Adjustment Disorder Is Hiding in Plain Sight

Often mistaken for situational stress or grief, adjustment disorder is a stress-related psychiatric disorder that affects a wide range of patients. Estimates of its prevalence range from 0.5% to 2% in the general population, up to 11.5% of patients at outpatient psychiatric clinics, and up to triple that number among patients with cancer.^1-10

Psychiatrists across settings face specific challenges in diagnosing adjustment disorder, but the picture is improving. Growing recognition of the mental health consequences of cancer in particular have driven integration of mental health services in cancer centers, increasing the chances of accurate diagnosis. To improve the outlook for patients with adjustment disorder, we need to understand why it often goes unrecognized and demand greater diagnostic clarity.

Removing Barriers to Diagnosis

Adjustment disorder can often hide in plain sight for 2 primary reasons. First, its symptoms are similar to other psychological conditions. Patients with adjustment disorder who suffer from rumination, sadness or hopelessness, frequent crying, anxiousness or irritability, poor concentration, difficulty sleeping, withdrawal, or social or occupational problems might be diagnosed with major depressive disorder or anxiety disorder.^1,11 The clear difference is that adjustment disorder occurs in response to a specific stressor (an event or circumstance), while depression and anxiety often do not.¹²

Second, because adjustment disorder is triggered by a stressor, a patient’s symptoms can be mistaken for bereavement, complex grief, or a normal or proportional reaction to stress. By definition, patients with adjustment disorder develop symptoms disproportionate to the event or stressor, often including functional impairment.¹ Symptoms also overlap with other stress-related psychiatric disorders such as posttraumatic stress disorder, complex posttraumatic stress disorder, and acute stress disorder.

To help clinicians identify adjustment disorder, diagnostic criteria have been revised in both the Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR) and the International Classification of Diseases and Related Health Problems (ICD-11) (Figure 1). These criteria include an onset of symptoms within 1 to 3 months after the stressor, and symptoms are classified as acute if their duration is less than 6 months or chronic if persisting for 6 months or more. Further, adjustment disorders can be subtyped by their predominant symptoms including depressed mood, anxiety, mixed anxiety and depressed mood, disturbances of conduct, disturbances of emotions and conduct, or unspecified. The diagnosis requires that symptoms significantly impact a patient’s lives, including their ability to function, making it important to diagnose and treat this problem.

Stressors to Watch For

Because adjustment disorder is differentiated from other psychiatric conditions by its stressor initiation, it is useful for clinicians to watch for the full range of potential stressors involved. Most discussions focus on acute stressors—for example, the death of a family member, diagnosis of a serious illness such as cancer in oneself or a loved one, divorce, job loss, or loss of a home.^1,3,13 However, adjustment disorder stressors can also be chronic, such as ongoing medical difficulties, conflicts with family or friends, financial difficulties, or relocation.^1,3,13 

Patients with a diagnosis or progression of a serious illness are at high risk for developing adjustment disorder and other mental health problems. Estimates of the prevalence of adjustment disorder among cancer patients ranges from 6% to 35%.^3-10 Physicians should be watchful for adjustment disorder in patients with other serious medical illnesses where patients’ rates of depression and anxiety are high, such as idiopathic pulmonary fibrosis (24%-49%), Parkinson’s disease (17%-40%), multiple sclerosis (22%-31% of patients), and amyotrophic lateral sclerosis (10%-45%).^14-17

The development of an adjustment disorder is not limited to adults. Its prevalence in children and adolescents is estimated at about 4%, with greater prevalence in those over age 10.^17,18 In young patients with diabetes, end-stage renal disease, and heart transplants, the prevalence of adjustment disorder ranges from 14% to 60%.^18-20

Studies have also emerged examining rates of adjustment disorder in patients with non-medical stressors. For example, the condition has been diagnosed in 27% of people who lost their jobs and 18% of people who lost a loved one.¹ COVID-19 presented a unique mental health challenge where researchers found 18.2% of subjects self-reported adjustment disorder due to stressors such as fear, crisis management, social isolation, and work or childcare problems.²¹ Another study of adults at an outpatient psychiatric clinic found that adjustment disorder was more prevalent with certain socioeconomic factors, including young age, students, low education level, single marital status, and urban residence.³

Consequences of Missed Diagnoses

Patients with untreated adjustment disorder face a worrying range of burdens, some of which present risks for their overall health. They are at higher risk for suicidal ideation and suicide.^2,24 They also have high rates of disability, a lower quality of life, problems with daily activities, and trouble going to work—placing jobs and income at risk.^11,22 Over time, they face a greater incidence of other mental health diagnoses.^1,23,24

The negative effect of adjustment disorder on the health of patients with medical problems is a ciritcal consideration. Like other psychiatric diagnoses in individuals battling illness, adjustment disorder is associated with lower adherence with therapeutics, poorer outcomes, and higher healthcare utilization.^5,25Although the DSM-V-TR and ICD-11 diagnostic criteria indicate that adjustment disorder typically resolves in the 6-month period after the stressor is removed, the condition can continue if the stressor still exists—for example, in cases of ongoing cancer treatment or financial problems—and can reoccur as ongoing problems bring up new challenges.^1,13,23,26 Thus, it is essential for patient health to receive an accurate diagnosis early and ensure that they receive treatment for the duration of the disorder.

Therapeutic Options

Despite adjustment disorder’s prevalence, the scarcity of targeted research in high-risk patient populations has resulted in few evidence-based treatment guidelines.^26,27 This landscape may change now that clear diagnostic criteria exist and can be incorporated into a study framework. Because symptoms of adjustment disorder overlap with depression and anxiety, physicians currently rely on approved, guideline-driven therapies for those conditions: supportive therapy, psychotherapy, and medications (prescribed off-label for adjustment disorder).

Perhaps because adjustment disorder is related to the experience of a stressor, psychological interventions are the most common treatment, but there have been few high-quality studies to support their efficacy.^26,28 Acceptance of a mental health diagnosis or need for treatment may prove a barrier to patients receiving appropriate care. Studies show that among patients experiencing psychological distress about a cancer diagnosis, up to half reject psychological intervention, although it helps those who do accept.^4,29

High-quality studies about efficacy of off-label prescription medications for adjustment disorder have also been limited.^4,28 The transient nature of the condition can make treatment with depression and anxiety medications a challenge. The most commonly prescribed drugs are benzodiazepines, generally a short-term therapy with longer term treatment potentially problematic, but unlikely to be effective in the face of significant depressive symptoms.²² Selective serotonin reuptake inhibitors (SSRIs) generally take weeks to work and may also be associated with a range of adverse side effects.^30-32 What’s more, meta-analyses have not shown SSRIs to be superior to placebo for adjustment disorder.³¹ As a final challenge, patients with complex or serious medical illnesses often have multiple treatments and pharmacotherapies to take into consideration when prescribing.²⁵

Currently, the clinical potential of psychedelics for treating mental health disorders, including adjustment disorder, is being explored, particularly in patients with serious medical conditions.³³ Studies have already shown the efficacy of psychedelics for treatment of anxiety and depression, including in cancer patients, where, as noted, adjustment disorder is common.³⁴ Patients with cancer have shown significant, rapid, sustained reduction of depression and anxiety after single-dose psilocybin treatment, which has been well-tolerated.^35-39 Patients with life-threating cancer reported decreased hopelessness and better spiritual well-being and quality of life.⁴⁰ A clinical trial is now underway to specifically study a psilocybin analogue for adjustment disorder in patients diagnosed with cancer or other serious illnesses.⁴¹

Building on Better Diagnoses

The adoption of concrete diagnostic criteria for adjustment disorder is a major advance in the effort to get patients appropriate help. More physicians are seeing that patients who show a disproportionate reaction to a major stressor, often including impaired daily function, may be experiencing adjustment disorder. Although there are currently no treatment guidelines and no treatments specifically proven to effectively treat the condition, improvements appear to be building momentum.

Dr Pollack is chief medical officer of Reunion Neuroscience, based in Morristown, New Jersey.

Author’s Note: Professional medical writing and editorial assistance were provided by Erin Murphy of Precision AQ.

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