Adjustment Disorder
Adjustment disorder, sometimes referred to as situational depression, is a lengthy, abnormal, and excessively negative 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. Adjustment disorder is typified by symptoms such as depression, anxiety, difficulty moving past the stressful event, and reckless behavior.
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.
In addition to its common symptoms of depression, anxiety, or reckless behavior, adjustment disorder is also associated with an increased risk of suicidal behavior and substance abuse, as well as the prolonging of medical disorders or interference with medical treatment. When adjustment disorder persists, it may progress into a more severe condition such as major depressive disorder.
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. These symptoms may include:
- depressed mood
- anxiety
- lack of appetite
- difficulty concentrating
- norm-violating or inappropriate conduct (getting into fights, driving recklessly, etc.)
- problems at work or school
- physical complaints, such as jitteriness or fatigue
- social isolation or withdrawal from normal activities
- suicidal ideation
According to the DSM-5, the symptoms or behaviors must be clinically significant, typically evidenced by one or both of the following:
- 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.
- 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. One challenge to diagnosis is that the person experiencing the symptoms may not be aware of the specific stressor that brought on the disturbance. Thus, diagnosis usually requires a clinical interview that encompasses recent stressors, a history of mental health or medical issues, and the individual's current ability to function in day-to-day life.
Adjustment disorders are thought to be relatively common. According to the DSM-5, between 5 and 20 percent of those in outpatient mental health treatment can be diagnosed with adjustment disorder. In in-hospital psychiatric settings, it is an even more common diagnosis, sometimes approaching 50 percent.
Adjustment disorder appears to be equally prevalent in both males and females.
Children and teens with adjustment disorders tend to display more negative behavioral symptoms, such as disobeying authority figures or getting into fights; they may also be more prone to physical symptoms such as stomachaches. Adults with adjustment disorder, by contrast, tend to be more prone to depressive symptoms.
By definition, adjustment disorder symptoms should last for no longer than six months after the stressor has ended. If symptoms persist beyond that mark, a different diagnosis such as depression may be warranted.
Adjustment disorder is caused by one or more life stressors. In adults, these stressors are most commonly related to marital discord, finances, or problems at work. In adolescents, common stressors include academic or social challenges, family discord or parents' marital problems, or issues around sexuality. Other types of stressors include the death of a loved one, life changes, unexpected catastrophes or natural disasters, 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 support and occupational and recreational opportunities. Factors leading an individual to be more or less susceptible to stressors include social skills, intelligence, genetics, and mastery of existing coping strategies.
Genetics are theorized to play some role in adjustment disorder, as they may influence how an individual responds to stress. However, adjustment disorders are not due to genetics alone, and are instead a complex interaction between environmental, psychological, and biological factors.
Individuals of any age, gender, and socioeconomic background can develop adjustment disorder. However, the DSM-5 notes that individuals from disadvantaged circumstances tend to experience higher rates of stressors and may thus be at higher risk for adjustment disorders.
Recommended treatments for adjustment disorder include individual psychotherapy, family therapy, behavior therapy, group therapy, and self-help groups. 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.
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. These goals 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 also 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.
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.
Treatment of adjustment disorder does not typically call for the use of prescription medications, but in some cases, medication may be helpful in easing the depression or the anxiety associated with the disorder. When medication is used, it is almost always in addition to psychotherapy.