At some point in their life, everyone experiences especially large changes that can be stressful, even traumatic. Whether or not it is something we have experienced before, it is often difficult to immediately return to a normal state of thinking and living afterwards. Most people experience some amount of difficulty in emotionally regulating themselves after a stressful or traumatic event, and this is what we typically understand as grieving, coping, etc. Adjustment disorder is associated with that period shortly following a stressful event in which people’s emotional state is altered. However, adjustment disorder symptomatology is much more severe than the typical emotional and behavioral changes we might expect someone to demonstrate following a challenging experience. Adjustment disorder is a common psychiatric concern that is not widely known and is often misunderstood even in those who have heard of it. Despite its relative lack of recognition in comparison to more popular mental illnesses like depression and anxiety, adjustment disorder also requires assessment and treatment from a mental health professional as it can lead to more serious consequences if left untreated. In this blog, we discuss adjustment disorder: what it is, its symptomatology, and how it can be treated.
What is Adjustment Disorder?
Originally referred to as “Transient Situational Personality Disorder” by the DSM-1 (1952), adjustment disorder is a mental illness that involves an intense emotional and/or behavioral response to a significant, stressful event in a person’s life. Most notably, it is characterized by a response that is considered exceedingly unhealthy, disproportionate, or abnormal to the event that caused it. Adjustment disorder in the DSM-5 is categorized as one of the seven Trauma- and Stressor-Related Disorders and has six subtypes. They are listed below followed by their verbatim distinctions as reported in the DSM-5.
- Adjustment disorder with depressed mood: Low mood, tearfulness, or feelings of hopeless are predominant
- Adjustment disorder with anxiety: Nervousness, worry, jitteriness, or separation anxiety is predominant
- Adjustment disorder with mixed anxiety and depressed mood: A combination of depression and anxiety is predominant
- Adjustment disorder with disturbance of conduct: Disturbance of conduct is predominant
- Adjustment disorder with mixed disturbance of emotions and conduct: Both emotional symptoms (e.g., depression, anxiety) and a disturbance of conduct are predominant
- Unspecified adjustment disorder: For maladaptive reactions that are not classifiable as one of the specific subtypes of adjustment disorder
Of the limited demographic data that has been gathered for adjustment disorder, prevalence rates generally fall between 11% and 18%, although it is estimated that it is largely under-reported in most populations given its short-term nature. One study aimed at assessing the prevalence and risk factors of adjustment disorder found the following factors to be associated with higher rates of adjustment disorder: young age, low educational level, a single relationship status, being a student, and coming from urban areas. Additionally, the study found adjustment disorder with mixed anxiety and depressed mood to be the most common subtype and the most common stressors were illness, love affairs, and domestic problems.
”Adjustment disorder affects people of all ages, but is most commonly diagnosed in children and adolescents. Although the onset of adjustment disorder symptomatology is most often brought about by significant, negative experiences, it is ultimately the result of a large change in a person’s life, and therefore, can be caused by positive events as well.
Dr. Kirsten ThompsonFounder, CEO & Supervising Psychiatrist
Examples of common experiences that could contribute to the onset of adjustment disorder are:
- Death of a loved one
- Personal or approximate (i.e. parents) relationship issues, such as infidelity, breakups, or divorce
- Getting married
- Having a baby or birth of a sibling
- Moving to a new city
- Financial difficulties
- Work issues, such as toxic culture, unkind boss, loss job
- Retiring or changing careers
- Academic struggles
- Natural disasters and pandemics
In both the ICD-10 and DSM-5, adjustment disorder is one of the few disorders that consider the potential cause of the disorder in its diagnosis. A key characteristic of adjustment disorder is that it can largely be attributed to a specific, identifiable stressor or event. However, the biological cause of it is still poorly researched. As with most other disorders that involve changes in mood, chemical imbalances of the neurotransmitters involved in feelings of joy, contentment, excitement, and motivation, such as dopamine and serotonin, are thought to contribute to the emotional distress and behavioral changes exhibited by those with adjustment disorder. Another explanation provided by the limited research that has been done on adjustment disorder is that those who have family members with mental illnesses are at a greater risk for developing adjustment disorder following a significant change in their life. This is because inherited genes, learned behavior, personality, temperament, and life-experiences can significantly impact one’s emotional sensitivity and resiliency.
Adjustment Disorder Symptoms
The range of the symptoms a person with adjustment disorder could experience is extensive since symptomatology can vary depending on which subtype the disorder manifests as. Additionally, it is important to note that adjustment disorders present themselves differently in children than they do in adults. Signs of adjustment disorder in children tend to involve more behavioral symptoms, such as acting recklessly or abusing substances. In contrast, signs of adjustment disorder in adults tend to involve more emotional – especially depressive – symptoms, such as crying easily or experiencing suicidal ideation. Although there are certain distinctions between the subtypes of adjustment disorder, they are all still closely related and ultimately stem from the same root – an abnormally aversive reaction to stress and change. Commonly seen physical symptoms across the subtypes are:
- Body aches and soreness
- Headaches and migraines
- Stomach pain
- Feeling ill
- Racing heart
- Sweaty hands
Commonly seen emotional and behavioral symptoms across the subtypes are:
- Trouble concentrating
- Emotionally sensitive or crying easily
- Frequently feeling anxious or irritated
- Frequently feeling trapped or hopeless
- Lack of motivation to carry out daily functions, such as showering or making food
- Changes in eating patterns
- Socially isolating and/or lacking the energy to be in social settings
- Behaving in a more rebellious, reckless, impulsive, or self-destructive manner
- Substance abuse, such as alcohol or drugs
- Experiencing suicidal ideation
Diagnostic Criteria and Treatment of Adjustment Disorder
Given its typically temporary nature, adjustment disorder is often misunderstood as more severe than normal behavior, but less severe than full-scale mood disorders, such as Major Depressive Disorder. This, of course, is largely incorrect. As detailed by the diagnostic criteria below, adjustment disorder takes a significant emotional toll on a person, and more often than not, disrupts their ability to participate in day-to-day activities. According to the DSM-5, the diagnostic criteria for adjustment disorder includes the following:
- The development of emotional or behavioral symptoms in response to an identifiable stressor(s) within 3 months of the onset of the stressor(s)
- Symptoms must be clinically significant, which involves demonstrating one or both of the following:
- Distress that is out of proportion to the severity or intensity of the stressor*
- Significant impairment in social, occupational, or other important areas of functioning
- The stress-related disturbance does not meet the criteria for another mental disorder and is not an exacerbation of a preexisting mental disorder
- The symptoms do not represent normal grieving
- Once the stressor (or its consequences) have ended, the symptoms do not persist for more than an additional 6 months
- Specify if symptomatology aligns with any of 6 subtypes (listed above)
* (As with all assessment and diagnosis, mental health providers should account for a person’s cultural background to best determine if their response to a stressor is excessive and/or inappropriate).
Although it is no longer a specified diagnostic criteria (not included in the transition from DSM-4 to DSM-5), the duration of a person’s symptoms can be used to describe their condition as acute or chronic adjustment disorder. Those with acute adjustment disorder exhibit signs and symptoms for six months or less, while the signs and symptoms in those with chronic adjustment disorder last longer than six months. Demonstrating characteristics of chronic adjustment disorder may prompt your mental health provider to reassess your mental and emotional condition for another psychiatric disorder, such as Post-Traumatic Stress Disorder (PTSD) which is another Trauma- and Stressor-Related Disorder defined by the DSM-5.
Treatment options for adjustment disorder are ample and should be utilized as soon as possible to avoid the risk of developing psychiatric comorbidities. The two most common forms of treatment for adjustment disorder are psychotherapy (talk therapy) and medications. Other types of treatment include support groups and family therapy, especially in cases of adjustment disorder in young children and adolescents. Most often, a person’s treatment plan for adjustment disorder involves a combination of methods. In psychotherapy, a patient can learn and practice coping mechanisms in a safe, controlled environment with their therapist as a guide. A person may also use psychotherapy to develop a routine with their therapist that can help them regain a sense of normalcy after the stressor/event left them with unregulated emotions and behaviors. If the patient’s case of adjustment disorder is especially severe, medications like anti-anxiety or antidepressant drugs may help a person reach a mental and emotional state that is more readily able to benefit from psychotherapy. Forms of therapy that involve more than the patient with the disorder, like family therapy and support groups, are useful in providing a person with adjustment disorder the external support that could make recovery easier for them.