43.8) where the presentation is better described that way. Here adjustment disorder is a legitimate diagnosis, and the report should say why full criteria were not met.
Where the events do not meet Criterion A on a strict reading, but the person presents with re-experiencing, avoidance, negative alterations in cognition and mood, and hyperarousal, PTSD cannot be coded under DSM-5-TR without a Criterion A event. The honest options are Other Specified Trauma- and Stressor-Related Disorder with the PTSD-like profile described, or a different specified disorder (such as major depressive disorder or generalised anxiety disorder) if criteria are met, with the trauma-related symptoms documented in full. What is not defensible in this situation is a bare adjustment disorder diagnosis that leaves the trauma symptoms unrecorded, because those symptoms drive both prognosis and the choice of treatment.
Across all three pathways, the ICD-11 complex PTSD framework remains useful as a clinical formulation and as the basis for measuring outcomes, and the reasons for any divergence between the ICD-11 formulation and the DSM-5-TR code should be stated in the report.
Why adjustment disorder gets applied when it does not fit
Several factors combine to produce the pattern. Some are structural and some are clinical.
The first contact in a Victorian claim is a general practitioner completing a Certificate of Capacity, usually within a standard consultation, often before the person has told the full story, and under a legislative requirement to record a DSM diagnosis. In that setting adjustment disorder is a reasonable provisional diagnosis. The problem arises when it is never revisited. Once a diagnosis is on the initial certificate, subsequent certificates tend to repeat it, and the treating psychologist's more detailed assessment may not reach the general practitioner in a form that prompts a change.
A second factor is a narrow reading of Criterion A. Some assessors conclude that bullying or harassment is not a traumatic event and stop there. As set out above, WorkSafe Victoria's own Directive treats these behaviours as potentially traumatic, and the symptom evidence warrants a full assessment regardless of how the Criterion A question is ultimately resolved.
A third is the absence of structured assessment. Without a validated instrument such as the PTSD Checklist for DSM-5 (PCL-5), the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) or the International Trauma Questionnaire (ITQ), the four PTSD symptom clusters are not systematically canvassed, and avoidance in particular is easy to miss because the person is often avoiding talking about the very material that would establish the diagnosis (Weathers et al., 2018; Bovin et al., 2016; Cloitre et al., 2018).
A fourth factor is one I offer as a clinical inference rather than an established finding. Workers' compensation schemes are adversarial by design, and PTSD carries longer expected recovery, more treatment sessions and higher cost than adjustment disorder. It would be surprising if that did not create some pressure, whether conscious or not, towards the less costly label. I am not aware of Australian research that has tested this directly in the compensation context, and I would welcome being pointed to it.
Why the mismatch matters
The treatment pathways diverge. Adjustment disorder is generally expected to respond to brief supportive intervention and to the removal or resolution of the stressor (Casey, 2014). PTSD does not resolve that way. The Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD recommend trauma-focused psychological treatment, specifically trauma-focused cognitive behavioural therapy, Cognitive Processing Therapy, Prolonged Exposure and Eye Movement Desensitisation and Reprocessing (Phoenix Australia, 2020). A person with PTSD who receives supportive counselling alone is likely to remain symptomatic, and every month of misdirected treatment is a month in which avoidance consolidates and return to work recedes.
The diagnosis also governs access. In the Victorian scheme the number of approved sessions, the expectations about recovery timeframes, and the willingness to fund trauma-focused treatment all follow from what is written on the certificate. An adjustment disorder diagnosis carries an implicit expectation of resolution within months. When the person is still unwell at twelve months, the gap between the label and the presentation can be read against them rather than against the label.
There is a further cost that is harder to measure. People who have been bullied at work commonly describe the experience of not being believed as worse than the bullying itself. A diagnosis that frames their response as disproportionate to an ordinary stressor repeats that experience in clinical form. It communicates that what happened to them was a manageable difficulty and that the problem lies in their reaction. For many, this mirrors precisely what the workplace told them.
Moral injury, the dimension the diagnosis misses
Litz and colleagues (2009) described moral injury as the lasting psychological, social and spiritual harm that follows perpetrating, failing to prevent, or witnessing acts that transgress deeply held moral beliefs, particularly when those acts are committed or sanctioned by legitimate authority. The concept was developed in military populations and has since been applied more widely, and I note that its application to workplaces remains an extension of the original model rather than a separately validated construct.
The pattern it describes is nonetheless familiar in workers' compensation practice. People who reported a colleague's misconduct and were then managed out, who watched an employer bury a complaint, or who were disciplined for raising a safety concern often present with shame, guilt, anger and a corrosive loss of trust in institutions, alongside their PTSD symptoms. These features shape how the person engages with the compensation system, with return-to-work conferencing and with treatment itself. Adjustment disorder does not capture them, and neither does PTSD in its narrow form, so they need to be named in the formulation.
What a structured assessment involves
In my own practice the assessment of a person referred with a workplace psychological injury follows a consistent sequence, and I set it out here because much of it is transferable.
I begin with the stressor history taken chronologically, with dates, so that Criterion A can be assessed event by event rather than as a general impression. I then administer the PCL-5 and, where the history involves prolonged or repeated interpersonal harm, the ITQ, and I follow these with a structured clinical interview covering all four DSM-5-TR symptom clusters, duration and functional impact. Avoidance is asked about specifically, in concrete terms (emails, the building, particular people, news about the industry), because people rarely volunteer it.
I assess for the ICD-11 disturbances in self-organisation, for moral injury features, and for major depressive disorder and generalised anxiety disorder as alternative or co-occurring specified diagnoses. I document functional impairment in the terms the scheme uses, namely significant behavioural, cognitive or psychological dysfunction, so that the general practitioner has what they need for the certificate.
Finally, I write the report so that the diagnostic reasoning is visible. If the presentation meets PTSD criteria, the report says so and maps the evidence to each criterion. If Criterion A is not met but the trauma-symptom profile is present, the report says that too, names the DSM-5-TR pathway that best fits, and records the symptoms in full so they are not lost. Either way the report is written for the general practitioner and, where relevant, the WorkSafe agent, in language that allows the diagnosis on the certificate to be reconsidered on evidence.
Where this leaves clinicians and the people they assess
The research is consistent that sustained workplace bullying, harassment and discrimination produce trauma-symptom profiles in a majority of the people exposed to them, and the Victorian scheme now recognises those behaviours as potentially traumatic events. Adjustment disorder remains a legitimate diagnosis in the early weeks and in cases that genuinely fall short of PTSD criteria after a proper assessment. It is not a defensible resting place for a person who is re-experiencing, avoiding, hypervigilant and still unwell a year on.
For clinicians, the practical step is to treat every adjustment disorder diagnosis on an incoming certificate as provisional, assess formally for PTSD and complex PTSD, and communicate the result to the certifying practitioner. For individuals who recognise themselves in this article, it may help to know that a structured assessment exists, that the label on the first certificate is not final, and that the treatments with the strongest evidence for trauma are available under the Victorian scheme when the diagnosis supports them.
Behavioural Edge Psychology provides treatment for work-related psychological injury under WorkCover, independent psychological assessment, and fitness for work and return to work assessment. Related reading on this site includes WorkCover psychology in Victoria and what changed in 2024 and psychosocial safety in Australian workplaces.
Frequently asked questions
Can workplace bullying cause PTSD?
Sustained workplace bullying is strongly associated with PTSD symptoms. A meta-analysis of 29 studies found that 57 per cent of people exposed to bullying at work or school scored above the screening threshold on self-report PTSD measures (Nielsen et al., 2015). Whether a formal PTSD diagnosis can be made under DSM-5-TR depends on whether the events meet Criterion A, which requires actual or threatened death, serious injury or sexual violence. WorkSafe Victoria's Practice Directive treats bullying, harassment and discrimination as potentially traumatic events for compensation purposes.
What is the difference between adjustment disorder and PTSD?
Adjustment disorder describes emotional or behavioural symptoms arising within three months of a stressor, involving distress out of proportion to the stressor or significant impairment, and is a diagnosis of exclusion that cannot be made where criteria for another disorder are met. PTSD requires a qualifying traumatic event and symptoms in four clusters (intrusion, avoidance, negative changes in cognition and mood, and changes in arousal and reactivity) lasting more than one month. Adjustment disorder does not include intrusive re-experiencing, trauma-related avoidance or hyperarousal as defining features.
Why is adjustment disorder so common on WorkCover certificates in Victoria?
Under the Workplace Injury Rehabilitation and Compensation Act 2013 a mental injury must be diagnosed by a medical practitioner (a general practitioner or psychiatrist) in accordance with the DSM, so the first diagnosis is usually made by a GP within a standard consultation. Adjustment disorder is a reasonable provisional diagnosis at that point. It becomes a problem when it is repeated on later certificates without a structured trauma assessment having been carried out.
Can a psychologist diagnose a mental injury for a WorkCover claim in Victoria?
No. WorkSafe Victoria's Practice Directive states that psychologists cannot provide a diagnosis of a mental injury for the purposes of the WIRC Act. A psychologist's structured assessment and report can inform the diagnosis made by the treating GP or psychiatrist, and can prompt that diagnosis to be revised.
What assessment tools are used to identify PTSD after workplace trauma?
Validated instruments include the PTSD Checklist for DSM-5 (PCL-5), the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the International Trauma Questionnaire (ITQ), which also assesses ICD-11 complex PTSD. These are used alongside a structured clinical interview that covers all four DSM-5-TR symptom clusters, duration and functional impairment.
Is complex PTSD a recognised diagnosis in Australia?
Complex PTSD is a diagnosis in ICD-11 (code 6B41) but does not appear in DSM-5-TR. Because Victorian workers' compensation law requires a DSM diagnosis, complex PTSD cannot be the compensable diagnosis on a Certificate of Capacity, although it can be used in clinical formulation and treatment planning.
What is moral injury in a workplace context?
Moral injury describes the lasting psychological harm that follows witnessing or being subjected to acts that violate deeply held moral beliefs, particularly when committed or condoned by those in authority (Litz et al., 2009). In workplaces it is commonly described after an employer fails to act on a complaint or penalises a person for raising one. It is not a DSM diagnosis, and its application outside military populations is an extension of the original model.
References
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Bachem, R., & Casey, P. (2018). Adjustment disorder: A diagnosis whose time has come. Journal of Affective Disorders, 227, 243–253. https://doi.org/10.1016/j.jad.2017.10.034
Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391. https://doi.org/10.1037/pas0000254
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About Behavioural Edge Psychology
Behavioural Edge Psychology Pty Ltd is an adults-only private psychology practice in Victoria, Australia, with consulting rooms in Caulfield South and St Kilda and telehealth available Australia-wide. The practice combines individual therapy with organisational psychology, and provides psychological treatment for work-related injury under WorkCover and TAC, fitness for work and return to work assessment, independent psychological assessment for legal and insurance purposes, NDIS functional capacity assessment, adult ADHD and autism assessment, and organisational psychology consulting on psychosocial hazards.
About the author
Dr Sarah Fischer is Principal Psychologist and Director of Behavioural Edge Psychology. She is a registered psychologist with the Psychology Board of Australia (AHPRA registration PSY0001719709) holding an Area of Practice Endorsement in Organisational Psychology, a PhD in Psychology, a Master of Organisational Psychology, and full membership of the Australian Psychological Society (MAPS) and the Australian Association of Psychologists Inc (MAAPi). Her clinical work centres on trauma, anxiety, depression, stress and burnout, adult neurodivergence, and the assessment and treatment of workplace psychological injury, and her consulting work addresses psychosocial hazard management under Victoria's Occupational Health and Safety Amendment (Psychological Health) Regulations 2025.
Registration can be checked on the AHPRA Register of Practitioners. Publications are listed on ResearchGate.
This article is general information drawn from published research, regulatory guidance and the author's clinical practice. It does not replace individual psychological assessment or treatment. People seeking assessment or support are encouraged to consult a registered psychologist or their general practitioner.
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