What is adjustment disorder

Adjustment disorder also known as stress response syndrome, situational depression or grief reactions, is an exaggerated reaction to a stressful or traumatic event. Stressors can be single events (like a bad breakup, relationship issue or health change) or can be multiple events (like work problems, struggles at school, financial issues) or any other negative or positive life event. Stressors can happen to an individual, a family or an entire group (such as disaster survivors). Stressors can also be recurrent (like factors associated with seasonal business) or with specific “milestone” events (like going to school, getting married or retiring). The Diagnostic and Statistical Manual of Mental Disorders – fifth edition (DSM-5) defines adjustment disorder as “a maladaptive emotional and/or behavioral response to an identifiable psychosocial stressor, capturing those who experience difficulties adjusting after a stressful event at a level disproportionate to the severity or intensity of the stressor” ¹. Adjustment disorder is thought to affect 2 to 8% of the general population. Adjustment disorder can affect anyone at any age. Adjustment disorder affects twice as many females as males.

Adjustment disorder common physical symptoms:

• Being tired, but can’t sleep (insomnia).
• Body aches and soreness; thinking that you’re sick.
• Headaches or stomachaches.
• Heart palpitations.
• Sweating hands.

Adjustment disorder common behavioral or emotional symptoms:

• Acting rebellious, destructive, reckless or impulsive.
• Being anxious or agitated, feeling trapped, hopeless.
• Crying easily.
• Trouble concentrating.
• Being withdrawn or isolated; feeling sad; lacking energy or enthusiasm; loss of self-esteem.
• Loss of interest in everyday activities.
• Changes in eating habits.
• Feeling overwhelmed and stressed.
• Abusing alcohol or drugs.
• Having suicidal thoughts or behaviors.

Adjustment disorder symptoms are characterized by stress responses that are out of step with socially or culturally expected reactions to the stressor and/or which cause marked distress, feeling sad or hopeless and physical symptoms with impairment in daily functioning ². The symptoms occur because you are having a hard time coping. Your reaction is stronger than expected for the type of event that occurred. Unlike posttraumatic stress disorder (PTSD) or acute stress disorder, which have clear criteria for what constitutes a traumatic event, adjustment disorder criteria does not specify any requirements for what can be regarded as a stressor ². Research has identified, however, that stressor events may include both traumatic events, such as exposure to actual or threatened death, as well as non-traumatic stressful events such as interpersonal conflict, death of a loved one, unemployment, financial difficulties, or illness of a loved one or oneself ³. Generally there are many possible causes of adjustment disorders. Stressors can be any situation you perceive as stressful and that causes significant problems in your work, social or home life. They can be both positive and negative events.

Stress is a normal psychological and physical reaction to positive or negative situations in your life, such as a new job or the death of a loved one. Stress itself isn’t abnormal or bad. What’s important is how you deal with stress.

When you have so much trouble adjusting to a stressful change that you find it difficult to go about your daily routine, you may have developed an adjustment disorder.

The stress causes significant problems in your relationships, at work or at school.

Work problems, going away to school, an illness, death of a close family member or any number of life changes can cause stress. Most of the time, people adjust to such changes within a few months. But if you have an adjustment disorder, you continue to have emotional or behavioral reactions that can contribute to feeling anxious or depressed.

You don’t have to tough it out on your own, though. Treatment can be brief and it’s likely to help you regain your emotional footing. The main treatment for a adjustment disorder is talk therapy (psychotherapy), but some doctors might recommend medications like anti-anxiety drugs (benzodiazepines). Since a situation or stress is what causes adjustment disorder, having someone to talk to that you trust and getting the tools you need to learn how to better cope with the situation can be really helpful. Individual, family or group therapy (support groups) are also helpful. Family therapy is often used if the person is a child or teenager. There is no evidence that antidepressants have any effect on mood changes associated with adjustment disorder, but pharmacological treatments may help alleviate sleep and anxiety symptoms ⁴. Randomized, controlled trials of pharmacotherapy are uncommon and have mainly been conducted on subjects with the anxiety subtype. Psychological treatments have received more attention, and brief forms are the best tested. These may truncate the symptoms and improve functioning, but such improvement is usually contingent upon the removal of the stressor.

Adjustment disorder is diagnosed in an individual who experiences a stressful or traumatic event and shows an exaggerated response. The symptoms overlap with those of other conditions such as major depressive disorder, generalized anxiety disorder and behavioral problems but fail to reach the threshold for these major syndromes ⁴. Nevertheless, the symptoms of adjustment disorder are regarded as clinically significant and do not represent an adaptive response to a stressor. There may also be impairment in day-to-day functioning. The diagnosis cannot be made unless there is a trigger—unlike major depressive disorder, which can occur without any precipitant although it is frequently preceded by a stressful life event. Adjustment disorder resolves over time when the stressor is removed or when the person’s own adaptive skills and resilience enable this. Also, removing an individual from the stress-inducing situation facilitates improvement. Thus, it differs from major depressive disorder, which invariably requires some intervention, either pharmacological or psychological, to achieve recovery.

According to the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10) classification, adjustment disorder is classified under the category of reaction to severe stress and adjustment disorders ⁵. This category includes acute stress reaction, post-traumatic stress disorder (PTSD), adjustment disorder, other reactions to severe stress, reaction to severe stress unspecified.

Take the following example: Ms. A. worked in an office. Her relationship with her co-workers was good except for her line manager, whom she felt treated her less fairly than she did other workers. One day, in the presence of co-workers, the manager reprimanded Ms. A. for an error. When she tried to explain that she was not responsible because she was on annual leave on the day the error had occurred, she was ignored. She was upset and went home early. She lay awake at night thinking about the injustice of what had happened; she cried when she thought about her perceived humiliation, and her appetite abated. She returned to work for the rest of the week but found herself too anxious to return thereafter. She sought assistance from a counselor, and her family physician prescribed hypnotics to be taken as required. She never returned to work at that firm and obtained employment elsewhere, and her symptoms subsequently resolved.

This scenario is typical of adjustment disorder (anxiety subtype). The interventions she received were limited, and once her psychosocial situation improved, so did her symptoms. Her reaction was considered in excess of what would be considered “normal.” Ultimately, with little structured intervention, she returned with good functioning to new employment.

Can adjustment disorders affect children?

Yes. Adjustment disorder can affect both adults and children. Boys and girls are equally affected.

What can I expect if I have a diagnosis of adjustment disorder?

Adjustment disorder is usually a self-limiting disorder that goes away over time. Your symptoms will go away when your stressor goes away or when you adapt to the situation. Usually any medical interventions are limited and once the situation has improved, so too will your symptoms.

What’s the difference between adjustment disorder and major depression and generalized anxiety disorder?

A diagnosis of adjustment disorder is based on the presence of a stressor and the fact that the condition goes away when the stressor goes away. By definition of this diagnosis, the condition must end six months after the triggering event. With major depression and generalized anxiety disorder, there doesn’t need to be an identifiable stressor and the duration of symptoms can be ongoing.

What’s the difference between adjustment disorder and post-traumatic stress disorder (PTSD)?

With adjustment disorder, the severity of the stressor doesn’t matter. With PTSD, you have to fear for your life or the life of someone else. The severity is very high.

Types of adjustment disorders

The DSM-5 lists six different types of adjustment disorders. Although they’re all related, each type has unique signs and symptoms. Adjustment disorders can be:

1. Adjustment disorder with depressed mood. Symptoms mainly include depressed mood, feeling sad, tearfulness and hopeless and experiencing a lack of pleasure in the things you used to enjoy.
2. Adjustment disorder with anxiety. Symptoms mainly include nervousness, worry, jitteriness, difficulty concentrating or remembering things, and feeling overwhelmed. Children who have an adjustment disorder with anxiety (also known as separation anxiety) may strongly fear being separated from their parents and loved ones.
3. Adjustment disorder with mixed anxiety and depressed mood. Symptoms include a combination of depression and anxiety.
4. Adjustment disorder with disturbance of conduct. Symptoms mainly involve behavioral problems, such as violation of the rights of others. Violation of society’s norms and rules (truancy, destruction of property, reckless driving or fighting). Youths may skip school or vandalize property.
5. Adjustment disorder with mixed disturbance of emotions and conduct. Symptoms include a mix of depression and anxiety as well as behavioral problems.
6. Adjustment disorder unspecified. Symptoms don’t fit the other types of adjustment disorders, but often include physical problems, problems with family or friends, or work or school problems.

Outlook (Prognosis) for adjustment disorder

With the right help and support, you should get better quickly. The problem usually does not last longer than 6 months, unless the stressor continues to be present.

Complications of adjustment disorder

If adjustment disorders do not resolve, they can eventually lead to more serious mental health problems such as anxiety disorders, depression or substance abuse.

Causes of adjustment disorder

Many different events may trigger symptoms of an adjustment disorder. Whatever the trigger (stressor in your life) is, the event may become too much for you.

Genetics, your life experiences, and your temperament may increase your likelihood of developing an adjustment disorder.

Stressors for people of any age include:

• Death of a loved one
• Divorce or problems with a relationship
• General life changes
• Illness or other health issues in yourself or a loved one
• Moving to a different home or a different city
• Unexpected catastrophes
• Worries about money

Triggers of stress in teenagers and young adults may include:

• Family problems or conflict
• School problems
• Sexuality issues

There is no way to predict which people who are affected by the same stress are likely to develop adjustment disorder. Your social skills before the event, your personality, temperament, well-being, life experiences and family history and how you have learned to deal with stress in the past may play roles in the possible development of adjustment disorder.

Risk factors for adjustment disorder

Some things may make you more likely to have an adjustment disorder.

Stressful events

Stressful life events — both positive and negative — may put you at risk of developing an adjustment disorder. For example:

• Divorce or marital problems
• Relationship or interpersonal problems
• Changes in situation, such as retirement, having a baby or going away to school
• Adverse situations, such as losing a job, loss of a loved one or having financial issues
• Problems in school or at work
• Life-threatening experiences, such as physical assault, combat or natural disaster
• Ongoing stressors, such as having a medical illness or living in a crime-ridden neighborhood

Your life experiences

Life experiences can impact how you cope with stress. For example, your risk of developing an adjustment disorder may be increased if you:

• Experienced significant stress in childhood
• Have other mental health problems
• Have a number of difficult life circumstances happening at the same time.

Adjustment disorder prevention

There are no guaranteed ways to prevent adjustment disorders. But developing healthy coping skills and learning to be resilient may help you during times of high stress.

If you know that a stressful situation is coming up — such as a move or retirement — call on your inner strength, increase your healthy habits and rally your social supports in advance. Remind yourself that this is usually time-limited and that you can get through it. Also consider checking in with your doctor or mental health professional to review healthy ways to manage your stress.

Adjustment disorder symptoms

Signs and symptoms depend on the type of adjustment disorder and can vary from person to person. You experience more stress than would normally be expected in response to a stressful event, and the stress causes significant problems in your life.

Your symptoms can vary from mild to severe, depending on the intensity of the triggering situation and the personal significance it has for you.

Adjustment disorders affect how you feel and think about yourself and the world and may also affect your actions or behavior.

Symptoms of adjustment disorder are often severe enough to affect work or social life. Symptoms include:

• Feeling sad, hopeless or not enjoying things you used to enjoy
• Frequent crying
• Worrying or feeling anxious, nervous, jittery or stressed out
• Trouble sleeping
• Lack of appetite
• Difficulty concentrating
• Feeling overwhelmed
• Difficulty functioning in daily activities
• Withdrawing from social supports
• Avoiding important things such as going to work or paying bills
• Suicidal thoughts or behavior
• Acting defiant or showing impulsive behavior
• Acting nervous or tense
• Crying, feeling sad or hopeless, and possibly withdrawing from other people
• Skipped heartbeats and other physical complaints
• Trembling or twitching
• Poor school or work performance
• Relationship problems
• Sadness
• Thoughts of suicide
• Worry
• Anxiety

Symptoms of an adjustment disorder start within three months of a stressful event and last no longer than 6 months after the end of the stressful event. However, persistent or chronic adjustment disorders can continue for more than 6 months, especially if the stressor is ongoing, such as unemployment.

To have adjustment disorder, you must have the following:

• The symptoms clearly come after a stressor, most often within 3 months
• The symptoms are more severe than would be expected
• There do not appear to be other disorders involved
• The symptoms are not part of normal grieving for the death of a loved one

Sometimes, symptoms can be severe and the person may have thoughts of suicide or make a suicide attempt.

Length of symptoms

How long you have signs and symptoms of an adjustment disorder also can vary. Adjustment disorders can be:

• Acute. Signs and symptoms last six months or less. They should ease once the stressor is removed.
• Persistent (chronic). Signs and symptoms last more than six months. They continue to bother you and disrupt your life.

Adjustment disorder diagnosis

Your health care provider will do a mental health assessment to find out about your behavior and symptoms. You may be referred to a psychiatrist to confirm the diagnosis.

Diagnosis of adjustment disorders is based on identification of major life stressors, your symptoms and how they impact your ability to function. Your doctor will ask about your medical, mental health and social history. He or she may use the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

For diagnosis of adjustment disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists these criteria ¹:

• Your emotional or behavioral symptoms developed within three months of the start of the stressful event in your life.
• Your emotional or behavioral symptoms are clinically significant. This means that your distress must exceed what would normally be expected and/or the distress is causing significant problems in your relationships, work, home, school or social life.
• Your symptoms are not the result of another mental health disorder or a flare-up or worsening of an existing mental health problem.
• Your symptoms are not part of a normal grieving process.
• Your symptoms don’t last more than six months after the triggering event has ended.

Acute adjustment disorder means your symptoms last less than six months. Chronic adjustment disorder means your symptoms last six months or longer.

Your healthcare provider should also take into account your cultural background in determining if your response to a stressor is in excess of what would be expected.

Table 1. Summary of DSM-5 and the International Statistical Classification of Diseases and Related Health Problems, 11th edition (ICD-11) diagnostic criteria for adjustment disorder

DSM-5	ICD-11
A. Onset of emotional or behavioral symptoms must occur in response to identifiable stressor, and within 3 months of the stressor.	1. Presence of an identifiable psychosocial stressor(s). Symptoms emerge within 1 month of the stressor.
B. These symptoms are clinically significant, marked by:	2. Preoccupation related to the stressor or its consequences in the form of at least one of the following:
– Distress that is disproportionate to the severity or intensity of the stressor, taking into account contextual and cultural factors.	(a) excessive worry about the stressor (b) recurrent and distressing thoughts about the stressor (c) constant rumination about the implications of the stressor.
or
– Significant impairments in social, occupational or other domains of functioning.	3. Failure to adapt to the stressor that causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning
C. The disturbance does not meet the diagnostic criteria for another mental disorder, and is not an exacerbation of a pre-existing disorder.	4. Symptoms are not of a sufficient specificity or severity to justify diagnosis of another mental or behavioral disorder.
D. The symptoms do not represent normal bereavement.
E. Symptoms do not last for more than six additional months after the stressor or its consequences have been resolved.	5. Symptoms typically resolve within 6 months, unless the stressor persists for a longer duration

[Sources ¹, ⁶ ]

Adjustment disorder treatment

The main goal of treatment is to relieve symptoms and help you return to a similar level of functioning as before the stressful event occurred.

Many people with adjustment disorders find treatment helpful, and they often need only brief treatment. Others, including those with persistent adjustment disorders or ongoing stressors, may benefit from longer treatment. Treatments for adjustment disorders include psychotherapy (talk therapy), medications or both.

Most mental health professionals recommend some type of talk therapy (psychotherapy). This type of therapy can help you identify or change your responses to the stressors in your life.

Cognitive behavioral therapy (CBT) is a type of talk therapy (psychotherapy). It can help you deal with your feelings:

• First the therapist helps you recognize the negative feelings and thoughts that occur.
• Then the therapist teaches you how to change these into helpful thoughts and healthy actions.

Other types of therapy may include:

• Long-term therapy, where you will explore your thoughts and feelings over many months or more
• Family therapy, where you will meet with a therapist along with your family
• Self-help groups, where the support of others may help you get better

Medicines may be used, but only along with talk therapy. These medicines may help if you are:

• Nervous or anxious most of the time
• Not sleeping very well
• Very sad or depressed

To date, there is only one published systematic review of treatments available for adjustment disorder ². A 2018 review examined 29 treatment trials investigating current options for psychological and pharmacological intervention ⁷. They found that the quality of evidence in these studies was “low” to “very low” according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines ⁸. A key limitation to most of these studies was the lack of a measure of adjustment disorder, small sample sizes, and lack of follow-up assessments. The authors also raised the issue of the divergence of the International Statistical Classification of Diseases and Related Health Problems, 11th edition (ICD-11) and DSM-5 diagnostic classification. For example, the recent trial on self-help intervention was based on the beta version of ICD-11 and they found this intervention had its most useful impact on preoccupation about the event including rumination, worry and intrusive thoughts ⁹. While this is very relevant for the ICD-11 diagnosis of adjustment disorder, as discussed earlier, the degree to which this would be useful for those meeting criteria for DSM-5 adjustment disorder is unknown.

Since the publication of the systematic review in 2018, two further randomized controlled trials (RCTs) have been published. One investigated an internet-based self-help intervention known as Brief Adjustment Disorder Intervention (BADI) for the treatment of ICD-11 adjustment disorder ¹⁰. In the self-help trial, completer analysis revealed that Brief Adjustment Disorder Intervention (BADI) reduced ICD-11 adjustment disorder symptoms and increased psychological well-being for those participants who used the intervention at least once in 30 days. The high drop-out rates from this trial (86%) prevent firm conclusions from being drawn. A second study targeted ICD-10 and DSM-4 adjustment disorder, and compared a face-to-face and virtual reality delivered cognitive behavioral therapy (CBT) to the waitlist ¹¹. Both the face-to-face and virtual reality CBT resulted in significantly greater improvements to adjustment disorder relative to the wait-list controls at pre/post treatment. The virtual reality group had significantly greater longer-term improvements than the standard and wait-list groups. Despite very small sample sizes in this study, as well as the high drop-out rates from the Eimontas et al. study ¹⁰, there is early support that technology assisted interventions for adjustment disorder may be useful, though further methodologically rigorous studies are needed.

Psychotherapy

Psychotherapy, also called talk therapy, is the main treatment for adjustment disorders. This can be provided as individual, group or family therapy.

Treatment may include:

• Individual psychotherapy using cognitive-behavioral approaches. Cognitive-behavioral approaches are used to improve age-appropriate problem-solving skills, communication skills, impulse control, anger management skills and stress management skills.
• Family therapy. Family therapy is often focused on making needed changes within the family system, like improving communication skills and family interactions. An additional area of focus is to increase family support among family members.
• Peer group therapy. Peer group therapy is often focused on developing and using social skills and interpersonal skills.

Psychotherapy can:

• Provide emotional support
• Help you get back to your normal routine
• Help you learn why the stressful event affected you so much
• Help you learn stress-management and coping skills to deal with stressful events

Adjustment disorder medications

Medicines have very limited value in the treatment of adjustment disorders. Medications such as antidepressants (selective serotonin reuptake inhibitors [SSRI] or serotonin and norepinephrine reuptake inhibitors [SNRI]) and anti-anxiety drugs (benzodiazepines) may be added to help with symptoms of depression and anxiety.

As with any therapy, you may need medications only for a few months, but don’t stop taking any medication without talking with your doctor first. If stopped suddenly, some medications, such as certain antidepressants, may cause withdrawal-like symptoms.

Lifestyle and home remedies

There’s some evidence that Ginkgo biloba, kava-kava and valerian are useful in treating adjustment disorder with anxiety.

Tips to improve resilience

Here are some steps you can take to care for your emotional well-being. Resilience is the ability to adapt well to stress, adversity, trauma or tragedy — basically, the ability to bounce back after experiencing a difficult event. Building resilience may vary from person to person, but consider these strategies:

• Stay connected with healthy social supports, such as positive friends and loved ones.
• Do something that gives you a sense of accomplishment, enjoyment and purpose every day.
• Live a healthy lifestyle that includes good sleep, a healthy diet and regular physical activity.
• Learn from past experiences about how you can improve your coping skills.
• Remain hopeful about the future and strive for a positive attitude.
• Recognize and develop your personal strengths.
• Face your fears and accept challenges.
• Make a plan to address problems when they occur, rather than avoid them.

Find support

It may help you to talk things over with caring family and friends, receive support from a faith community, or find a support group geared toward your situation.

Talk to your child about stressful events

If your child is having difficulty adjusting, try gently encouraging your child to talk about what he or she is going through. Many parents assume that talking about a difficult change, such as divorce, will make a child feel worse. But your child needs the opportunity to express feelings of grief and to hear your reassurance that you’ll remain a constant source of love and support.

References

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6. World Health Organization . World Health Organisation International Statistical Classification of Diseases and Related Health Problems. 11th ed. World Health Organization; Geneva, Switzerland: 2004.
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8. GRADE Working Group Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490. doi: 10.1136/bmj.328.7454.1490
9. Bachem R., Maercker A. Self-help interventions for adjustment disorder problems: A randomized waiting-list controlled study in a sample of burglary victims. Cogn. Behav. Ther. 2016;45:397–413. doi: 10.1080/16506073.2016.1191083
10. Eimontas J., Rimsaite Z., Gegieckaite G., Zelviene P., Kazlauskas E. Internet-based self-help intervention for ICD-11 adjustment disorder: Preliminary findings. Psychiatr. Q. 2018;89:451–460. doi: 10.1007/s11126-017-9547-2
11. Quero S., Molés M., Campos D., Andreu-Mateu S., Baños R.M., Botella C. An adaptive virtual reality system for the treatment of adjustment disorder and complicated grief: 1-year follow-up efficacy data. Clin. Psychol. Psychother. 2019;26:204–217. doi: 10.1002/cpp.2342