Adjustment Disorder

When a stressful event in someone's life prompts a lengthy and extremely or excessively negative reaction, that person can be considered to be suffering from adjustment disorder, which is typified by anxiety, difficulty moving forward, and reckless behavior.

Adjustment disorder, sometimes referred to as situational depression, is an abnormal and excessive reaction to an identifiable life stressor. The reaction is more severe than would normally be expected and can result in significant impairment in social, occupational, or academic functioning.

The extreme response may be linked to a single event—a flood or fire, marriage, divorce, starting school, losing a job or starting a new job—or to the concurrence of multiple events, such as marital problems coinciding with difficult business challenges. Stressors may be recurrent events, such as a child repeatedly witnessing his or her parents fighting, or continuous, such as living in a crime-ridden neighborhood.

Adjustment disorder often brings on depressed mood, anxiety, norm-violating or inappropriate conduct, or other maladaptive reactions such as problems at work or school, physical complaints, or social isolation.

Adjustment disorder is associated with increased risk of suicidal behavior and substance abuse, as well as the prolonging of medical disorders or interference with medical treatment. When it persists, it may progress into a more severe condition such as major depressive disorder.

Adjustment disorders are common; the percentage of individuals receiving outpatient mental health treatment whose principal diagnosis is adjustment disorder ranges from 5 to 20 percent. In hospital psychiatric consultation settings, it may be the most common diagnosis, frequently approaching 50 percent.

Symptoms

Adjustment disorder involves the development of emotional or behavioral symptoms in response to an identifiable stressor (or stressors) occurring within three months of the onset of the stressor and lasting no longer than six months after the stressor has ended.

According to the DSM-5, the symptoms or behaviors must be clinically significant, typically evidenced by one or both of the following:

  1. Marked distress out of proportion to the severity or intensity of the stressor, taking into account the external context and cultural factors that might influence symptom severity and presentation.
  2. Significant impairment of social, occupational, or other important areas of functioning.

The distress or impairment associated with adjustment disorders frequently manifests in decreased performance at work or school, or in temporary changes in social relationships. Further, the stress-related disturbance does not meet the criteria for another mental disorder and is not merely an exacerbation of a pre-existing disorder. The symptoms also must not represent normal bereavement.

Adjustment disorder symptoms can vary widely, though, and one challenge to diagnosis is that the person experiencing the symptoms may not be aware of the stressor which brought on the disturbance. Individuals from disadvantaged circumstances tend to experience higher rates of stressors and may be at higher risk for adjustment disorders.

Causes

Adjustment disorder is caused by one or more life stressors. In adults, these stressors are most commonly related to marital discord, finances, or work. In adolescents, common stressors include school problems, family or parents' marital problems, or issues around sexuality. Other types of stressors include the death of a loved one, life changes, unexpected catastrophes, and medical conditions (such as cancer) and their subsequent treatments.

Factors that influence how well a person reacts to stress may include economic conditions, as well as the availability of social supports and occupational and recreational opportunities. Factors leading an individual to be more susceptible to stressors include social skills, intelligence, genetics, and mastery of existing coping strategies.

Treatment

The primary goal of treatment for adjustment disorder is to relieve symptoms and to help an individual achieve a level of functioning comparable to what they demonstrated prior to the stressful event.

Recommended treatments include individual psychotherapy, family therapy, behavior therapy, and self-help groups. Realistic short-term goals should be established at the start of therapy, as the course of adjustment disorder tends to be short-term in nature.

Goals of therapy will often center around recognizing and taking advantage of the social supports available to an individual in the form of family, friends, and community. The individual's coping and problem-solving skills will be explored and developed. Relaxation techniques might be explored to deal with feelings of stress. Treatment will include eliciting the patient's concern and helping the individual understand his or her role in the stressors, reviewing and reinforcing any positive steps the patient may have already taken to deal with the stressors, teaching additional ways to cope with or avoid future stressors, helping the individual put stressors in perspective to their life overall, helping the person better understand his or her reaction to the stressors, and helping the patient come to perceive stressors as an opportunity for positive change or improvement.

Family therapy, as well as effective communication and coping skills, may be recommended when the patient is a child or adolescent. When medication is used, it is typically in addition to psychotherapy. Treatment of adjustment disorder typically excludes the use of prescription medications, but in some cases, medication may be helpful in easing the depression or the anxiety associated with the disorder.

Most people recover from adjustment disorder without any remaining symptoms if they have no previous history of mental illness and have access to stable social support. Individuals suffering from adjustment disorder should work to develop and maintain a healthy diet and sleep pattern, as well as a strong social support system.

References

  • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • National Cancer Institute
  • National Institutes of Health
  • Pelkonen, M., Marttunen, M., Henriksson, M., & Lönnqvist, J. (2005). Suicidality in adjustment disorder. European child & adolescent psychiatry, 14(3), 174-180.

Last reviewed 02/26/2019