Adjustment Disorders

People are diagnosed with an adjustment disorder when they react to stressors in ways that are more severe than normal but that do not qualify them for diagnosis of a more persistent disorder like PTSD.

Sometimes misunderstood as inconsequential, adjustment disorders can be quite severe. Intense adjustment reactions to unexpected stressors may include emotional volatility and impulsive behavior. While limited in duration by definition, the acute phase of an adjustment disorder can include a period of extreme hopelessness and a significant risk of suicide.

Because adjustment disorders are situational and often arise suddenly, people who experience them are at risk of acting on self-destructive impulses before anyone realizes they need help. With the right intervention, however, people can get the help they need to cope and recover.

What Is an Adjustment Disorder?

People are diagnosed with an adjustment disorder when they react to stressors in ways that are more severe than normal but that do not qualify them for diagnosis of a more persistent disorder likepost-traumatic stress disorder(PTSD) ormajor depressive disorder(MDD).

While adjustment disorders were listed under their own category in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), they are listed under “Trauma and Stressor-Related Disorders” in the fifth edition (DSM-5). This reflects their origin in acutely stressful situations.

Symptoms of Adjustment Disorder

According to the DSM adjustment disorder definition, symptoms meet criteria for an adjustment disorder diagnosis when they develop within three months of the onset of a stressor and do not persist for more than six months after the stressor has passed.

Symptoms are nonspecific but are generally defined by these two adjustment disorder criteria:

• Marked distress that is disproportionate to the severity of the stressor
• Significant functional impairment in social, occupational or other areas

While adjustment disorders affect thought and emotion, their greatest risks lie in their effects on behavior. Adjustment disorders are associated with impulsive, self-destructive and suicidal actions.

Adjustment disorders have two layers: the emotional reactions that are caused by the mind’s inability to adjust to an external stressor, and the behavioral reactions that reflect a person’s difficulty adjusting to these inner psychological states.

General Adjustment Disorder Symptoms

Adjustment disorder symptoms typically reflect either an anxious or depressed adjustment reaction. Sometimes people experience a mixed response with features of both anxiety and depression. Specific psychological and physical symptoms of adjustment disorders can include:

• Anxious or worried thoughts
• Hopeless or depressed thoughts
• Depressed mood, sadness or flat affect
• Difficulty concentrating or thinking clearly
• Tearfulness, mood instability or frequent crying
• Anhedonia, or loss of pleasure in regular activities
• Fatigue or difficulty with physical exertion
• Elevated heart rate or heart palpitations
• Headaches or gastrointestinal distress
• Change in appetite or eating habits
• Insomnia or other sleep problems

Adjustment Disorder Unspecified Symptoms

For adjustment disorder unspecified type, symptoms do not fit a typical pattern ofdepressionoranxietysymptoms. This type of adjustment disorder often features more external symptoms like physical symptoms and changes to behavior, such as the following:

• Reckless driving or other dangerous, impulsive behaviors
• Social isolation or withdrawal from family and friends
• Increased aggression or proneness to conflict
• Frequent absences from work or school
• Poor performance at work or school

Adjustment Disorder Symptoms in Children

Adjustment disorder is one of the DSM-5 disorders that can be diagnosed in children. It occurs when children are unable to adjust to unexpected changes in their lives such as social problems at school, moving to a new location or learning that their parents are divorcing. Symptoms of adjustment disorder in children include:

• Difficulty sleeping
• Frequent crying episodes
• Irritability and temper outbursts
• Withdrawal from family and friends
• Behavioral or academic problems at school
• Somatic symptoms like headaches and stomachaches

Not every period of difficult adjustment meets the criteria for an adjustment disorder, even if some of the above symptoms are present. Careful diagnosis from a qualified clinician is required to discern a subclinical pattern of difficulty from an adjustment disorder.

Types of Adjustment Disorders

Mental health clinicians diagnose adjustment disorders using criteria from either the DSM or the World Health Organization’s 10th edition of the International Classification of Diseases (ICD-10). Different subtypes of adjustment disorders listed in these reference guides include:

• Adjustment disorder with anxiety (DSM-5)
• Adjustment disorder with depressed mood (DSM-5 and ICD-10)
• Adjustment disorder with brief depressive reaction (ICD-10)
• Adjustment disorder with prolonged depressive reaction (ICD-10)
• Adjustment disorder with mixed anxiety and depressed mood (ICD-10 and DSM-5)
• Adjustment disorder with mixed disturbance of emotions and conduct (ICD-10 and DSM-5)
• Adjustment disorder with disturbance of conduct (DSM-5)
• Adjustment disorder with predominant disturbance of conduct (ICD-10)
• Adjustment disorder with predominant disturbance of other emotions (ICD-10)
• Adjustment disorder with other specified predominant symptoms (ICD-10)
• Adjustment disorder unspecified (DSM-5)

As the names suggest, there is no substantial difference in the criteria for the disorders in the DSM-5 and ICD-10. For example, there is no difference between adjustment disorder with depressed mood (DSM-5) and adjustment disorder with depressed mood (ICD-10).

In general, the only difference is the code assigned to each diagnosis. The DSM-5 code for adjustment disorder with depressed mood is 309.0, while the ICD-10 code for adjustment disorder with depressed mood is F43.21.

Causes of Adjustment Disorder

Unlike many othermental health conditions, adjustment disorders cannot arise independently from external events. Internal factors like genetic predisposition and biology can make some people more prone to adjustment disorders, but they are always linked to changes in people’s lives. Stressors that can trigger adjustment disorders include:

• Health issues
• Family conflicts
• Financial problems
• Starting or ending a job
• Moving to a new location
• Facing the end of a long-term relationship
• The death of a partner, friend or family member
• Conflicts with bosses or colleagues at school or work

These changes can dramatically affect a person’s sense of self and feelings of competence, overwhelming their standard coping strategies and existing supports. When people can’t find practical solutions to new challenges, they may start feeling overwhelmed psychologically.

Diagnosing Adjustment Disorders

Neither diagnostic guide specifically lists the symptoms of each subtype. In general, they align with the symptoms of other depressive, anxiety or conduct disorders. It is common for people to develop adjustment disorder with mixed emotional features, which includes symptoms of depression, agitation, irritability and anxiety.

Like most mental health conditions, adjustment disorders are diagnosed through a series of clinical interviews. Mental health professionals ask targeted questions to determine whether symptoms indicate an adjustment disorder or a more persistent mood or anxiety disorder likemajor depressive disorderorPTSD.

They may simply ask questions and take notes or use a standard assessment test or questionnaire to evaluate when symptoms began, whether they are linked to a stressor and how long ago the stressor occurred.

Adjustment Disorder vs. PTSD

While adjustment disorder criteria are broad enough for a range of different reactions to qualify for the diagnosis, adjustment disorders usually involve depression or anxiety symptoms (or both). They do not typically include any of the intrusive symptoms associated withPTSDlike flashbacks. This is because they are usually not responses to traumatic or violent events, but to unexpected disappointments and losses, like the end of a relationship or losing a job.

The psychology of trauma defines the mind’s natural response to overwhelming events that cause a person to lose their basic sense of safety and trust. While not everyone develops PTSD, trauma can be overwhelming and always requires more than a simple adjustment to recover from. For most, the healing process requires significant time and effort.

The psychology of adjustment defines the way the mind responds to environmental challenges by changing only to the extent required to meet them. Normally, people cope with obstacles by relying on established behaviors like seeking warmth when it gets cold or seeking shelter when it rains. However, there are some circumstances under which people cannot adjust so easily:

• When environmental changes are too extreme for a normal response to suffice
• When the mind is temporarily unable to handle regular stressors due to fatigue
• When an acute stressor occurs during a general period of elevated stress

For example, a person might be able to accept the loss of a job more easily when they have a strong support network and a few other stressors. However, if they lose a job just after moving to a new city when they are socially isolated and under additional financial stress, they might become psychologically overwhelmed and develop an adjustment disorder.

Who Is at Risk of Adjustment Disorders?

Anyone who experiences significant stressors is at risk of developing an adjustment disorder. However, people with certain characteristics are more vulnerable. Risk factors for adjustment disorders include:

• Susceptibility to stress
• Sensitive temperament
• History of childhood abuse
• Not having a strong social support system
• Comorbid anxiety or depressive disorders
• Working in a high-stress job or school environment
• Recent history of prolonged stress or multiple changes or losses

People who experience a new acute stressor after a period of elevated stress are more likely to be overwhelmed and to have an adjustment reaction. People who react more intensely to stress in general are also at an increased risk of developing an adjustment disorder.

Adjustment Disorder Statistics

Research suggests adjustment disorder is diagnosedalmost three timesas much as major depression in inpatient treatment settings.

Adjustment disorder is the most common diagnosis for people admitted to outpatient psychiatric settings, with36 percentof patients receiving the diagnosis.

From11 to 18 percentof people seen by primary care doctors meet the criteria for adjustment disorders.

As many as25 percentsof adolescents and 60 percent of adults with adjustment disorder make suicide attempts or gestures.

One study found that among people treated at a psychiatric facility for an adjustment disorder, a little more than75 percenthad a comorbid substance use disorder.

Another study showed that after five years,71 percent of adults and 44 percent of adolescentswho had been treated for adjustment disorder had fully recovered.

Adjustment Disorder Treatments

The primary component of anadjustment disorder treatment planis therapy. People who are overwhelmed by stress need practical help to address the obstacles they need to overcome, psychological help with managing their stress, and emotional support.

Often, brief therapeutic interventions are all people with adjustment disorders need. With the right treatment, a person can recover from an adjustment disorder in a few months or even just a few weeks.

Possible forms of therapy for adjustment disorders include:

• Cognitive Behavioral Therapy.People with adjustment disorders can benefit fromcognitive behavioral therapy (CBT)to help them challenge distorted thoughts about the meaning of stressful events as well as behavioral techniques that help them improve their abilities to manage stress and relax.
• Dialectical Behavior Therapy.For people whose adjustment disorders arise during periods of prolonged stress or chaos,dialectical behavior therapy (DBT)can be useful.In DBT, people learn skills for emotional self-regulation and interpersonal effectiveness that are particularly useful during stressful periods. People with adjustment disorders can benefit from learning DBT-based coping techniques that help them release self-judgment.
• Support Groups.Support groups are a great resource for people with adjustment disorders. In some cases, people may be able to find groups focused on a particular stressor. Many communities offer support groups for bereavement, job loss and divorce. These groups provide opportunities to learn practical techniques for resolving stressors and can also be sources of emotional support and encouragement.

In some cases, medications are used to treat adjustment disorders as well. Medications prescribed depend on the subtype of adjustment disorder a person develops. For example, people who primarily experience depressive symptoms may benefit fromantidepressant medication, especially selective serotonin reuptake inhibitors (SSRIs).

One study showed that people with adjustment disorder weretwice as likelyas people with major depressive disorder to respond to antidepressants. Commonly prescribed SSRIs include the following:

• Paroxetine (Paxil)
• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Sertraline (Zoloft)
• Fluoxetine (Prozac)

For people with dominant anxiety symptoms, anti-anxiety medications likebenzodiazepinesmay be prescribed. However, these medications are typically not recommended for people with co-occurring adjustment and substance use disorders as they are highly addictive. Selective serotonin reuptake inhibitors can effectively treat anxiety and are safer to prescribe.

Adjustment Disorders and Substance Abuse

As many as75 percentof people with adjustment disorders also abuse substances. In some cases, they may have had substance abuse problems before encountering a stressor. In other cases, they may have started abusing substances to cope with stress, anxiety, depression or other symptoms that followed from a stressful life change.

Fortunately, there are effective treatment options for people with co-occurring adjustment and substance use disorders. Integrated treatment that incorporates group and individual therapy can help people heal from the pain of what happened to them while also learning how to control cravings and avoid triggers to use substances.

The Recovery Village is part of a network of rehab facilities across the United States that provide care for people withco-occurring substance use and mental health disorders. Facility staff work with clients to help them address the stressors in their lives while improving their mental health. If you or a loved one are struggling to overcome addiction and feel overwhelmed,contact a Recovery Village representativetoday to learn how you can recover.