When you think about mental health in the military, your mind likely jumps straight to posttraumatic stress disorder (PTSD), and then maybe to depression and anxiety. But adjustment disorders?
In fact, adjustment disorders are one of the most prevalent mental health disorders in both military and civilian populations, and they are the most commonly diagnosed group of disorders among active duty service members. In 2017, 7.1 percent of active duty service members were diagnosed with an adjustment disorder. To put that in perspective, 2.1 percent were diagnosed with PTSD, 4.2 percent with a depressive disorder, and 4.8 percent with an anxiety disorder. Despite their high prevalence, adjustment disorders are one of the least researched and understood of the more prevalent mental health disorders.
Why might that be? Let’s take a closer look.
What are adjustment disorders?
Adjustment disorders arise, first and foremost, in response to an identifiable stressor. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria, adjustment disorders occur within three months after the start of the stressor and resolve within six months of the stressor’s termination. Unlike PTSD, adjustment disorder stressors can be just about anything, from marital problems or health issues to adapting to the military or a new duty station. To qualify as an adjustment disorder, the symptoms have to be clinically significant, such that the distress is more than what you would expect such a stressor to normally elicit, or the individual has difficulty functioning in a social, occupational, or other important context.
Adjustment disorders can be difficult to precisely characterize, as they are largely described in the DSM as what they are not. The patient’s symptoms cannot meet criteria for another mental health problem, say, generalized anxiety disorder or depression. However, adjustment disorders are commonly diagnosed with the specifiers with depressed mood, with anxiety, or with mixed anxiety and depressed mood, making them quite similar to other mental health disorders. Further, the stressor does not have to be a single defining event, such as a car accident or marital separation. As spelled out in the DSM-5, it can be pervasive and non-discrete. In such a context, it can be difficult to precisely identify the onset of the stressor or the termination of the stressor and it consequences. Such a lack of well-defined symptom and stressor criteria makes this group of disorders difficult to consistently define and measure in research.
Why do adjustment disorders receive so little attention?
While substantial resources have been devoted to research and health care for PTSD and depression in military personnel, far less attention has been devoted to adjustment disorders. Why might that be?
Adjustment disorders are considered to be a more benign class of disorders than PTSD or depression. By definition, there is an expectation of a good outcome soon after the stressor has been removed. In 2017, active duty service members diagnosed with an adjustment disorder had fewer health care encounters and were less costly per patient than those diagnosed with PTSD or depression. Historically, the majority of new PTSD cases are diagnosed after deployment, while the majority of new adjustment disorder cases are diagnosed in active duty service members who have never deployed.
However, some research studies link adjustment disorders to an increased rate of suicidal ideation, and a recent longitudinal study found that the majority of patients diagnosed with an adjustment disorder still had a mental health diagnosis at 12 months, suggesting a chronic course. In addition, the combined cost of health care for active duty service members with adjustment disorders in 2017 exceeded that for patients with PTSD or anxiety disorders.
The lack of well-defined symptom and stressor criteria makes adjustment disorders easy to diagnose when a case conceptualization is incomplete but also makes them difficult to research. In the 2013 release of the DSM-5, adjustment disorders were placed in the Axis I Disorders’ heavily trafficked Trauma- and Stressor-Related Disorders section, with Posttraumatic Stress Disorder as their close neighbor. Location, location, location. Researchers are hoping that adjustment disorders’ close proximity to PTSD will bring them some much needed attention.
What can research tell us?
There is much we don’t know about adjustment disorders, or the role they play in the well-being or fitness for duty of service members. Their symptoms and diagnostic criteria overlap with PTSD as well as with the depressive and anxiety disorders.
Biopsychological studies could elucidate the role of the hypothalamic-pituitary-adrenal (HPA) axis stress response system and indicate whether the disorder subtypes are best represented by a singular stress response system or by their individual specifier disorder (i.e., anxiety or depression). Knowing more about their physiological features might help in guiding the development of targeted psychotherapies and pharmacotherapies.
Vague definitions and a lack of screening instruments that assess adjustment disorders lead to questions about diagnostic accuracy. Providers might be using adjustment disorder diagnoses when they are not sure how to diagnose a patient or in order to avoid applying a more serious disorder diagnosis or one with immediate career consequences. Thus, further improvement in diagnostic criteria of adjustment disorders should inform provider training and diagnosing practices, and allow for more accurate prevalence information.
Though we do not know what type of treatment interventions are most effective in treating adjustment disorders, low intensity interventions (e.g., web-based self-help interventions) may be most appropriate and do show some promise. Advances in these areas of research might help in guiding the development of targeted psychotherapies and pharmacotherapies for adjustment disorders, improve diagnostic accuracy of providers trying to distinguish adjustment disorders from other related disorders, and ensure that patients receive appropriate treatment.
What is PHCoE doing?
As part of our Psych Health Evidence Briefs series, we recently evaluated evidence about the effectiveness of cognitive behavioral therapy for adjustment disorders. We found that cognitive behavioral therapy has been adapted for use with adjustment disorders. However, the DoD does not have a clinical practice guideline for adjustment disorders, and the use of cognitive behavioral therapy for adjustment disorders has not been substantiated by authoritative reviews.
Based on stakeholders’ ratings of topics with the potential to inform care in the Military Health System, PHCoE is devoting its 2018 annual Research Gaps Prioritization Report to adjustment disorders (more to come on this in a future Clinician’s Corner Blog). The report’s goal is to inform future research by identifying important gaps in current research on adjustment disorders.
Our Health Services & Population Research studies utilize large health and administrative data sets in order to inform policy and decision-making. In addition to other topics under investigation, one of our studies will examine longitudinal health care trajectories of service members with adjustment disorders.
For prevalence data and interactive graphs and maps for multiple mental health disorders, including adjustment disorders, see our Psychological Health by the Numbers section.
Review the five new Psych Health Evidence Briefs and all past briefs for scientific evidence and clinical guidance for various treatment topics.
Morgan is a contracted senior research psychologist at the Psychological Health Center of Excellence. She has a doctorate in experimental psychology/behavioral neuroscience and a master’s degree in clinical psychological science.
Kelber is a contracted health research methodologist at the Psychological Health Center of Excellence. She has a doctorate in social psychology and has conducted research on emotions and group dynamics as predictors of ethnic conflict, intergroup aggression, and gang violence.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.