Everyone has stress in their lives. But for some people, a specific traumatic episode or major life change can lead to a mental health problem called adjustment disorder.
“When the severity of this stress-related event causes a disturbance in your normal daily functioning, it can become identified as an adjustment disorder,” says Awstin Gregg, senior vice president and behavioral health expert and therapist at Vertava Health, a national behavioral health care system for mental health and substance use conditions headquartered in Nashville, Tennessee.
Justin Baker, clinical director of the Suicide and Trauma Reduction Initiative for Veterans and assistant professor of research in the department of psychiatry and behavioral health at the Ohio State University in Columbus, says that adjustment disorder is defined in the “Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition” (DSM-5) as “the presence of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within three months of the onset of the stressor(s).”
This distress is “over and above what would be typically expected when considering the severity or intensity of the stressor,” he explains. He cites two classic examples:
— College students sometimes have difficulty adjusting to the stressors of their first year of college.
— Military service members may experience difficulties adjusting to being in the military.
As the definition notes, adjustment disorders occur in response to a stressful life situation such as:
— A job loss.
— Relationship disruption or family conflict.
— Legal difficulties.
— Financial problems.
— Illness or chronic disease.
— Major life changes.
Gregg adds that “adjustment disorders are predominantly diagnosed in children and adolescents, as they’re in a more vulnerable stage of development. However, adults are also routinely affected by adjustment disorders.”
“The most commonly reported stressor that precedes the onset of an adjustment disorder is relationship difficulty, typically a recent breakup,” Baker says.
However, adjustment to military life can be a major reason some people develop an adjustment disorder, and that’s a big area of focus for Baker.
“Adjustment disorder is a highly prevalent disorder diagnosed in the military,” he says, for a variety of reasons, not least of which is that “providers within the military health system tend to be more conservative in their diagnostic approach with active duty military members. Disorders like PTSD, depression and anxiety are disorders that qualify a service member for a potential medical evaluation board (review) that could result in the military member being medically retired and/or separated from service. Adjustment disorder typically doesn’t qualify as a disorder warranting a medical board, so providers may initially diagnose an adjustment disorder until they have sufficient evidence to ‘upgrade’ the disorder to a more severe diagnosis.”
The problem with this approach is that for the period that the person with anxiety or depression is being treated for an adjustment disorder, they’re not getting the optimal treatment for what’s really going on with them, he says. “This potentially leads to the service members receiving misaligned care, as the provider may be hesitant to initiate more aggressive treatment approaches with the service member when diagnosing adjustment disorder instead of another more severe diagnosis.”
A Sometimes-Difficult Diagnosis to Make
Though it’s now considered a cousin to more widely known post-traumatic stress disorder, adjustment disorder first appeared in the DSM-3 in 1980, Baker explains. “Prior to this, adjustment disorder went by the name of ‘transient situational disturbances’ in the DSM-2, and ‘transient situational personality disorder’ in DSM-1.”
In 2013, with the publication of the DSM-5, the current version of the diagnostic manual that clinicians use to guide identification and treatment of mental health disorders, adjustment disorder “was moved from its own category to the stressor- and trauma-related disorders section, where other diagnoses include post-traumatic stress disorder and acute stress disorder. This highlights its similarity to these disorders and an emotional distress response to a specified stressor,” Baker says.
He adds that it’s not always clear whether a patient has adjustment disorder or another mental health concern, because “the disorder actually lacks specific symptoms or criteria, as do other disorders listed in the DSM-5. The only requirement for an adjustment disorder diagnosis is that symptom onset is preceded by a stressor.”
This lack of specificity means that “providers typically utilize a diagnosis of adjustment disorder as a less severe form of PTSD, depression or anxiety,” Baker says.
Gregg adds that the most identifiable sign of an adjustment disorder tends to be alterations in typical daily functioning. “For example, someone who has a strong track record of punctuality begins to show up late or call out of work consistently, or a student who you notice has oddly begun neglecting their daily hygiene. These are significant indicators that someone might have experienced a stressful event that has led to them struggling to adjust.”
These signs “look very similar to the signs accompanying depression and anxiety,” Gregg adds, and may include:
— Somber or depressed mood.
— Feelings of hopelessness.
— Increased worry or fear.
— Decreased awareness of personal boundaries of self and/or others.
— Abnormal fluctuations in appetite.
— Withdrawing from social supports.
— Avoiding important things.
— Suicidal thoughts or behaviors, in the most severe cases.
Because adjustment disorder is not well delineated, that makes it difficult to study, too, Baker says. “However, with the research that has been done, individuals with an adjustment disorder diagnosis often experience a poorer quality of life, higher anxiety and report more depressive symptoms than those without a mental health diagnosis,” Baker says. These symptoms are generally “less severe than those who meet full criteria for PTSD, depression or generalized anxiety disorder.”
But beware: Though it’s often thought of as a less severe form of PTSD or anxiety disorder, in some cases, people with adjustment disorder may actually attempt suicide “on average sooner than those diagnosed with a major depressive disorder,” Baker says. “These suicide attempts also tended to be made more impulsively.”
Treatment of Adjustment Disorder
Baker says that while research into adjustment disorder is slim, therapy and psychotherapy are usually the go-to approaches for treating it. “Brief psychological therapy likely receives the best support and can consist of supportive counseling and psychoeducational, as well as more robust cognitive behavioral or psychodynamic approaches of therapy for the treatment of adjustment disorder.”
Gregg adds that a combination of therapy and medication management can help you get back to “your average level of functioning. The emotional support that a therapist offers can help you better understand what an adjustment disorder is and how you’re specifically responding to it.”
Adding mood stabilizers, antidepressants or anxiety medications “can help regulate thinking and aid in your ability to feel like yourself again. Both therapy and medication management can be effective treatment strategies by themselves but will be more successful when utilized together.”
The good news with adjustment disorder, though, is that it’s “typically short-lived,” Gregg adds. “This disorder doesn’t usually last more than six months in most cases and can be preventable in many ways,” including:
— Developing a solid support system and network of friends or confidants.
— Working to maintain a sense of optimism and humor in difficult times.
— Establishing positive self-esteem.
With these supports in place, the adverse effects that lead to an adjustment disorder are less likely to take hold. These factors can also be the differentiating reasons why some people develop these disorders while others don’t. “Your social skills, ability to cope with stressful events and the methods you attempt to cope” with a stressful event, can all keep you healthier no matter what challenges you face, Gregg says.
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