Adjustment Disorder Causes & Prevention

What is adjustment disorder? Adjustment disorder refers to an abnormal emotional or behavioural response to a stressor, which is identifiable and of a psychosocial nature. The term captures people who have difficulties in responding and adjusting after they experience a stressful event at a level which is not in proportion with the intensity of the stressor.

Symptoms of adjustment disorder are defined by stress responses which are not what they would be expected by social or cultural norms. These responses can cause an array of emotions, ranging from marked distress to impairment in activities of daily living. It is important to mention that what distinguishes post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) from adjustment disorder is that the first two have clear criteria for what constitutes a traumatic event and the latter does not have any specific requirements for what can be regarded as a stressor.It has been identified that stressor events are made up of both traumatic events (for example exposure to actual or threatened death) as well as non-traumatic events which could include inter relational conflicts, death of a close one, troubles with finances, illness either personal or of someone close and unemployment.¹

Stressors triggering adjustment disorder can manifest as singular events, such as the aftermath of a difficult breakup, or as a complex interplay of multiple challenges, like work-related issues, academic struggles, and financial burdens. These stressors can impact individuals, families, or even entire communities, as is often the case with disaster survivors. Additionally, stressors may take on a recurring nature, as seen in seasonal business fluctuations, or be linked to specific "milestone" events in one's life, such as the transition to school, marriage, or retirement.¹

What Causes Adjustment Disorder

Adjustment disorders can stem from a wide range of causes, typically arising when an individual perceives a situation as stressful and experiences significant disruptions in their work, social life, or home life. These triggers can encompass both positive and negative life events. Some illustrative examples encompass:

• Coping with the loss of a family member or close friend.
• Navigating relationship challenges, such as breakups, marital difficulties, or divorce.
• Experiencing major life transitions, such as marriage or becoming a parent.
• Confronting serious health issues.
• Struggling with academic challenges.
• Dealing with financial hardships.
• Facing difficulties at work, such as job loss or failing to meet career goals.
• Residing in a neighbourhood marked by high crime rates.
• Adjusting to retirement.
• Coping with disasters or unexpected tragedies.

Furthermore, an individual's personality, temperament, overall well-being, life experiences, and family history are believed to contribute to the potential development of adjustment disorders.²

Signs and Symptoms

Each individual's experience of an adjustment disorder is unique, with symptoms ranging from mild to severe. The severity of these symptoms is influenced by the intensity of the triggering situation and its significance to the individual.

Typical physical symptoms may include:

• Experiencing fatigue and insomnia, making it difficult to sleep.
• Suffering from body aches and feeling as if one is unwell.
• Developing headaches or stomach aches.
• Experiencing heart palpitations.
• Having sweaty hands.

Common behavioural or emotional symptoms might encompass:

• Engaging in rebellious, destructive, or impulsive behaviours.
• Feeling anxious, agitated, trapped, or hopeless.
• Easily shedding tears.
• Struggling with concentration and focus.
• Withdrawing from social interactions, experiencing sadness, a lack of energy or enthusiasm, and a decrease in self-esteem.
• Losing interest in activities once enjoyed.
• Experiencing changes in eating habits.
• Feeling overwhelmed and stressed.
• Turning to alcohol or drugs as a coping mechanism.
• Encountering thoughts of self-harm or exhibiting self-destructive behaviours.

It's important to note that the manifestation and severity of these symptoms can vary widely among individuals facing adjustment disorders.³

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook used by healthcare professionals in the United States and much of the world as the authoritative guide to diagnosing mental disorders.

In the DSM IV, adjustment disorder is characterised by the emergence of notable emotional or behavioural symptoms in response to an identifiable psychosocial stressor or stressors within three months of the stressor's onset. These symptoms must exhibit a level of distress that goes beyond what would be expected from exposure to the stressor and must lead to substantial impairment in social or occupational functioning.

Once the stressor ceases, the symptoms may subside within six months (termed Acute Adjustment Disorder) or persist for an extended period if the stressor's consequences are enduring (referred to as Chronic Adjustment Disorder). It's worth noting that DSM IV identifies bereavement as a separate diagnosis, distinct from Adjustment Disorder, specifically for abnormal grief reactions.

The DSM-IV TR criteria outline the diagnosis of Adjustment Disorder as follows:

• The symptoms must arise within three months of the stressor's onset.
• The distress exhibited should be more pronounced than anticipated, considering the nature of the stressor or should lead to significant social or occupational impairment.
• This diagnosis is inappropriate if the disturbance meets the criteria for another Axis I disorder or if it results from a worsening of a pre-existing Axis I or Axis II condition.
• Adjustment Disorder should not be diagnosed when the symptoms are characteristic of bereavement.
• Symptoms must resolve within six months after the stressor ends. However, if they stem from a chronic stressor or one with enduring consequences, they may persist beyond six months.²

Types of Adjustment Disorder

Within the DSM-5, six distinct types of adjustment disorders are identified:

• Adjustment Disorder with Depressed Mood: this subtype is characterised by symptoms such as persistent feelings of sadness, hopelessness, frequent crying, and a diminished ability to experience joy from previously enjoyable activities.
• Adjustment Disorder with Anxiety: individuals with this subtype often experience heightened anxiety, excessive worry, and a sense of being overwhelmed. Concentration difficulties may also be present. Notably, separation anxiety tends to be a predominant symptom in children.
• Adjustment Disorder with Mixed Anxiety and Depressed Mood: in this category, individuals grapple with a combination of anxiety and depression symptoms, which can manifest concurrently.
• Adjustment Disorder with Disturbance of Conduct: symptoms in this subtype primarily involve behavioural issues, including rebelliousness, destructiveness, recklessness, and impulsivity.
• Adjustment Disorder with Mixed Disturbance of Emotions and Conduct: this category encompasses a blend of symptoms, including anxiety, depression, and behavioural challenges.
• Adjustment Disorder Unspecified: this subtype is characterised by a diverse range of symptoms, including physical complaints such as headaches, body aches, stomach discomfort, heart palpitations, and insomnia, among others.

These distinct subtypes within the realm of adjustment disorders reflect the various ways in which individuals may react to and cope with challenging life circumstances.²

Coping and Treatment

The limited duration and self-resolving nature of adjustment disorders may account for the scarcity of research on therapeutic interventions, particularly randomised controlled trials. However, this does not warrant the notion that specific interventions are unnecessary, except in cases of acute suicidality. Individuals with adjustment disorders (AD) present valuable opportunities for preventive research. Additionally, those experiencing prolonged AD also warrant scientific attention due to the detrimental impact on their quality of life.

Currently, the consensus is that psychotherapy remains the preferred treatment for adjustment disorders. Notably, there is a lack of substantial pharmacotherapy studies supporting the use of antidepressants for this condition. Unfortunately, access to psychotherapy can be limited, as AD is often diagnosed in general practice.⁴

The question of which psychotherapy approach may be beneficial in adjustment disorders remains unanswered due to the absence of controlled clinical trials comparing various psychotherapeutic methods.

Considering the fundamental characteristics of the disorder, namely its short-term nature and its link to a specific stressor, it seems reasonable to explore solution-focused therapies. Approaches such as interpersonal psychotherapy or problem-solving therapy may aid individuals in addressing their specific life challenges effectively.²

A study involving adolescents with major depression or other depressive disorders, including adjustment disorders, demonstrated improvements in psychosocial functioning regardless of whether their treatment involved psychotherapeutic methods alone or combined with psychotropic medication.⁵

Prevention

While we cannot always control the external world, there are actions we can take to enhance our well-being in the face of stressors. Consider the following strategies:

• Cultivate a Support Network: Reach out to your family, friends, and the communities you're a part of for support and encouragement during challenging times.
• Prioritise Self-Care: Dedicate regular time to self-care activities. This might involve indulging in a soothing bath, immersing yourself in a good book, journaling your thoughts and feelings, taking strolls, or spending quality moments with your pets. Allocate a consistent schedule for "me time" to engage in activities that bring you joy and improve your overall well-being.

Summary

Adjustment disorder typically follows a self-limiting course, meaning that your symptoms tend to dissipate as the underlying stressor resolves. Life is a journey filled with both challenging and joyful experiences, all of which can elicit varying degrees of stress. Your social connections, including friends, family, and religious affiliations, play a crucial role in celebrating life's joys and providing support during difficult times.

In situations where you find yourself overwhelmed by a particularly stressful event, remember that your healthcare team is readily available to assist you. Assistance is always within reach and your well-being matters.

FAQs

What distinguishes adjustment disorder from major depression and generalised anxiety disorder?

Adjustment disorder is diagnosed based on the presence of a specific stressor, and the condition typically resolves when the stressor is removed. According to this diagnosis, symptoms should abate within six months following the triggering event. In contrast, major depression and generalised anxiety disorder may not necessitate an identifiable stressor, and their symptoms can persist continuously.

How does adjustment disorder differ from post-traumatic stress disorder (PTSD)?

In the case of adjustment disorder, the severity of the stressor is not a determining factor. However, for a diagnosis of PTSD, there must be a significant fear for one's own life or the life of someone else, and the level of severity is notably much higher.