Adjustment Disorder and the Link to Substance Abuse
Adjustment disorders are related to stressful life events. While disorders like PTSD are related to extreme traumatic or stressful events, adjustment disorders are related to much less stressful events. The difference between disorders like PTSD, acute stress disorder, and an adjustment disorder is in the nature of the stressful event and the duration of symptoms.
With adjustment disorders, the events that are related to the adjustment issues can be nearly anything that results in stress, whereas with PTSD and acute stress disorder, the events triggering the behavior are much more extreme. This designation has resulted in some controversy and claims regarding the American Psychiatric Association (APA) pathologizing and medicalizing what many consider to be normal reactions to everyday stressors. Nonetheless, according to APA, an adjustment disorder represents an overreaction to commonly experienced types of stress and a resulting level of impairment that would not be expected in normal circumstances given the nature of the event.
Adjustment disorders are reactions to stressful events that are time-limited. A stressful event can be any event that results in a person developing significant tension, worry, pressure, or physical strain. Nearly any event perceived as stressful and trying to an individual can be involved in an adjustment disorder. These may include:
- Losing one’s job
- The death of someone close
- The dissolution of an important relationship, such as a romantic relationship (e.g., marriage), a business relationship, friendship, etc.
- Buying a new home
- Financial issues
- Getting married, planning a wedding, or planning some important event
- Getting a new job or going away to school
- Coming into a lot of money
In addition, children may experience adjustment problems as a result of stress at home (e.g., parents arguing or separating), issues at school (e.g., poor academic performance), or expectations placed on them by peers, parents, and teachers.
The interesting thing about the way that “stressful events” are defined by APA is that they can include both negative and positive events, although it is far more common to experience adjustment issues as a result of negative stressors. Nonetheless, individuals experiencing what many would consider positive changes may also develop adjustment issues and an adjustment disorder. Unlike disorders like PTSD, where the types of events that precede the onset of the disorder are relatively well-defined, adjustment disorders can occur in response to nearly any type of event or situation. Of course, as mentioned above, this has led to some controversy regarding the diagnoses of these disorders.
According to APA, the symptoms used to diagnose an adjustment disorder consist of behavioral responses, emotional reactions, or a combination of both emotional and behavioral responses to the particular stressor. Adjustment disorders can only be diagnosed if the symptoms occur within three months of the stressful event and can only last for six months following the termination or conclusion of the event.
A general description provided by the APA diagnostic criteria indicate that:
- The symptoms the individual displays must be considered to be markedly in excess of what would normally be expected when other individuals experience the same type of stressful event.
- The individual experiences significant inabilities to function in order areas of their life as a result of their reaction to the event. The areas in which the individual is experiencing functional impairment include their ability to work, go to school, or participate in aspects of their personal relationships or social life.
- The distress the individual displays cannot be better explained by the direct effects of a medical condition (e.g., a stroke), some other psychological or psychiatric disorder, or the use of drugs.
Adjustment disorders are heterogeneous disorders, meaning that they can present in a number of different ways. APA specifies different types of adjustment disorders that are based on the major type of stressful reaction the individual displays. These include:
- Adjustment disorder with depressed mood
- Adjustment disorder with anxiety
- Adjustment disorder with mixed presentation (significant displays of anxiety and depression)
- Adjustment disorder with disturbance of conduct (primarily behavioral symptoms, such as becoming angry or aggressive)
- Adjustment disorder with a mixed disturbance of emotions and conduct (displays both emotional and conduct problems)
- Unspecified adjustment disorder (displays very transient and undefined symptoms)
Diagnoses that are related to stress and trauma that are considered to be far more serious than adjustment disorder, such as PTSD, are typically associated with more severe events. Both the severity of the stressor and the timing of the events distinguish adjustment disorders from acute stress disorder and PTSD.
Acute stress disorder is typically associated with a more severe stressful event and can only occur three days to one month after being exposed to the stressful event, whereas PTSD cannot be diagnosed until at least one month after the stressful event has occurred. Adjustment disorders can be diagnosed immediately and can only persist for six months after the stressor or its consequences have passed.
Adjustment Disorders and Comorbidity
Comorbidity refers to the presence of more than one illness or disorder in an individual. Adjustment disorders can be diagnosed with other mental health disorders and nearly any medical disorder; however, the symptoms of the adjustment disorder cannot be better explained by the expected symptoms of the comorbid disorder in question. For example, a person with bipolar disorder would only be diagnosed with an adjustment disorder if they experience a stressful event and the event was responsible for their emotional/behavioral presentation as long as the criteria for both disorders can be met separately. This is a bit of a tricky situation, and only licensed mental health professionals with experience in these disorders can tease apart these types of issues.
Adjustment disorders are relatively common. Reports of the prevalence of adjustment disorder ranges from 5 percent to 20 percent in individuals being treated for mental health issues. In inpatient psychiatric situations, the prevalence is often reported to be as high as 50 percent.
Adjustment disorders are associated with increased risks for suicide attempts. Individuals who have adjustment disorders and pre-existing medical conditions may often experience increased difficulty as a result of their emotional and behavioral issues as well as increased severity of their medical condition or other mental health disorder. Adjustment disorders are often associated with substance abuse issues for individuals who attempt to cope with stress with the use of alcohol or other drugs. Because individuals with adjustment disorders may choose maladaptive approaches to dealing with stress, they may also find themselves developing other psychological disorders, including substance use disorders or major depressive disorder.
Some signs that may indicate an individual is experiencing issues with adjustment include:
- Tearfulness, depressed mood, problems with motivation, and inability to experience pleasure
- Irritability, jitteriness, nervousness, feeling on the edge, and anxiety attacks
- Isolating oneself, withdrawing from activities once enjoyed, impulsivity, aggressiveness, or acting out
- Increased absences from work or school, or performance issues at work or school
- Headaches, muscle aches, tension, insomnia, loss of appetite, increased blood pressure, and general feelings of fatigue and malaise
- Conflicts with family and friends, supervisors, and/or coworkers
Signs that an individual is engaging in substance abuse in addition to having issues with adjustment include:
- The person suddenly spends a significant amount of time using drugs or alcohol, or spends a great deal of time recovering from their use.
- The person begins having issues with controlling their substance use, such as using more than they had originally intended to use or using drugs/alcohol more often than they originally intended.
- The person continues to use drugs or alcohol in spite of experiencing negative consequences, such as issues at work, in relationships, or legal or financial issues.
- The person becomes very defensive regarding their use of drugs or alcohol.
- The person mixes drugs or alcohol, engages in “doctor shopping” for prescription medications, or uses drugs or alcohol in situations where it is physically dangerous to do so.
Individuals with adjustment disorders can engage in any type of substance abuse, but the most common substances that these individuals abuse include alcohol, prescription medications (often due to being prescribed medications for anxiety or a medical condition), and marijuana.
Treatment for Adjustment Disorders
The approaches used to address adjustment disorders include either one or a combination of the following:
- Individual or group therapy: Most often, individuals with adjustment disorders are treated with individual or group therapy because their reactions are time-limited and expected to dissipate once the duration of the particular stressor has passed. Individuals need to engage in support, coping, and positive strategies to overcome their reaction to the stressful events, and they also need to develop skills to address similar types of stressful experiences in the future.Therapeutic interventions provide these resources to individuals who are willing to do the work. Most often, these types of interventions include cognitive behavioral approaches, such as stress reduction techniques, coping strategies, cognitive restructuring (learning to think differently about things), and exposure techniques (actually exposing oneself to stressful situations using imagery or actual real exposures). These techniques can only be applied by highly trained and skilled individuals, and they have excellent success rates.
- Medications: In some cases, medication may be required, including anti-anxiety and antidepressant medications. However, the use of medications does not assist the individual in developing coping strategies or in learning to deal with future stressors. Medications are best used in combination with therapy and should be discontinued once the individual has improved.
- Support groups: Support groups are not types of therapy, as they are not run by trained and licensed therapists; however, they are often organized and run by groups of individuals who have the same or similar issues. Social support is both a protective factor against the development of an adjustment disorder and a therapeutic intervention that can assist individuals in adjusting to life’s changing situations. Participants can also learn coping strategies from each other.
Often, combinations of the three major interventions can be used. Individuals with co-occurring adjustment disorders and substance use disorders need to be involved in an integrated treatment program that treats both disorders simultaneously and uses a multidisciplinary approach that addresses both conditions. These individuals may need to go through withdrawal management, inpatient treatment, outpatient treatment and therapy, and long-term aftercare programs in order to protect against relapse in the future.