Adjustment Disorder

Adjustment disorder is sometimes referred to as situational depression. Unlike regular depression, the cause(s) of which may be ongoing and/or unspecified, adjustment disorder is an abnormal emotional and/or behavioral response to stressors which are present in a particular period of a person’s life, often surrounding a major life event.

For example, a person may experience stressors that give rise to adjustment disorder after a major life change, such as a breakup, divorce, marriage, having a baby or moving house, or after an unfortunate event which involves stress, such as a car accident. It is also possible to develop the condition following a career change or break, especially one which alters a person’s daily environment or routine, such as discharge from military service or becoming unemployed.

Symptoms of adjustment disorder or situational depression include:

• Psychological symptoms associated with depression, such as a depressed mood and hopelessness. These can result in behaviours such as social withdrawal and introversion, but can also, less commonly, lead to irritable mood, aggressive behavior or acting out.
• Psychological symptoms associated with anxiety, such as nervousness and worry.

These symptoms will normally begin within three months of the onset of the stressor; for example, after moving home; and last for no longer than six months after the stressor or event has ended. 1

Adjustment disorder is most common in children and adolescents, but adults may often also develop the condition. The treatment goal for adjustment disorder is to relieve the symptoms. A typical treatment programme for adjustment disorder will normally feature a course of talking therapy, such as cognitive behavioral therapy (CBT) or group therapy and may include prescription medications and prescribed exercise. 2 3

If you think you or a loved one may be experiencing symptoms of adjustment disorder, try the Ada app for a free health assessment.

The symptoms of adjustment disorder will usually appear within three months of the stressful event or life change and disappear within six months. Most commonly, adjustment disorder which does not resolve after six months may develop into depression.

Generally, the symptoms of adjustment disorder will significantly interfere with the functioning of a person's life, for example by making it difficult to socialize, work or attend school.

Symptoms of adjustment disorder may vary according to the age of the person experiencing the condition. Children and adolescents may be more likely to display behavioral symptoms, such as acting out, school problems and sleep disturbances, whereas adults often tend to experience more emotional symptoms, such as anxiety and a depressed mood. 4 5

6 subtypes of adjustment disorder can be found according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association (DSM-5). 5 6

Symptoms of adjustment disorder with depressed mood may include feelings of depression, sadness and hopelessness. People who are affected may also be highly tearful and experience frequent bouts of crying.

Symptoms of adjustment disorder with anxiety may include feelings of nervousness, apprehension and worry. People may also be excessively jittery and fearful of separation, from parents or other significant people.

A person who is affected by adjustment disorder with mixed anxiety and depressed mood will experience a mixture of the symptoms of adjustment disorder with anxiety and those of adjustment disorder with depressed mood. People with this form of the condition may be affected by different symptoms or combinations of symptoms.

A person who is affected by adjustment disorder with disturbance of conduct will experience a change in behavior. This is typically characterized by:

• A lack of respect for the rights and feelings of others
• A lack of respect for social norms and rules

A person affected by adjustment disorder with mixed disturbance of emotions and conduct may experience a combination of the possible symptoms of adjustment disorder with depressed mood, anxiety or disturbance of conduct.

In the case of adjustment disorder unspecified, a person experiences a severe reaction to a stressor, but it does not fit into any of the above categories.

Adjustment disorder is a reaction to a particular stressor, whether a stressful life event or a major life change. In both children and adults, adjustment disorder can be caused by any event which feels greatly significant to the particular person, regardless of whether or not this event appears significant to others. 7

Common stressors that may lead to adjustment disorder in a person of any age include: 8

• Giving birth
• Marriage
• Unemployment
• Retirement
• Divorce or relationship problems
• Illness and health issues
• Moving to a new house or new location
• Financial difficulties
• The death of a loved one

Common stressors that may affect a child or young adult include:

• Parental divorce or separation
• Moving to a new house, neighborhood or new town
• Problems at school, such as not being able to keep up with demands from school, changing schools or not being able to connect with peers
• Health issues and/or sexuality issues, i.e. uncertainties related to sexual orientation
• Death of a close relative or friend

There is no clear way to identify why some people develop adjustment disorder in response to a given stressor and why others do not. Factors, such as a person’s coping skills, past experiences and social skills are among many others, all thought to play a role.

A person is at greater risk of experiencing adjustment disorder than the general population if they meet any one or more of the following criteria: 9 8 10

• Being female
• Being affected by other psychological conditions
• Experiencing long-term stressors, such as financial strain, a long-term illness, having an illicit love affair or domestic problems
• Lacking a social support system
• Having experienced certain types of stress during childhood, including sexual or physical abuse, other traumatic events, frequent house moves or overprotective parenting
• Being single
• Being at a low educational level
• Living in an urban area

A diagnosis of adjustment disorder usually requires a full psychological evaluation by a psychiatrist or other mental health professional. This evaluation will typically take into account past experiences, behaviors, emotions and sources of stress, among other factors. When diagnosing children or adolescents, parents may also be present during the evaluation. 11

The key diagnostic criteria for adjustment disorder are:

• The symptoms must have begun to appear within three months of the stressor occurring
• The condition must be characterized by stress that is in excess of what would be considered normal under the circumstances and which leads to significant impairment of a person’s personal life, social functioning, their work or school performance and/or attendance
• The symptoms must be distinct from similar disorders, such as post-traumatic stress disorder (PTSD)

Although adjustment disorder and post-traumatic stress disorder (PTSD) can have overlapping symptoms, the key difference between the two conditions is their cause. Adjustment disorder is typically triggered by a stressful event or phase, but one that is within the normal everyday range of human experience, such as a marriage breakup or financial difficulty.

Conversely, PTSD is caused by an exceptional, traumatic event. This is normally one involving the threat of death, serious injury or violence to oneself, or an event which involves witnessing the same happening to a very close or loved person. Experiencing this severe threat causes retrospective feelings of extreme fear, horror and helplessness.

PTSD can also be a long-term condition that may not present itself until several months or years after the initial event. Adjustment disorder, on the other hand, must present itself within three months of the triggering event. 13

Adjustment disorder – especially the depressed mood subtype – and depression are similar conditions. To properly differentiate them, a thorough evaluation by a medical professional is needed.

One major, generally accepted difference between the two conditions is that adjustment disorder is triggered by an identifiable stressful event or phase, and this will be clear-cut and easy to pinpoint. In contrast, when depression develops, the exact causes of the condition or the current depressive episode are often unclear. Adjustment disorder will also generally be a more short-term condition. However, the same time frame could apply to a depressive episode, which makes it all the more important that a person undergoes a proper medical evaluation and receives an accurate diagnosis.

Good to know: If a person who has been diagnosed with adjustment disorder (AD) continues to experience mental distress after six months, it is likely that the AD has developed into another mental health condition, most often depression. In this event, a new diagnosis will be considered. Other conditions developing from AD are usually anticipated to be longer-lasting and to require ongoing treatment. 14 15 If you think that you, or a loved one, may be affected by depression or another mental health condition, you may begin a free symptom assessment with Ada.

The chosen treatment method for adjustment disorder will usually depend on a variety of factors, including: 16

• Age
• Severity of symptoms
• The subtype being experienced
• Specific factors contributing to the development or worsening of the condition

Taking these factors into consideration, a psychiatrist or other mental health professional will recommend a treatment route. 17 18

Individual psychotherapy may take a cognitive-behavioral therapy (CBT) approach, particularly in the U.K., buy in the U.S., other kinds of talk therapy may often be recommended, too. Because the condition is defined as short-term, this will typically be solution-focussed, short course of psychotherapy. The treatment goal is to equip the affected person to understand how to overcome adjustment disorder by teaching them techniques for dealing more effectively with their particular problem and its effects on their life.

Family therapy will generally be recommended in cases of childhood or adolescent adjustment disorder. It is designed to overcome conflicts in family life and improve communication skills among family members. It may also be useful in teaching family members how to support the child/adolescent who is experiencing adjustment disorder.

In some cases, sharing challenge and coping techniques with a group of people also experiencing the condition can equip a person to understand how to overcome adjustment disorder in a practical sense and to apply this to their own life. Group therapy can also help the person improve their communication skills and can be a useful source of support and encouragement. 19

Although supportive, solution-oriented psychotherapy is the first-line treatment for adjustment disorder, medications are sometimes additionally prescribed. 20

When medications are prescribed, they are used in order to treat specific symptoms of adjustment disorder ‒ for example, if a person is sleeping badly, is experiencing nerves or anxiety most of the time or is excessively depressed. 8 It is for this reason that medications are usually only prescribed in severe cases, are carefully evaluated by a person’s medical care team and are most likely an adjunct to rather than a replacement for talk therapy, which targets the condition’s root cause. 21

Medications which may be used in the treatment of adjustment disorder include: 8 20 21

• Antidepressants. These will usually only be prescribed if depressive symptoms are still having a major impact on a person’s life three months after beginning non-medication-based treatment for adjustment disorder.
• Benzodiazepines. These medications may help alleviate anxiety and problems sleeping in the short-term. However, they are not recommended for long-term use due to their addictive potential and should only be prescribed and taken after careful evaluation by a doctor.

Good to know: There are some herbal remedies which are being investigated for their potential effects on adjustment disorder symptoms, especially those of anxiety and insomnia. These particular herbal remedies include extracts of passiflora and valerian. However, overall, these substances have not been sufficiently scientifically researched and evaluated for their safety and efficacy to be generally recommended. Always consult a doctor before using any type of herbal preparation, as they may not be safe for particular people or in combination with certain medications. 20

There is no known way to prevent the onset of adjustment disorder. Identifying the condition early and seeking professional help can be effective in reducing the severity of adjustment disorder and improving general wellbeing, however.

Q: What happens if adjustment disorder lasts longer than six months?
A: The time frame of adjustment disorder is variable. The condition <em>usually</em> develops some time after a stressful life event and gets better within six months of the stressor ending. 22 While this is the time frame referred to in most diagnostic manuals, others accept that some of the symptoms may persist longer, especially if the condition is caused by an ongoing stressor. Therefore, it is important to note that a person may be affected by the condition for longer than the usual time frame if the causal stressor is chronic, i.e. has long-term consequences or is itself long-lasting, for example unemployment or a severe, long lasting medical condition. 23 Adjustment disorder which is longer-lasting than usual is sometimes referred to as chronic adjustment disorder.

Q: Am I entitled to compensation if I need to take time off work due to adjustment disorder?
A: People who experience adjustment disorder and are in a paid position may be entitled to paid sick leave ‒ a kind of compensation ‒ if their condition is severe enough to warrant time off work for them to get better medically.

Q: Is there a diagnostic test for adjustment disorder?
A: Although various diagnostic questionnaires have been developed and trialed as possible screening tools for detecting adjustment disorder, i.e. the Adjustment Disorder New Module 20 Questionnaire, the idea of using a diagnostic test is not universally-accepted as a necessary part of the diagnostic process. Currently, the condition is usually diagnosed by considering the symptoms themselves, their timeline and the specific cause(s) of a person’s symptoms.