Adjustment disorders involve emotional and/or behavioral symptoms in response to an identifiable stressor. Diagnosis is based on clinical criteria. Treatment focuses on self-care; psychotherapy and pharmacotherapy may have a role.
(See also Overview of Trauma- and Stressor-Related Disorders.)
Adjustment disorders are common and are present in an estimated 5 to 20% of patients making outpatient mental health visits (1).
A stressor that leads to an adjustment disorder may be a single, discrete event (eg, losing a job), multiple events (eg, a series of financial problems or romantic setbacks), a common developmental milestone (eg, becoming a parent), or an ongoing set of problems (eg, caring for a disabled family member). The stressor may impact just one individual, an entire family or a large group of people.
Death of a loved one can be a precipitant of an adjustment disorder. However, clinicians must take into account the wide variety of grief reactions considered typical in different cultures and diagnose a disorder only if the bereavement response is beyond what is expected or is not better categorized as prolonged grief disorder.
General reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition,Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, pp 320-323.
Symptoms and Signs of Adjustment Disorder
Symptoms of an adjustment disorder typically begin within days of the stressful event and resolve within 6 months of the termination of the stressor and its consequences. There are 3 categories of adjustment disorder symptoms: depressed mood, anxiety, and conduct disturbance. Some patients may present with one of these symptoms being particularly prominent (eg, feeling nervous and jittery after a physical assault; behaving with uncharacteristic aggression in the context of a parental divorce), but most patients present with a mixture of symptoms.
Criteria for adjustment disorder are less specific than for either acute stress disorder or posttraumatic stress disorder, and it is a common diagnosis in both inpatient and outpatient psychiatric settings. While sometimes viewed by clinicians as a "mild" psychiatric diagnosis, adjustment disorder can be associated with significant distress and/or disability.
Patients with adjustment disorder also have an increased risk of suicide attempts and completed suicide (1). (See also Suicidal Behavior.)
Signs and symptoms reference
1. Casey P, Jabbar F, O'Leary E,et al: Suicidal behaviours in adjustment disorder and depressive episode. J Affect Disord 2015 Mar 15;174:441-6. doi: 10.1016/j.jad.2014.12.003
Diagnosis of Adjustment Disorder
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR) criteria
According to DSM-5-TR criteria, patients must have (1)
Emotional or behavioral symptoms within 3 months of having been exposed to a stressor
Symptoms must be clinically significant as shown by one or both of the following:
Marked distress that is out of proportion to the stressor (taking cultural and other factors into consideration)
The symptoms significantly impair social, occupational, or other important areas of functioning
Posttraumatic stress disorder (PTSD) and acute stress disorder (ASD) are part of the differential diagnosis, but they have different time frames and more specific descriptors of the stressors and the patient's response.
Adjustment disorders are frequently comorbid with other conditions, and the DSM-5-TR generally encourages inclusion of all pertinent diagnoses. For example, if a person meets criteria for adjustment disorder as well as obsessive-compulsive disorder, both diagnoses should be made. If on the other hand, the patient has developed depressive symptoms in the aftermath of a stressor, the clinician is encouraged to look at specific diagnostic criteria and make a judgment as to whether it might be more accurate and clinically useful to diagnose the patient with only the major depression.
The term adjustment disorder has often been misused by clinicians as a general term for a clinical picture that is nonspecific and relatively mild. As a result, the DSM-5-TR has included adjustment disorder in the chapter on trauma to highlight the fact that the symptoms must be in response to a stressor. Nevertheless, the clinical picture is often heterogenous (eg, with symptoms of anxiety, depression, and/or conduct issues), and the diagnosis remains one of the most common in both inpatient and outpatient settings. While such heterogeneity may be clinically reasonable, it complicates the approach to treatment.
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, pp 319-322.
Treatment of Adjustment Disorder
Self-care
Psychotherapy
Pharmacotherapy
Safety and self-care are important for successful recovery from adjustment disorder. Treatment is difficult if the traumatic experience is recurring and if the surrounding conditions remain unsafe. Other interventions are much more likely to be helpful if the patient with an adjustment disorder is living within an intact family and a healthy social system. Patients usually recover from an adjustment disorder over time and with the help of friends and family.
Although psychotherapy and medications may be used, there are limited data to support their efficacy.
Self-care
Self-care is crucial during and after a crisis or trauma. Self-care includes
Personal safety
Physical health
Mindfulness
Personal safety is fundamental. After a trauma, people are better able to process the experience when they know that they and their loved ones are safe. It can be difficult, however, to gain complete safety during ongoing crises such as domestic abuse, war, or an infectious pandemic. During such ongoing difficulties, people should seek the guidance of experts on how they and their loved ones can be as safe as possible.
Physical health can be put at risk during and after traumatic experiences. As much as possible, the at-risk person should try to maintain a healthy schedule of eating, sleeping, and exercise. Substances and medications that sedate (eg, benzodiazepines) and intoxicate (eg, alcohol) should be used sparingly, if at all.
A mindful approach to self-care aims to reduce the stress, boredom, anger, sadness, and isolation that traumatized people typically experience. If circumstances allow, at-risk individuals should make and follow a normal daily schedule, remain involved with their family and community, and practice familiar hobbies (or develop new ones).
It is useful to limit the amount of time spent on news and instead shift to other activities (eg, read a novel, do a puzzle, paint a picture, make cookies for a housebound neighbor).
Psychotherapy
Evidence to support the use of psychotherapy for adjustment disorder is limited (1), partly because of the heterogeneity of the disorder. However, data suggest benefit for various individual and group psychotherapies among subpopulations of patients with adjustment disorder. These interventions include cognitive-behavioral therapy, psychodynamic psychotherapy, family therapy, interpersonal therapy, and supportive psychotherapy. Some of these treatments have targeted specific elements of the adjustment disorder, such as grief, trauma, and role transitions, while other approaches appear to be more generalized. If psychotherapy is used, having a sensitive, trauma-informed clinician appears to be helpful.
Pharmacotherapy
As with psychotherapy, evidence is limited in regard to the use of pharmacotherapy for adjustment disorders (1). Antidepressant medications have been used with some success. Nevertheless, medications such as selective serotonin reuptake inhibitors are more likely to be effective if the symptoms meet criteria for a comorbid anxiety or depressive disorder. Benzodiazepines are often used to treat specific symptoms such as insomnia and anxiety in adjustment disorder, but evidence of efficacy is mixed. Further, benzodiazepine use can lead to dependence and misuse and can acutely worsen cognition. Multiple other medications and supplements have been tried without evidence for their efficacy.
Treatment reference
1. O'Donnell ML, Metcalf O, Watson L, et al: A systematic review of psychological and pharmacological treatments for adjustment disorder in adults. J Trauma Stress Jun;31(3):321-331, 2018. doi: 10.1002/jts.22295
