Adjustment disorders involve emotional and/or behavioral symptoms in response to an identifiable stressor. Diagnosis is based on clinical criteria. Treatment focuses on self-care; psychotherapy and pharmacotherapy may have a role but evidence is limited.
Adjustment disorders are common and are present in an estimated 5 to 20% of patients making outpatient mental health visits (1). Population-based prevalence estimates are few and use varying criteria, but they suggest a widely ranging prevalence ranging from 1 to 17% (2).
A stressor that leads to an adjustment disorder may be a single, discrete event (eg, losing a job), multiple events (eg, a series of financial problems or romantic setbacks), a common developmental milestone (eg, becoming a parent), or an ongoing set of problems (eg, caring for a disabled family member). The stressor may impact just 1 individual, an entire family, or a large group of people.
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 or is not better categorized as prolonged grief disorder.
General references
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed,Text Revision. American Psychiatric Association Publishing; 2022.
2. Shevlin M, Hyland P, Ben-Ezra M, et al. Measuring ICD-11 adjustment disorder: the development and initial validation of the International Adjustment Disorder Questionnaire. Acta Psychiatr Scand. 2020;141(3):265-274. doi:10.1111/acps.13126
Symptoms and Signs of Adjustment Disorders
Symptoms of an adjustment disorder typically begin within days of the stressful event and resolve within 6 months of the termination of the stressor and its consequences. There are 3 categories of adjustment disorder symptoms: depressed mood, anxiety, and conduct disturbance. Some patients may present with 1 of these symptoms being particularly prominent (eg, feeling nervous and jittery after a physical assault; behaving with uncharacteristic aggression in the context of a parental divorce), but most patients present with a mixture of symptoms.
Criteria for adjustment disorder are less specific than for either acute stress disorder or posttraumatic stress disorder, and it is a common diagnosis in both inpatient and outpatient psychiatric settings. While sometimes viewed by clinicians as a "mild" psychiatric diagnosis, adjustment disorder is associated with significant distress and/or disability.
Patients with adjustment disorder also have an increased risk of suicide attempts and completed suicide (1). (See also Suicidal Behavior.)
Symptoms and signs reference
1. Casey P, Jabbar F, O'Leary E,et al. Suicidal behaviours in adjustment disorder and depressive episode. J Affect Disord. 2015 Mar 15;174:441-6. doi: 10.1016/j.jad.2014.12.003
Diagnosis of Adjustment Disorders
Psychiatric assessment
According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria, patients must have emotional or behavioral symptoms within 3 months of having been exposed to a stressor that do not continue for more than 6 months after the stressor has terminated (1).
Symptoms must be clinically significant as shown by one or both 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, occupational, or other important areas of functioning
The symptoms do not meet the criteria for another psychiatric disorder (such as major depressive disorder) and are not better explained by normal bereavement, prolonged grief disorder, or an exacerbation of another psychiatric disorder
Posttraumatic stress disorder (PTSD) and acute stress disorder are part of the differential diagnosis, but they have different time frames and more specific descriptors of the stressors and the patient's response.
The DSM-5-TR encourages the use of clinical judgment to make the diagnosis. For example, a patient who has developed depressive symptoms in the aftermath of a stressor may be diagnosed with an adjustment disorder (with depressive features), major depressive disorder, or normal and culturally appropriate grief.
The term adjustment disorder has often been misused by clinicians as a general term for a clinical picture that is nonspecific and relatively mild. As a result, the DSM-5-TR has included adjustment disorder in the chapter on trauma to highlight the fact that the symptoms must be in response to a stressor. Nevertheless, the clinical picture is often heterogenous (eg, with symptoms of anxiety, depression, and/or conduct issues), and the diagnosis remains one of the most common in both inpatient and outpatient settings (2). While such heterogeneity may be clinically reasonable, it complicates the approach to treatment.
Diagnosis references
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed,Text Revision. American Psychiatric Association Publishing; 2022.
2. Morgan MA, Kelber MS, Bellanti DM, et al. Outcomes and prognosis of adjustment disorder in adults: A systematic review. J Psychiatr Res. 2022;156:498-510. doi:10.1016/j.jpsychires.2022.10.052
Treatment of Adjustment Disorders
Self-care
Sometimes psychotherapy
Sometimes pharmacotherapy
Safety and self-care are important for successful recovery from adjustment disorder. Treatment is difficult if the stressful event is recurring and if the surrounding conditions remain unsafe. Other interventions are much more likely to be helpful if the patient with an adjustment disorder is living within an intact family and a healthy social system. Patients usually recover from an adjustment disorder over time and with the help of friends and family.
Although psychotherapy and medications may be used, there are limited data to support their efficacy (1).
Self-care
Self-care is crucial during and after a significant stressor. Self-care includes attention to personal safety, physical health, mindfulness, and maintenance, when feasible, of a daily schedule and community involvement.
Psychotherapy
Evidence to support the use of psychotherapy for adjustment disorder is limited (1), partly because of the heterogeneity of the disorder. However, data suggest benefit for various individual and group psychotherapies among subpopulations of patients with adjustment disorder. These interventions include cognitive-behavioral therapy, psychodynamic psychotherapy, family therapy, interpersonal therapy, and supportive psychotherapy. Some of these treatments have targeted specific elements of the adjustment disorder, such as grief, trauma, and role transitions, while other approaches appear to be more generalized. If psychotherapy is used, having a sensitive, trauma-informed clinician appears to be helpful.
Pharmacotherapy
As with psychotherapy, evidence is limited in regard to the use of pharmacotherapy for adjustment disorders (1). Antidepressant medications have been used with some success. Note that medications such as selective serotonin reuptake inhibitors have a stronger evidence base if the diagnosis is ultimately an anxiety or depressive disorder rather than an adjustment disorder. Benzodiazepines are often used to treat specific symptoms such as insomnia and anxiety in adjustment disorder, but evidence of efficacy is mixed. Further, benzodiazepine use can lead to dependence and misuse and can acutely worsen cognition. Multiple other medications and supplements have been tried, without evidence of efficacy.
Treatment reference
1. O'Donnell ML, Metcalf O, Watson L, et al. A systematic review of psychological and pharmacological treatments for adjustment disorder in adults. J Trauma Stress. Jun;31(3):321-331, 2018. doi: 10.1002/jts.22295
