Merck Manual

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Adjustment Disorders

By

John W. Barnhill

, MD, Weill Cornell Medical College and New York Presbyterian Hospital

Last full review/revision Apr 2020| Content last modified Apr 2020
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Adjustment disorders involve markedly distressing and impairing emotional and/or behavioral symptoms caused by an identifiable stressor.

People often become sad, angry, or otherwise upset when unpleasant things happen. Such reactions are not considered a disorder unless the reaction is more intense than what is typically expected in the person's culture, or when the person's ability to function is significantly impaired.

Stressors may be a single, discrete event (eg, losing a job), multiple events (eg, both financial and romantic setbacks), or ongoing problems (eg, caring for a significantly disabled family member). Stressors do not have to be overwhelming traumatic events as in posttraumatic stress disorder (PTSD).

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.

Adjustment disorders are common and are present in an estimated 5 to 20% of outpatient mental health visits.

Symptoms and Signs

Symptoms of an adjustment disorder typically begin shortly after the stressful event and do not continue beyond 6 months after the stressor has stopped.

There are many manifestations of an adjustment disorder, common ones include

  • Depressed mood

  • Anxiety

  • Misconduct

Patients may have several manifestations.

There also is an increased risk of suicide attempts and completed suicide (see Suicidal Behavior).

Diagnosis

  • Clinical criteria

Diagnosis is based on criteria recommended by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Patients must have

  • Emotional or behavioral symptoms within 3 months of having been exposed to a stressor

Symptoms must be clinically significant as shown by ≥ 1 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 or occupational functioning

Posttraumatic stress disorder (PTSD) and acute stress disorder are part of the differential diagnosis but have different time frames and more specific descriptors of the stressors and the patient's response. Patients who have impairment or marked distress following a traumatic event but without meeting criteria for PTSD or acute stress disorder may be diagnosed with an adjustment disorder.

Treatment

  • Self-care
  • Psychotherapy

Adjustment disorders are distressing and can be associated with elevated rates of suicidality. They warrant a thorough evaluation and solid treatment plan. At the same time, there is limited evidence for any particular treatment for adjustment disorders. Clinicians have successfully worked with a wide variety of individual and group psychotherapies, including brief psychotherapy, cognitive behavioral therapy, and supportive psychotherapy. Other clinicians have developed psychological interventions that target specific issues, such as grief.

Evidence is lacking in regards to the pharmacologic management of adjustment disorders. Benzodiazepines are often used to treat symptoms such as insomnia and anxiety, but benzodiazepines can also worsen the course of acute stress disorder and posttraumatic stress disorder. Clinicians may also target subsyndromal depression and anxiety with selective serotonin reuptake inhibitors, but, again, evidence is lacking for this approach.

Self-care

Self-care is crucial during and after a crisis or trauma. Self-care can be divided into 3 components:

  • Personal safety

  • Physical health

  • Mindfulness

Personal safety is fundamental. After a single traumatic episode, 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. Drugs that sedate 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 normally experience. If circumstances allow, at-risk individuals should make and follow a normal daily schedule, for example, get up, shower, get dressed, go outside and take a walk, prepare and eat regular meals.

Community involvement can be crucial, even if maintenance of human connection is difficult during a crisis.

It is useful to practice familiar hobbies as well as activities that sound fun and distracting: draw a picture, watch a movie, cook.

Stretching and exercise are terrific, but it can be equally helpful to sit still and count one's own breaths or listen carefully for surrounding sounds. People can become preoccupied with the trauma or crisis, and so it is useful to choose to think of other things: read a novel or get engaged with a puzzle. Unpleasant emotions may typically feel "frozen" during and after a trauma, and it can be a relief to find activities that shift the feeling state: laugh, watch a fun movie, do something silly, draw with crayons.

Under stress, people can become short-tempered, even with people they care about. Spontaneous kindness can be a win/win solution for everyone: sending a nice note, making someone cookies, and offering up a smile may not only be a nice surprise for the recipient, but such actions can reduce the hopelessness and passivity that tend to be part of the sender's experience of trauma.

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