Merck Manual

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Adjustment Disorder

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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NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version

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 (for example, losing a job), multiple events (for example, both financial and romantic setbacks), or ongoing problems (for example, 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

A person may have several manifestations. 

There also is an increased risk of suicide attempts and completed suicide.

Diagnosis

  • A doctor's evaluation based on specific criteria

Doctors base the diagnosis on criteria recommended by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

People must have

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

Symptoms must be clinically significant as shown by one or more 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

People who have impairment or marked distress following a traumatic event but without meeting criteria for posttraumatic stress disorder or acute stress disorder may be diagnosed with an adjustment disorder.

Treatment

  • Self-care
  • Psychotherapy

  • Sometimes drugs to treat certain symptoms

Adjustment disorders must be thoroughly evaluated and treated. However, there is limited evidence supporting any particular treatment for adjustment disorders. A wide variety of individual and group psychotherapies, including brief psychotherapy, cognitive-behavioral therapy, and supportive psychotherapy, have been used successfully (see Treatment of Mental Illness: Psychotherapy). It is not uncommon for therapy to target a specific issue, such as grief. 

Drugs are often used to treat symptoms such as insomnia, anxiety, and depression.

Self-care

Self-care is crucial during and after a crisis or trauma. Self-care can be divided into three 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. Everyone should try to maintain a healthy schedule of eating, sleeping, and exercise. Drugs that sedate and intoxicate (for example, alcohol) should be used sparingly, if at all.

A mindful approach to self-care aims to reduce the feelings of stress, boredom, anger, sadness, and isolation that traumatized people normally experience. If circumstances allow, at-risk individuals should make and follow a daily normal daily schedule, for example, get up, shower, get dressed, go outside and take a walk, prepare and eat regular meals.

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

Community involvement can be crucial, even if it is difficult to maintain human connection during a crisis.

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, or 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 they can reduce the hopelessness and passivity that tends to be part of the sender's experience of trauma.

NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version
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