While many mental health conditions take years to develop, there are some instances where a person experiences a major life event — a death, a diagnosis, a sudden change in their life, or a loss of something that has always been there for them — and the emotional response to that event is greater than a person’s ability to cope with it.
This is known as adjustment disorder, which is a clinical diagnosis of an emotional response to a known stressor that has disrupted the person’s ability to function, and typically does not resolve on its own. In many cases, during a situation like this, the person will turn to alcohol or substances as their coping mechanism, which then creates an additional problem on its own. At All In Solutions, we treat adjustment disorders and substance use together.
What Is Adjustment Disorder?
As defined by the DSM-5, an adjustment disorder (also referred to in earlier editions as adjustment reaction) is a mental illness defined by the development of emotional or behavioral symptoms like anxiety or depression directly resulting from the experience of a specific identifiable stressor, which has led to significant distress or impairment in the patient’s normal day-to-day functioning.[1] Essentially, an adjustment disorder is an emotional or behavioral response to a significant life event in which the person’s response exceeds their ability to cope, and they now need help. It is important to understand that this is not a character defect or over-reacting, but a clinical diagnosis which responds well to treatment.
An adjustment disorder is unlike a typical normal stress response because it creates a level of distress or impairment that is greater than what is experienced following a normal stressor.[2] It is also different from major depressive disorder or post-traumatic stress disorder (PTSD) due to the fact that it results from a specific, identifiable stressor and typically resolves once the stressor is removed or the patient develops healthy coping skills, though this is not always the case.
Adjustment Reaction in the DSM-5
To qualify for an adjustment disorder diagnosis according to the DSM-5, the following criteria must be met:
- Development of emotional or behavioral symptoms within three months of experiencing a specific identifiable stressor
- Distress that is significantly greater than the severity of the stressor, or creating significant impairment in daily living
- Symptoms do not fit the criteria for any other mental health disorder and are not a typical grief reaction
- Symptoms typically resolve within six months of the identified stressor being removed or its consequences coming to an end (however, chronic adjustment disorder can also occur if ongoing stressors are present)
Types of Adjustment Disorders
The following are the six adjustment disorder types as defined in the DSM-5 based on the predominant symptom pattern:
- Adjustment disorder with depressed mood — Symptoms include sadness, crying, and hopelessness in response to the stressor.
- Adjustment disorder with anxiety — Symptoms include worry, nervousness, and hypervigilance.
- Adjustment disorder with mixed anxiety and depressed mood — Symptoms include both anxiety and depressive symptoms.
- Adjustment disorder with disturbance of conduct — Symptoms include behavior issues such as impulsivity, recklessness, or other conduct issues.
- Adjustment disorder with mixed disturbance of emotions and conduct — Both emotional and behavioral symptoms present.
- Unspecified adjustment disorder — Symptoms present do not fit within the five defined categories above.
What Causes An Adjustment Disorder?
Adjustment disorders are reactions caused by stressful events which a person cannot handle with their usual coping methods.
Common triggers include:
- Death of a loved one (when the response does not meet criteria for prolonged grief disorder)
- Divorce or separation
- Job loss or changes in work situation or career
- Illness or medical conditions in oneself or a family member
- Financial problems
- Moving or other large life changes
- Retirement or loss of identity
- Natural disasters or community trauma
- Legal problems
- For teens, academic stress, bullying, family disruption, or conflict with parents.
Risk factors that increase the likelihood of adjustment disorders are previous mental illnesses such as depression or anxiety, limited social support, traumatic past experiences, chronic stress, or developmental issues in adolescents who are still developing coping mechanisms.[3]
Symptoms of Adjustment Disorders
Adjustment disorders can manifest in emotional, physical, and behavioral ways.
Emotional symptoms include:
- Depression, sadness, and crying
- Anxiety, worry, and nervousness
- Feeling hopeless or overwhelmed
- Irritability or mood swings
- Feeling empty or disconnected from oneself or others
Physical symptoms include:
- Fatigue and poor sleep
- Headaches or stomachaches
- Increased or decreased appetite
- Feeling tense and having difficulty relaxing
Behavioral symptoms include:
- Withdrawing from friends and social activities
- Declining performance in school or at work
- Impulsive or reckless behavior
- Using alcohol or drugs to cope
- Suicidal thoughts, which always need to be evaluated by a professional
Is Adjustment Disorder Permanent?
Adjustment disorder is typically considered temporary. According to the DSM-5, symptoms should not last for more than six months after the stressor or its consequences are gone.[4] However, adjustment disorders can develop into a chronic condition if the stressor is ongoing, if someone does not have adequate coping resources, or if the adjustment disorder has developed into a chronic mental illness such as depression or generalized anxiety disorder.[5]
It is clinically significant to differentiate between adjustment disorder and major depression. Major depression has its own diagnostic criteria, does not need an associated identifiable stressor, and tends to be more serious and longer-lasting than an adjustment disorder.[6] If symptoms of an adjustment disorder meet criteria for major depression, the diagnosis and treatment plan will be altered accordingly.
How Situational Stress Can Lead to Adjustment Disorders and Alcoholism
Situational stress and adjustment difficulties can increase one’s vulnerability to using substance use as a coping strategy.[7]
When a stressful event overwhelms a person’s existing coping resources, significant distress symptoms emerge. The person then begins to use alcohol or other substances to cope with anxiety, depression, or disrupted sleep. From this point, use becomes habitual, tolerance develops quickly, and a substance use disorder develops alongside, and increasingly independent of, the original stressor.
It is vital to understand that once a person begins using alcohol or substances, they often forget or minimize the original stressor, and their focus becomes the substance use. Treatment that addresses only the substance use without looking at the original stressor that caused the person to turn to substances misses a key component of the clinical picture.[8] Understanding what the original stressor is remains part of the treatment.
Effective Coping Skills for Adjustment Disorder Recovery
Developing effective coping skills is the key component of recovery from adjustment disorders and is also the key to preventing an increase in the severity of mental health problems or substance use.
Evidence-based coping strategies include:
- Problem-solving skills — Structured techniques to identify and address the practical aspects of the stressor where possible; reduces the sense of helplessness often associated with adjustment disorders.
- Cognitive restructuring — Identifying and challenging negative or catastrophic thinking patterns that increase the level of distress beyond what the actual stressor warrants.
- Stress management techniques — Mindfulness, relaxation techniques, physical activity, and adequate sleep to help reduce the effects of stress on the body.
- Social support engagement — Actively engaging your social support system (family, friends, and community), which a person suffering from adjustment disorder may not do.
- Meaning-making — Processing the meaning of the stressful experience and what it means to you, rather than avoiding it, in a therapeutic setting.
- Behavioral activation — Staying engaged in meaningful activities despite a lack of desire to do so, which prevents the cycle of withdrawal that deepens depression.
Treatment for Adjustment Disorder
Adjustment disorder treatment should be tailored, have a specific time period for achieving symptom relief, and be flexible to handle new situations that develop as a result of previous stressors.
Psychotherapy: Talk therapy, particularly cognitive behavioral therapy (CBT), is the main evidence-based therapy for adjustment disorder.[9] CBT focuses on restructuring distorted thinking and behaviors associated with the adjustment disorders, builds problem-solving and stress management skills, and helps process the stressor within a formal, structured therapeutic relationship. Group therapy provides support through sharing and normalization of experiences related to life transitions.
Family Therapy: Family therapy can assist when a family stressor is involved — such as divorce, illness, or death — or when the adjustment disorder is impacting family relationships.[10] The family therapist addresses the relational aspects of the experience and helps restore connections between family members in their recovery.
Dual Diagnosis Treatment: When an adjustment disorder exists alongside a substance use disorder, concurrent dual diagnosis treatment addresses both at the same time. Understanding what stressor led to substance use is part of the clinical work, and providing the coping skills needed to address future stressors without substances is a major component of relapse prevention.[11]
