What is adjustment disorder

Adjustment disorder is a group of symptoms, such as stress, feeling sad or hopeless and physical symptoms that can occur in response to stressful situations or unexpected event. The symptoms occur because you are having a hard time coping. Your reaction is stronger than expected for the type of event that occurred.

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.

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 ¹⁾. 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.

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 ²⁾. 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.

According to ICD-10 classification, adjustment disorder is classified under the category of reaction to severe stress and adjustment disorders ³⁾. 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.

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 feeling sad, tearful 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, difficulty concentrating or remembering things, and feeling overwhelmed. Children who have an adjustment disorder with 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 fighting or reckless driving. 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, and how you have learned to deal with stress in the past may play roles.

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.

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 DSM-5 lists these criteria:

• Having emotional or behavioral symptoms within three months of a specific stressor occurring in your life
• Experiencing more stress than would normally be expected in response to a stressful life event and/or having stress that causes significant problems in your relationships, at work or at school
• Symptoms are not the result of another mental health disorder or part of normal grieving.

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, medications or both.

Most mental health professionals recommend some type of talk therapy. 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. 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

Lifestyle and home remedies

Here are some steps you can take to care for your emotional well-being.

Tips to improve resilience

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.