Ten weeks ago Andrés moved to Zaragoza for a promotion he had been waiting on for years. He is 34, earns more than before and his new flat gets far more light than the old one. He also has unopened boxes in the hallway, wakes up at four every night and last Tuesday had to walk out of a meeting because he couldn't breathe properly. "I should be happy," he says in the first session, almost apologising. He has never had a mental health problem. What he describes fits an adjustment disorder, one of the most common diagnoses in outpatient mental health and also one of the most often used as a catch-all.

This guide is for psychologists who see cases like this every week. It covers what adjustment disorder is under the DSM-5-TR and ICD-11, how it presents, what it gets confused with, how to assess it, which psychological treatments have support, how long it usually lasts and what to write down in the clinical record so the time limits that define the diagnosis don't slip past you.

What is adjustment disorder?

Adjustment disorder is an emotional or behavioural reaction to an identifiable stressor that is out of proportion to what you would expect in that context, or that clearly impairs the person's life at work, at home or with other people. The name sums it up quite well: there is a specific change to adjust to, and the adjustment isn't happening.

The DSM-5 moved it in 2013 into the chapter on trauma- and stressor-related disorders, alongside PTSD and acute stress disorder, and the DSM-5-TR (2022) keeps it there. The MSD Manual Professional Edition explains why: for years clinicians used the term for any non-specific, fairly mild clinical picture, and placing it in that chapter stresses that the symptoms have to be a response to a stressor. Outside the consulting room it is sometimes called situational depression or stress response syndrome, the alternative names listed by MedlinePlus.

It is a very common diagnosis. According to the same manual, it is present in an estimated 5 to 20% of people attending outpatient mental health services, and population estimates range from 1 to 17%. The range is that wide because each study uses different criteria. Being common, and often clearing up within a few months, doesn't make it a minor problem: it comes with significant distress and disability and a higher risk of suicidal behaviour than many people assume.

Adjustment disorder diagnostic criteria (DSM-5-TR and ICD-11)

The five DSM-5-TR criteria

The DSM-5-TR requires the following:

  • A. Emotional or behavioural symptoms develop in response to one or more identifiable stressors, within three months of the onset of the stressor.
  • B. The symptoms are clinically significant: marked distress that is out of proportion to the severity of the stressor (taking context and cultural factors into account), significant impairment in social, occupational or other areas of functioning, or both.
  • C. The disturbance doesn't meet the criteria for another mental disorder and isn't merely an exacerbation of a pre-existing one.
  • D. The symptoms don't represent normal bereavement and aren't better explained by prolonged grief disorder.
  • E. Once the stressor or its consequences have ended, the symptoms don't persist for more than an additional six months.

Criterion C is the one that gets argued about most in supervision. If the person meets the criteria for a major depressive episode, the diagnosis is major depression, however obvious the trigger. Adjustment disorder fills the gap between a normal reaction and the disorders with their own criteria: a picture that is already clinical but doesn't amount to something else.

Adjustment disorder subtypes

When you make the diagnosis you add a specifier for the predominant symptoms:

  • With depressed mood: low mood, tearfulness, hopelessness.
  • With anxiety: nervousness, worry, jitteriness or, in children, fear of being separated from their attachment figures.
  • With mixed anxiety and depressed mood: a combination of both.
  • With disturbance of conduct: behaviour that breaks rules or violates other people's rights, such as skipping work, reckless driving or getting into fights.
  • With mixed disturbance of emotions and conduct.
  • Unspecified: reactions that don't fit the others, such as physical complaints or social withdrawal.

As the MSD Manual points out, most patients present with a mixture of symptoms, so the mixed subtypes are very common in practice. Besides the subtype you record the duration: acute if symptoms last less than six months and persistent (or chronic) if they last six months or longer. The second is only possible when the stressor or its consequences drag on, as with a chronic illness or a divorce tied up in endless litigation.

Adjustment disorder in ICD-11

The WHO's ICD-11, in effect since January 2022, codes it as 6B43 (in ICD-10, which still turns up on many reports, it is F43.2). Its definition focuses on two features. The first is preoccupation with the stressor or its consequences, in the form of excessive worry, recurrent and distressing thoughts or constant rumination. The second is a failure to adapt that impairs personal, family, social, educational or occupational functioning. Symptoms usually appear within a month of the stressor and tend to resolve within six months, unless the stressor persists. ICD-11 has no subtypes.

For day-to-day work, the ICD-11 description has one advantage: rumination about what happened is exactly what most patients describe in their own words ("I can't stop going over it"), so it helps you recognise the picture in the first interview.

What can trigger adjustment disorder

Almost any change that forces someone to reorganise their life can act as a stressor. The MSD Manual distinguishes between a single event, several events in a row, a normal developmental milestone and an ongoing set of problems. In practice that looks like this:

  • Losing a job, a break-up, an accident or a burglary.
  • Money problems that arrive straight after a separation.
  • Having a baby, retiring, moving away to study or work.
  • Caring for a dependent relative, a workplace conflict that drags on for months, a chronic illness.

The stressor doesn't have to be a bad thing. Cleveland Clinic notes that a stressor can be a positive or a negative event and lists retiring, getting married or having a baby among the common examples. A promotion or a wedding also means new routines, new roles and a different support network. Many patients, like Andrés, arrive feeling guilty for struggling at a time that "should be good", and simply naming that contradiction brings some relief.

How serious the event looks from outside tells you less than you might think. What weighs more is what it means to the person, how many changes are piling up at once and the resources they have: their support network, their finances, how they got through earlier crises and whether they have a history of anxiety or depression. That is why two siblings can live through their parents' divorce in very different ways. For people who have emigrated, losing their support network, the language and the paperwork add stressors that are not always visible from outside.

Adjustment disorder symptoms

Few people come in saying they can't adjust. They come because they aren't sleeping, because they cry in the car, because they are on sick leave or because their partner has told them they are short-tempered. The most common adjustment disorder symptoms fall into these groups:

  • Emotional. Sadness, anxiety, irritability, feeling overwhelmed, hopelessness.
  • Cognitive. Rumination about what happened, worry about what comes next, poor concentration, a sense of not recognising yourself.
  • Physical. Insomnia, tiredness, muscle tension, headaches or stomach aches, palpitations.
  • Behavioural. Avoiding anything linked to the change, withdrawing, drinking more, impulsiveness, arguments, missing work or school.
  • Functional. Performance drops, tasks pile up and decisions get put off.

What points to the diagnosis is the link with time. If you ask "since when have you felt like this?", the answer is usually a date: "since the shop closed", "since we moved". Write it down exactly as they say it, because it will be your reference for the three-month criterion and, later on, the six-month one.

Differential diagnosis: what adjustment disorder is not

A good part of the diagnosis is ruling out other explanations. These are the most common mix-ups.

A normal stress reaction

After a loss or a big change, it is to be expected that someone sleeps worse, feels sad or worries for a while. We talk about a disorder when the distress is clearly out of proportion or when the person stops functioning: they can't work, don't leave the house, neglect their children or themselves. The DSM-5-TR asks you to judge that disproportion in light of each person's culture and context, which makes sense, because in some cultures grief or a crisis is expressed far more openly without that being a disorder.

PTSD and acute stress disorder

They share a chapter, but PTSD and acute stress disorder require exposure to actual or threatened death, serious injury or sexual violence, and a specific pattern of symptoms: intrusive memories, avoidance, negative changes in thinking and mood, and hyperarousal. Someone can go through a traumatic event and develop an adjustment disorder rather than PTSD if they don't meet those criteria. The reverse also holds: an ordinary stressor such as being made redundant doesn't lead to PTSD, however distressing it is. Our guide to post-traumatic stress disorder treatment goes through its criteria and assessment.

Major depression and generalised anxiety

If the criteria for a major depressive episode or generalised anxiety disorder are met, that is the diagnosis, even when the trigger is obvious. And clinical pictures change: a redundancy can start as an adjustment disorder and turn into depression within a few weeks. It is worth reviewing the criteria every few sessions rather than treating the diagnosis as settled from the first one.

Grief and prolonged grief

The death of a loved one can trigger an adjustment disorder, but normal grief is not one, however much it hurts. Since the DSM-5-TR there is also prolonged grief disorder, considered when, at least twelve months after the loss in adults (six in children and adolescents), intense yearning for the person who died or preoccupation with them persists nearly every day, along with other symptoms.

Medical causes and substances

A thyroid problem, anaemia, the effects of some medicines such as corticosteroids, or drinking that has crept up can mimic the picture or make it worse. If the physical symptoms are prominent or don't fit the history, refer to the GP before going further.

Adjustment disorder and suicide risk

The fact that many professionals see it as a "mild" diagnosis is a problem, because the risk isn't always mild. The MSD Manual points out that patients with adjustment disorder have a higher risk of suicide attempts and completed suicide. Crises can coincide with the hardest moments of the stressor, such as the redundancy letter or the news of a separation, and there isn't always a history to warn you.

Ask directly about thoughts of death and suicide in the first session and whenever the stressor takes a new turn. Asking doesn't put the idea in anyone's head, and not asking can leave it unattended. If you pick up risk, follow a protocol; our guide on handling a suicidal crisis in your practice sets out the steps. In Spain, the 024 line offers free, confidential support 24 hours a day; in the US and Canada, you can call or text 988.

How to assess adjustment disorder in practice

There is no test that confirms the diagnosis. Assessment is clinical, and questionnaires help you organise the information and measure change. In the first sessions you want to be clear about:

  • The timeline: what happened, when, what has changed since and whether the stressor is still active. With dates.
  • How the person functioned before: work or studies, relationships, sleep, leisure. Without that baseline it is hard to talk about impairment.
  • What they have already tried to cope and what worked for them in earlier crises.
  • Their support network and the practical consequences of the stressor: money, housing, paperwork, custody of the children.
  • Personal and family mental health history, alcohol and other substance use, and suicide risk.

Among the specific instruments, the ADNM-20 (Adjustment Disorder – New Module), which has an eight-item short form (ADNM-8), was built on the model that ICD-11 later adopted, and the IADQ (International Adjustment Disorder Questionnaire) is based directly on the ICD-11 criteria. Both explore preoccupation with the stressor and failure to adapt. To track progress, the PHQ-9 and the GAD-7 are widely used because they are short and can be repeated every few weeks. None of them replaces the interview.

Psychological treatment of adjustment disorder

Adjustment disorder treatment has two aims: to relieve symptoms and to help the person get back to a level of functioning similar to the one they had before the stressor. That is how MedlinePlus puts it, adding that most mental health professionals recommend some type of talk therapy and that medicines, if used, go along with it.

The evidence is thinner than you might expect for such a common diagnosis. The MSD Manual cites a 2018 systematic review that found limited data, partly because patients with this diagnosis are so different from one another, although several individual and group psychotherapies show benefit in some groups of patients. In practice, treatment is usually brief and combines several of these tools.

Psychoeducation

Explaining what is happening, and that it has to do with the change rather than some weakness of theirs, lowers distress from the first session. It helped Andrés to see that a promotion also brings losses: his city, his old friends and a job he knew inside out.

Problem solving

Many people arrive stuck because they mix up what they can change with what they can't. Separating the two on paper and choosing a concrete first step for each practical problem (calling the lawyer, booking the accountant, finding a nursery place) gives them back a sense of control. It works especially well when the stressor has practical consequences, such as a redundancy or a separation.

Brief cognitive behavioural therapy

It works on rumination and worry, brings back activities that have been dropped (behavioural activation), sorts out sleep and trains coping skills. It suits a brief format well. A simple record between sessions of what the person thinks, what they do and how they sleep gives you material for the next one.

Acceptance and commitment when the stressor won't go away

If there is no going back from the stressor (a chronic illness, a disability, a separation the patient didn't want), pushing to change it only adds frustration. Acceptance and commitment therapy helps people live with what can't be changed and steer their lives towards what still matters to them.

Interpersonal, family and group therapy

When the stressor is a role transition, such as retirement, becoming a parent or emigrating, interpersonal therapy gives you a clear frame: saying goodbye to the old role, exploring the new one and rebuilding support. With children and adolescents the family nearly always has to take part. And groups of people in the same situation (unemployment, divorce, caring for a relative) ease isolation.

What about medication?

It isn't the first choice. According to the MSD Manual, the evidence for medication in this disorder is limited, and benzodiazepines, often used for insomnia or anxiety, have mixed results and can lead to dependence. If the patient is already taking something or the insomnia won't budge, liaise with their doctor.

Adjustment disorder and sick leave

Patients often arrive already signed off work, with an adjustment disorder diagnosis from their GP. In Spain, sick leave is signed by a doctor, not by the psychologist. What you can do, with the patient's consent, is keep their doctor informed about how treatment is going and plan the return to work together with the patient. A few things that help:

  • Talk about going back to work from the start, not the week before they are signed fit.
  • Keep routines going during the leave (sleep times, activity, contact with other people) so that going back isn't a leap into the void.
  • If the stressor is at work itself, think about what can be negotiated: different tasks or shifts, mediation, a phased return if the employer allows it.
  • Rehearse the difficult conversations with the manager, the team or HR in session.

If the underlying problem is long-standing exhaustion rather than a specific change, consider whether it is closer to chronic work stress, which calls for a different approach.

Adjustment disorder in children and adolescents

In childhood, typical stressors are the parents' divorce, a change of school or town, the birth of a sibling, bullying or illness in the family. Conduct symptoms weigh more than in adults: tantrums that come back, defiance, fights, falling grades or stomach aches before school. Adolescents may also start using alcohol or cannabis, take risks or shut themselves away in their room.

With minors, you work with the family. Ideally both parents are kept informed and, where required, both sign the consent. If the stressor is the conflict between them, take great care not to end up in the middle. It also helps to talk to the school, with permission, because that is where changes tend to show first.

How long does adjustment disorder last?

By definition, symptoms shouldn't last more than six months after the stressor or its consequences have ended. MedlinePlus sums it up: with the right help and support, people usually get better quickly, and the problem usually doesn't last longer than six months unless the stressor is still present. There are three situations in which it is worth rethinking the case:

  • The stressor ended more than six months ago and the symptoms are still there. It is probably a different diagnosis (depression, generalised anxiety, prolonged grief) and the treatment needs to change.
  • The stressor is still active, such as an illness, a court case or caring for a relative. The picture becomes persistent and the aim shifts towards long-term adjustment.
  • New stressors arrive before the person has recovered from the first, which is very common in financial crises or separations.

In adults the outlook is usually good. Adolescents need closer follow-up, because sometimes it is the first sign of a problem that later becomes established. When the patient is doing better, space out the sessions before discharge and agree on the warning signs that would mean they should come back.

What to record in the clinical record

With this diagnosis, the clinical record has to let you check the time limits and see whether the picture is changing. This is usually enough:

  • The stressor, with its start date and, when it comes, its end date. These are the reference points for the three- and six-month criteria.
  • The subtype and duration (acute or persistent).
  • How the person functioned before and how they function now: work or studies, relationships, sleep, self-care.
  • Scale scores, if you use them, with their dates.
  • Suicide risk at every review, even if only to note that you asked and there was none.
  • The work situation (sick leave, return to work) and anything discussed with the GP or the school, with the relevant permission.
  • Changes of diagnosis: if the picture becomes major depression, when and why.

If you still keep all this on paper or spread across separate documents, our page on digital clinical records for psychologists explains how to keep it organised and protected in one place.

Following adjustment disorder with My Psico Agenda

My Psico Agenda doesn't diagnose or decide treatment. It takes work off your hands around the sessions and helps you keep track of the time limits, which in adjustment disorder are part of the diagnosis itself.

  • Under Settings ▸ General, the "Additional fields in patient records" section lets you create your own fields. For these cases, a date field for when the stressor started, a drop-down list for the subtype and a long text field to describe what happened all work well. They appear under "Additional data" in every patient record, so it is best to leave them optional.
  • Each appointment can last 30, 45 or 60 minutes, 1 h 30 min or 2 hours, and when you pick the patient you see which session number it is, "(Appointment no. 6)". Handy in brief treatments with an agreed number of sessions.
  • Each patient's statistics show the sessions they have had, their attendance, the average cadence between appointments and the days since the last one. They help you space out sessions sensibly towards the end of treatment and notice who has stopped coming.
  • WhatsApp reminders go out 24 hours before with buttons to confirm or cancel. Each patient also has their own space to request or cancel appointments within your working hours, and if they cancel from there, that hour shows up as free in your diary.
  • In the clinical record you write the note for each session, and in the patient's files you keep scales or reports (the space available depends on the plan). If their doctor needs information, you download the patient record as a PDF, choosing which data to include and, if you like, a table of the sessions completed.
  • For minors, the record lists both mother and father, and informed consent is signed in the app or remotely through a link.

The app doesn't do video calls: if a session is online, you note the link to whatever tool you use in the appointment. There's a summary of everything on the software for psychologists page. Individual plans start at €4.99/month + VAT (Semilla plan, with up to 25 patients) and centre plans at €124.99/month + VAT. No lock-in: cancel whenever you like.

→
Don't leave the diagnosis time limits to memory. Create your account and try it free for 1 month, no card needed · See pricing

Frequently asked questions

The questions that come up most in sessions and supervision about adjustment disorder.

What is an adjustment disorder?

It is an emotional or behavioural reaction to an identifiable stressor (losing a job, a separation, a move, an illness) that starts within three months, is out of proportion or impairs the person's functioning, and doesn't meet the criteria for another mental disorder. The DSM-5-TR places it among the trauma- and stressor-related disorders, and ICD-11 codes it as 6B43.

What are the types of adjustment disorder?

The DSM-5-TR has six subtypes depending on what predominates: with depressed mood, with anxiety, with mixed anxiety and depressed mood, with disturbance of conduct, with mixed disturbance of emotions and conduct, and unspecified. You also record whether it is acute (under six months) or persistent. ICD-11 doesn't use subtypes.

How long does adjustment disorder last?

Symptoms begin within three months of the stressor and shouldn't last more than six months after the stressor and its consequences have ended. If the stressor continues, the picture can go on longer and is called persistent adjustment disorder. If symptoms remain six months after everything has ended, the diagnosis needs reviewing.

How is adjustment disorder different from depression?

In the criteria. If the person meets those for a major depressive episode, the diagnosis is depression even when there is a clear trigger. Adjustment disorder with depressed mood describes clinically significant distress that falls short of those criteria. The same case can move from one to the other, which is why it is worth reviewing the diagnosis during treatment.

Can a positive change cause adjustment disorder?

Yes. A promotion, a wedding, the birth of a child or retirement also mean reorganising routines, roles and support. What counts is how hard the person finds it to adjust, whether the change is good or bad. Many patients arrive feeling guilty for struggling at a time that is supposed to be happy.

Can you be signed off work with adjustment disorder?

Yes, if the symptoms stop the person from working. In Spain, sick leave is signed by a doctor, usually the GP, not by the psychologist. With the patient's consent, the psychologist can keep the doctor informed about treatment and plan the return to work with the patient from the first sessions.

What is the treatment for adjustment disorder?

Brief psychotherapy is the first option: psychoeducation, problem solving, cognitive behavioural therapy, acceptance and commitment therapy or interpersonal therapy depending on the case, plus work with the family for children and adolescents. Medication is not first-line and the evidence for it is limited; if used, it goes alongside psychotherapy and is coordinated with the doctor.

Can adjustment disorder be serious?

Yes. Although it is often seen as a mild diagnosis, it comes with significant distress and disability and a higher risk of suicide attempts. Ask directly about thoughts of death and suicide and follow a protocol if they come up. In Spain, the 024 line offers free, confidential support 24 hours a day; in the US and Canada, you can call or text 988.