Clinical supervision presentation

Adjustment Disorders

Diagnosis, assessment, and treatment when life changes faster than we can adapt

David Robles
Therapy by David · Pasadena, Texas
Monday, November 9, 2026

Goals for today

Frame adjustment as the core of much of what brings clients to therapy
Apply DSM-5-TR criteria A to E, the six specifiers, and the acute or persistent duration specifier
Compare the DSM-5-TR and ICD-11 views
Sort out common differentials and screen for suicide risk
Choose assessment tools and evidence informed treatments
Practice on a fictional composite case and get your feedback

Why adjustment matters

Most people come to therapy because something happened that they have not adjusted to yet.

What I see in practice

A move, a layoff, a diagnosis, a divorce, a new baby, a death
Even when it gets called anxiety or depression, the person is still adjusting to a new way of life
Naming the adjustment gives clients a story that makes sense and a direction

What the literature says

Adjustment disorder is among the most frequently diagnosed conditions in clinical practice (Bachem & Casey, 2018; Zelviene & Kazlauskas, 2018)
DSM-5-TR places it with disorders that require exposure to a stressor (APA, 2022)
Yet it remains under researched (Casey, 2014)

Sources: Bachem & Casey, 2018; Zelviene & Kazlauskas, 2018; Casey, 2014; APA, 2022

Where adjustment disorders sit in DSM-5-TR

The DSM is how we diagnose. Adjustment disorders live in the chapter Trauma and Stressor Related Disorders.

Reactive attachment disorderDisinhibited social engagement disorderPosttraumatic stress disorderAcute stress disorderAdjustment disordersProlonged grief disorder (new in DSM-5-TR)Other specified and unspecified trauma and stressor related disorder

The shared feature: exposure to a traumatic or stressful event is an explicit diagnostic criterion
DSM-5 (2013) was the first edition to group adjustment disorders with the trauma and stressor related disorders (Casey, 2014)
Unlike PTSD, the stressor can be any event, not only actual or threatened death, serious injury, or sexual violence (O'Donnell et al., 2019)

Sources: APA, 2022; Casey, 2014; O'Donnell et al., 2019

DSM-5-TR criteria A to C

A

Emotional or behavioral symptoms develop in response to an identifiable stressor or stressors, within 3 months of the onset of the stressor.

B

The symptoms are clinically significant, shown by one or both:
1. Marked distress out of proportion to the severity or intensity of the stressor, taking into account external context and the cultural factors that might influence symptom severity and presentation
2. Significant impairment in social, occupational, or other important areas of functioning

C

The disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a preexisting mental disorder.

Source: APA, 2022, p. 319

DSM-5-TR criteria D and E

D

The symptoms do not represent normal bereavement and are not better explained by prolonged grief disorder.

E

Once the stressor or its consequences have ended, symptoms do not persist for more than an additional 6 months.

What changed in the text revision

Criterion D now names prolonged grief disorder, because DSM-5-TR added it as its own diagnosis. Grief that meets those criteria is coded there, not as an adjustment disorder.

Coding

F43.21 depressed mood · F43.22 anxiety · F43.23 mixed anxiety and depressed mood · F43.24 disturbance of conduct · F43.25 mixed disturbance of emotions and conduct · F43.20 unspecified

Source: APA, 2022, pp. 319 and 320

Specifier 1: With depressed mood (F43.21)

Low mood, tearfulness, or feelings of hopelessness are predominant.

Clinical picture

Tearful, flat, discouraged after a clear life event
Hopeless about the situation, not a pervasive global depression
Fewer than the five symptoms over two weeks needed for major depression

Adjustment Disorder with Depressed Mood Case Study (DSM-5-TR)

Symptom Media (clinical training simulation) · 1:45

Open on YouTube

Source: APA, 2022, p. 319; video: Symptom Media

Specifier 2: With anxiety (F43.22)

Nervousness, worry, jitteriness, or separation anxiety is predominant.

Clinical picture

Worry focused on the stressor and what it means
Restlessness, poor sleep, trouble concentrating
In children, separation anxiety can be the main sign

Adjustment Disorder with Anxiety Video, DSM-5-TR Case, Diagnosis Training

Symptom Media (clinical training simulation) · 1:16

Open on YouTube

Source: APA, 2022, p. 319; video: Symptom Media

Specifier 3: With mixed anxiety and depressed mood (F43.23)

A combination of depression and anxiety is predominant.

Clinical picture

Probably the presentation I see most often in outpatient work [David to verify against your own caseload]
Worry and sadness braided together around the same life change
Watch sleep, appetite, and any hopeless thinking

Adjustment Disorder With Mixed Anxiety & Depressed Mood Clinical Case

Symptom Media (clinical training simulation) · 1:33

Open on YouTube

Source: APA, 2022, p. 319; video: Symptom Media

Specifier 4: With disturbance of conduct (F43.24)

Disturbance of conduct is predominant.

Clinical picture

Acting out that is new since the stressor: fighting, truancy, reckless driving, vandalism
More common in teens than adults, per hospital patient education material
Check for substance use and school or legal consequences

No video embedded for this specifier.

Source: APA, 2022, p. 319

Specifier 5: With mixed disturbance of emotions and conduct (F43.25)

Both emotional symptoms (such as depression or anxiety) and a disturbance of conduct are predominant.

Clinical picture

Sad or anxious and also acting out
Example: a teen who withdraws and cries at home and is suspended for fighting at school
Often brings families to therapy

Adjustment Disorder with Mixed Disturbance Example, DSM-5-TR Video Case

Symptom Media (clinical training simulation) · 0:57

Open on YouTube

Source: APA, 2022, p. 319; video: Symptom Media

Specifier 6: Unspecified (F43.20)

For maladaptive reactions that are not classifiable as one of the specific subtypes.

Clinical picture

Physical complaints, social withdrawal, or work or school inhibition without a clear mood or conduct pattern
Use when the picture is real and impairing but does not fit the other five
Document why none of the others fit

No video embedded for this specifier.

Source: APA, 2022, p. 319

Acute vs persistent (chronic)

Acute

Symptoms have lasted less than 6 months.

Persistent (chronic)

Symptoms have lasted 6 months or longer. Applies when the stressor is chronic or has enduring consequences.

Symptoms still cannot last more than 6 months after the stressor and its consequences end
DSM-5-TR examples of enduring stressors: a chronic disabling medical condition, or the financial and emotional fallout of a divorce
Persistent cases deserve a fresh look for another diagnosis

Sources: APA, 2022, p. 320; O'Donnell et al., 2016, 2019

The ICD-11 view

Code 6B43, in the grouping Disorders Specifically Associated with Stress
A maladaptive reaction to an identifiable psychosocial stressor that usually emerges within 1 month
Two core features:
Preoccupation with the stressor (excessive worry, recurrent distressing thoughts, rumination)
Failure to adapt, causing significant impairment
Usually resolves within 6 months unless the stressor persists
No subtypes

Andreas Maercker: Introduction to Adjustment disorder (ICD-11)

Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders (Nasjonal kompetansetjeneste ROP) · 12:19

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Sources: WHO, 2024a, 2024b; O'Donnell et al., 2019; video: Nasjonal kompetansetjeneste ROP

DSM-5-TR and ICD-11 side by side

	DSM-5-TR	ICD-11
Onset	Within 3 months of stressor	Usually within 1 month
Core symptoms	Not specified; distress or impairment	Preoccupation and failure to adapt
Clinical significance	Disproportionate distress or impairment	Impairment required
Subtypes	Six specifiers	None
Duration	Not more than 6 months after stressor ends; acute or persistent	Typically resolves within 6 months unless stressor persists
Bereavement	Excludes normal bereavement and prolonged grief disorder	Not mentioned in core description

Sources: O'Donnell et al., 2019; APA, 2022; WHO, 2024a

Differential 1: Normal stress reaction

Expected stress

Upset that fits the size of the event and the person's culture
Functioning mostly holds
Improves as the person adapts

Adjustment disorder

Distress clearly out of proportion, judged in cultural context
Or significant impairment at work, school, home
Stuck: preoccupation and failure to adapt

Neither DSM-5-TR nor ICD-11 gives a symptom count, so this line is a clinical judgment. Document your reasoning.

Sources: APA, 2022; Casey, 2014; O'Donnell et al., 2019

Differential 2: PTSD and acute stress disorder

	Adjustment disorder	Acute stress disorder	PTSD
Stressor	Any stressor	Actual or threatened death, serious injury, or sexual violence
Timing	Onset within 3 months	3 days to 1 month after trauma	More than 1 month
Symptoms	No required profile	Intrusion, avoidance, negative mood or cognition, arousal (specific counts)

A person exposed to trauma who does not meet full PTSD or acute stress disorder criteria can receive an adjustment disorder diagnosis

Sources: APA, 2022; O'Donnell et al., 2016, 2019

Differential 3: Major depression and GAD

Major depressive disorder

Five or more symptoms, same two week period, including depressed mood or loss of interest
A stressor does not rule out MDD
If MDD criteria are met, diagnose MDD (Criterion C)

Generalized anxiety disorder

Excessive worry about many things, more days than not, for at least 6 months
Not tied to one stressor
If GAD criteria are met, diagnose GAD

Screen with PHQ-9 and GAD-7, then confirm with a clinical interview.

Sources: APA, 2022; Kroenke et al., 2001; Spitzer et al., 2006; Casey et al., 2015

Prevalence across settings

0.9%German general population meeting criteria with impairment; a further 1.4% met criteria without impairmentMaercker et al., 2012

12%of psychiatric consultations, multisite study, U.S., Canada, Australia (plus 11% possible)Strain et al., 1998, as cited in O'Donnell et al., 2019

15 to 19%of adults in oncology, hematology, and palliative care settingsMitchell et al., 2011

32%most common diagnosis in an emergency department sample presenting mostly with self harmTaggart et al., 2006, as cited in O'Donnell et al., 2019

DSM-5-TR text: about 5 to 20% of outpatient mental health clients carry it as the principal diagnosis, and up to about 50% in hospital psychiatric consultation [David to verify DSM-5-TR wording and page]

Sources: Maercker et al., 2012; Mitchell et al., 2011; O'Donnell et al., 2019; APA, 2022

Maercker et al. (2012): representative German sample, n = 2,512, ages 14 to 93. 0.9 percent met criteria including clinically significant impairment; a further 1.4 percent met criteria without the impairment criterion.

Mitchell et al. (2011) meta-analysis of 94 interview based studies: adjustment disorder 19.4 percent in oncology and hematology settings, 15.4 percent in palliative care.

The 12 percent consultation figure (Strain et al., 1998) and 32 percent emergency department figure (Taggart et al., 2006) are cited as reported in the O'Donnell et al. (2019) review. I have not read those primary papers. O'Donnell also reports higher rates in recently unemployed (27 percent) and bereaved (18 percent) samples.

The DSM outpatient and consultation figures are from my memory of the DSM text and must be checked against the DSM-5-TR Prevalence section before I present them.

Risk factors and course

Common triggers and risks

Acute events like moving; chronic stressors like serious illness, job or neighbor conflict (Maercker et al., 2012)
Serious medical illness, especially in hospital settings (Mitchell et al., 2011)
Job loss and bereavement samples show higher rates (O'Donnell et al., 2019)
Disadvantaged life circumstances bring more stressors [David to verify in DSM-5-TR Risk and Prognostic Factors]

Course

Often time limited, but not always
About a third still met criteria at 12 months after injury (O'Donnell et al., 2016)
Can be an early marker of PTSD, MDD, or GAD (O'Donnell et al., 2016, 2019)
Most German cases had symptoms that began 6 to 24 months before assessment (Maercker et al., 2012)

Sources: Maercker et al., 2012; Mitchell et al., 2011; O'Donnell et al., 2016, 2019

Suicide risk: what the research shows

Suicidality in adjustment disorder appears at lower depressive symptom scores than in depressive episodes (Casey et al., 2015)
In an adolescent psychological autopsy study, the suicidal process was shorter and faster in those with adjustment disorder, often with no earlier warning history (Portzky et al., 2005)
Among adolescent outpatients with adjustment disorder, suicidal symptoms were found in 27% of girls and 18% of boys (Ferrer & Kirchner, 2014)
In a hospital sample, 60.5% had prior suicide attempts (Kryzhanovskaya & Canterbury, 2001)

"Subthreshold" diagnosis does not mean low risk. Ask every time.

Sources: Casey et al., 2015; Portzky et al., 2005; Ferrer & Kirchner, 2014; Kryzhanovskaya & Canterbury, 2001

Casey et al. (2015): 370 liaison psychiatry patients in Dublin. Younger age, single status, and higher depression severity were linked with suicidality in both groups.

Portzky et al. (2005): psychological autopsy of 19 adolescent suicides; small sample and retrospective informant interviews, so interpret with care.

Ferrer and Kirchner (2014): 97 Spanish adolescent outpatients. Only 6 percent of girls and no boys showed clear suicidal tendencies, but symptoms were common, especially in girls.

Kryzhanovskaya and Canterbury (2001): retrospective, 119 inpatients at the University of Virginia Hospital, so this reflects a high acuity sample, not outpatients. Many also had personality disorder and substance use diagnoses.

The Medcom adolescent video on the teen slide also shows suicidal ideation after a family conflict.

Safety assessment in practice

Ask and understand

Ask directly about suicidal thoughts and behavior; a structured tool like the C-SSRS can help organize the conversation (Posner et al., 2011)
Build a risk formulation, not a low, medium, high label (NICE, 2022)
Do not use risk scales to predict suicide or decide who gets care (NICE, 2022)

Plan together

Collaborative Safety Planning Intervention: warning signs, coping, people and places, professional contacts, lethal means safety (Stanley & Brown, 2012)
Safety planning plus follow up calls was linked to 45% fewer suicidal behaviors after ED discharge (Stanley et al., 2018)
Share the 988 Suicide and Crisis Lifeline

Sources: Posner et al., 2011; NICE, 2022; Stanley & Brown, 2012; Stanley et al., 2018

Assessment tools

Tool	What it does	Notes
ADNM-20	20 item self report; stressor checklist plus ICD-11 based symptoms	Cut off 47.5 for high risk (Lorenz et al., 2016); developed by Einsle et al., 2010
ADNM-8	Brief version: preoccupation and failure to adapt	Two factor structure supported (Kazlauskas et al., 2018)
ADNM-4	Ultra brief screen	Alpha above .80; correlated above .91 with full scale (Ben-Ezra et al., 2018)
IADQ	Self report for ICD-11 adjustment disorder	(Shevlin et al., 2020)
DIAD	Structured interview for DSM based criteria	Limited outside validation (Cornelius et al., 2014; O'Donnell et al., 2019)
PHQ-9, GAD-7, C-SSRS	Rule in or out MDD, GAD; screen suicide risk	(Kroenke et al., 2001; Spitzer et al., 2006; Posner et al., 2011)

Sources: see table

Einsle et al. (2010) developed the ADNM self report; factors were intrusion, avoidance, and failure to adapt, with internal consistency alpha .74 to .91.

Lorenz et al. (2016): optimal ADNM-20 cut off 47.5 to separate high from low risk, in a sample of 80 burglary victims. Small sample, so treat as a guide.

Ben-Ezra et al. (2018): Israeli national sample of 1,003. Brief versions correlated r above .918 with the original; Cronbach's alpha above .800. They established cut offs; I have not listed them. [David to verify ADNM-4 cut off before using it clinically.]

O'Donnell et al. (2019) note that the SCID and MINI only include a few adjustment disorder items.

[David to verify licensing and permission terms for the ADNM before clinical use, and whether a validated Spanish version exists for my clients.]

Across the lifespan: children

Common triggers in kids: a move, parents separating, a new sibling, a death, illness in the family, loss of a pet
Look for regression, irritability, school refusal, separation worries, physical complaints
Assess with the child and caregivers; include developmental and school history
Family involvement is a usual part of care

Ellen and Gene on Adjustment Disorders in Kids

Clay Center for Young Healthy Minds, Massachusetts General Hospital · 0:53

Open on YouTube

Sources: Boston Children's Hospital, n.d.; Fernández-Buendía et al., 2024; video: MGH Clay Center

Across the lifespan: adolescents

Conduct symptoms are more common in teens than adults
Risk can move fast: the suicidal process was short in adolescents with adjustment disorder (Portzky et al., 2005)
Ask about peers, social media, school, substances, and family conflict
Girls with adjustment disorder showed more suicidal symptoms than boys in one outpatient sample (Ferrer & Kirchner, 2014)

Content note: the clip depicts a teen describing suicidal thoughts.

Adjustment Disorder Series: Adolescent Adjustment Disorder, Case 1: Kramer (preview clip)

Medcom, Inc. (nursing and mental health training films) · 1:23

Open on YouTube

Sources: Portzky et al., 2005; Ferrer & Kirchner, 2014; NICE, 2022; video: Medcom, Inc.

Conduct versus mood pattern by age: Boston Children's Hospital patient education ("Adolescent symptoms of adjustment disorders are more behavioral such as acting out, while adults experience more depressive symptoms"). Hospital patient education, not peer reviewed. [David to verify against DSM-5-TR text.]

NICE NG225 (2022) recommendation 1.5.11 says assessments of young people who self harm should ask about social, peer group, education and home situations, and social media and internet use.

Video: Medcom, Inc., a company that makes nursing and mental health training films. This is a 1 minute 23 second preview of a longer paid film. The description says a teen named Kramer is brought in after threatening suicide following an argument with his mother, and that the case "focuses in on adolescent adjustment disorder." Actors, not real clients. I could not find a credible free full length adolescent video. [David to verify you are comfortable showing a commercial preview.]

Across the lifespan: adults

What is Adjustment Disorder?

Dr. Todd Grande, licensed professional counselor and counselor educator · 6:06

Open on YouTube

Analyzing Adjustment Disorder: Dr. Jennifer Hartstein

Dr. Jennifer Hartstein, clinical psychologist (NBC News Now segment) · 4:08

Open on YouTube

Grande walks through each criterion and the six specifiers (recorded 2018, uses DSM-5 wording before the PGD update)
Hartstein explains adjustment disorder for a general audience on NBC News Now

Videos: Dr. Todd Grande; Dr. Jennifer Hartstein

Treatment: what the evidence says

16 RCTs3,027 participants. Internet based and in person CBT may be effectiveCowansage et al., 2025

Low to very lowGRADE quality for all psychological and medication treatments, 29 studiesO'Donnell et al., 2018

9 studiesTechnology supported treatments outperformed controls; high heterogeneityFernández-Buendía et al., 2024

As a milder, stressor linked condition, adjustment disorder may respond to brief, lower intensity care (O'Donnell et al., 2019)
A CBT self help manual reduced preoccupation symptoms in burglary victims (Bachem & Maercker, 2016)

Sources: Cowansage et al., 2025; O'Donnell et al., 2018, 2019; Fernández-Buendía et al., 2024; Bachem & Maercker, 2016

Cowansage et al. (2025), Defense Health Agency Psychological Health Center of Excellence: systematic review and meta-analysis of 16 RCTs, 3,027 participants. Conclusion: internet based and in person CBT may be effective; more trials needed for other approaches.

O'Donnell et al. (2018): 29 studies, 1980 to 2016. Most psychological studies had CBT components (53 percent), three were psychodynamic, three behavioral, two relaxation. Evidence quality low to very low for everything.

Fernández-Buendía et al. (2024): 8 RCTs and 1 pre-post study of computerized and virtual reality treatments.

Bachem and Maercker (2016): 54 burglary victims randomized, no therapist contact, effect sizes d = .17 to .67.

Honest summary for supervision: CBT has the best support, but the field still lacks strong trials.

Cognitive behavioral therapy

Strongest current support among adjustment disorder treatments (Cowansage et al., 2025)
Targets: rumination and worry about the stressor, avoidance, and getting back to valued activity
Tools: psychoeducation, thought records, behavioral activation, graded return to roles, stress management
Dutch occupational guidelines use stress inoculation and graded activity to build problem solving (van der Klink & van Dijk, 2003)
Caution: CBT did not shorten time to return to work vs no treatment (Arends et al., 2012)

Structure of a CBT Session

Beck Institute for Cognitive Behavior Therapy · 4:00

Open on YouTube

Sources: Cowansage et al., 2025; van der Klink & van Dijk, 2003; Arends et al., 2012; video: Beck Institute

Problem solving therapy

A natural fit: the stressor often involves real problems to solve, like work, money, housing, care for a family member
Steps: define the problem, generate options, weigh them, act, review
Problem solving therapy shortened time to partial return to work vs non guideline care (Arends et al., 2012)
No effect found on time to full return to work (Arends et al., 2012)
NICE names CBT informed approaches such as problem solving therapy for adults who self harm (NICE, 2022)

Introduction to Problem Solving Therapy

Veterans Health Administration (U.S. Department of Veterans Affairs) · 4:48

Open on YouTube

Sources: Arends et al., 2012; NICE, 2022; video: Veterans Health Administration

Arends et al. (2012) Cochrane review: moderate quality evidence that PST significantly reduced time to partial return to work at one year compared with non guideline based care (mean difference minus 17 days, one study, 192 participants), but no significant effect on full return to work.

NICE NG225 recommendation 1.11.3: offer a structured, person centred, CBT informed psychological intervention (for example, CBT or problem solving therapy) tailored for adults who self harm, typically 4 to 10 sessions. This is about self harm, not adjustment disorder specifically.

The five steps are a simplified summary of problem solving therapy. [David to verify against a PST manual such as Nezu, Nezu, and D'Zurilla if you want exact step names.]

Video: Veterans Health Administration, "Introduction to Problem Solving Therapy," about 5 minutes. It describes PST for Suicide Prevention (PST-SP) for veterans, so it is a PST overview rather than adjustment disorder specific.

Brief psychodynamic and supportive therapy

Brief psychodynamic

Explores what the stressor means given the person's history and relationships
In an RCT of minor depressive disorders that included adjustment disorder with depressed mood, brief dynamic therapy beat waitlist and held gains better than supportive therapy at 6 months (Maina et al., 2005)
Small evidence base: three psychodynamic studies in the 2018 review (O'Donnell et al., 2018)

Supportive therapy

Validation, normalizing, strengthening coping and social support
Brief supportive therapy also improved symptoms vs waitlist (Maina et al., 2005)
Often the foundation underneath any approach

Sources: Maina et al., 2005; O'Donnell et al., 2018

Medication notes and referral

Psychotherapy is the first line approach; medication evidence is low to very low quality (O'Donnell et al., 2018)
No RCTs of medication for return to work in adjustment disorder were found (Arends et al., 2012)
Do not offer drug treatment as a specific intervention to reduce self harm (NICE, 2022)

When I refer to a prescriber or PCP

Severe insomnia or anxiety blocking engagement · symptoms now meet MDD, GAD, PTSD, or a substance use disorder · rising suicide risk · no improvement after a fair trial of therapy · medical contributors to rule out

Sources: O'Donnell et al., 2018; Arends et al., 2012; NICE, 2022

Cultural considerations

Criterion B asks us to judge distress in cultural context (APA, 2022)
Use the DSM-5-TR Cultural Formulation Interview to hear how the client explains the problem, what helps, and what they expect from care (APA, 2022)
Know the DSM-5-TR cultural concepts of distress, such as ataque de nervios and nervios (APA, 2022)

Consider identity, context, and intersectionality (Clauss-Ehlers et al., 2019)
Stressors like migration, discrimination, and language barriers can be ongoing, which matters for the persistent specifier
Pasadena, TX serves a large Hispanic and Spanish speaking community [David to verify with U.S. Census QuickFacts]
Offer services and measures in the client's preferred language when possible

Sources: APA, 2022; Clauss-Ehlers et al., 2019

DSM-5-TR Criterion B1 explicitly says "taking into account the external context and the cultural factors that might influence symptom severity and presentation" (APA, 2022, p. 319).

The Cultural Formulation Interview and the Glossary of Cultural Concepts of Distress are in DSM-5-TR Section III, Culture and Psychiatric Diagnosis. [David to verify page numbers.]

APA Multicultural Guidelines executive summary (Clauss-Ehlers et al., 2019) frames an ecological approach to context, identity, and intersectionality.

Ongoing stressors like migration related stress and discrimination are an illustration of enduring stressors per the DSM persistent specifier logic. Yue and Lau (2025) studied adjustment disorder among Hong Kong migrants in the UK, if you want a migration example. [David to verify that paper before citing it aloud.]

Several ADNM translations exist (for example a Japanese version, Nakagawa et al., 2025). [David to verify whether a validated Spanish ADNM or IADQ exists.]

Fictional composite case: presentation

FICTIONAL COMPOSITE. Not a real client. No real client information.

"Marco," 41

Laid off 7 weeks ago after 15 years at a plant
Moved his family in with his sister to save money
Poor sleep, constant worry about bills, tearful when alone, snapping at his kids
Stopped going to church and soccer with friends; drinking a little more on weekends
Passive thoughts that "my family would be better off with the insurance"; no plan, no intent, no past attempts

Screening at intake

PHQ-9 and GAD-7 in the moderate range, MDD criteria not met on interview
ADNM-20 above 47.5
C-SSRS: passive ideation only
No prior mental health history; no trauma exposure meeting PTSD Criterion A

Fictional teaching case

Fictional composite case: formulation

FICTIONAL COMPOSITE

Working diagnosis: F43.23 Adjustment disorder with mixed anxiety and depressed mood, acute

PresentingWorry, low mood, irritability, withdrawal, passive suicidal thoughts

PredisposingIdentity built around providing; few past coping challenges of this size

PrecipitatingJob loss and move

PerpetuatingRumination about money, avoidance of church and friends, more drinking, poor sleep

ProtectiveSupportive sister and wife, faith, work history, no prior attempts, engaged in care

ICD-11 lens: preoccupation (money rumination) plus failure to adapt (withdrawal, sleep, family conflict).

Fictional teaching case

Fictional composite case: treatment plan

FICTIONAL COMPOSITE

Plan

Safety first: collaborative safety plan, lethal means discussion, 988, wife involved with consent
Brief CBT with problem solving: job search steps, budget plan, benefits paperwork
Target rumination: worry time, thought records
Behavioral activation: return to church and soccer, time with kids
Sleep and alcohol: sleep routine, monitor drinking

Measure and review

Brief, time limited course; length is a clinical judgment
Repeat PHQ-9, GAD-7, ADNM-8 every 2 to 4 weeks
Ask about suicidal thoughts every session
Refer to PCP or prescriber if symptoms worsen, MDD emerges, or sleep does not improve
Review diagnosis at 6 months

Fictional teaching case

Discussion questions for supervision

When a client meets criteria for MDD or GAD after a clear life change, how do you hold the diagnosis and the adjustment frame together?
How should I document the clinical judgment that distress is "out of proportion" in cultural context?
Would you add ADNM-8 or ADNM-4 to my intake, alongside PHQ-9 and GAD-7?
What are your expectations for safety planning and follow up with passive ideation like Marco's?
When do you see persistent adjustment disorder as a signal to rediagnose?
Where am I blind? What would you do differently in the fictional case?

Key takeaways

Adjustment is at the heart of much of our work, and adjustment disorder is common in clinical settings
DSM-5-TR: stressor, onset within 3 months, disproportionate distress or impairment, no other disorder, not grief, resolves within 6 months after the stressor ends
ICD-11 adds a useful lens: preoccupation and failure to adapt
Subthreshold does not mean low risk. Ask about suicide and build a safety plan
CBT has the best evidence; problem solving, psychodynamic, and supportive therapy have smaller bases; medication evidence is weak
Measure, re-screen, and rediagnose when the picture changes

References

Diagnostic manuals and guidelines

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

National Institute for Health and Care Excellence. (2022). Self-harm: Assessment, management and preventing recurrence (NICE Guideline NG225). https://www.nice.org.uk/guidance/ng225

World Health Organization. (2024a). ICD-11 for mortality and morbidity statistics: 6B43 Adjustment disorder. https://icd.who.int/browse/2024-01/mms/en#264310751

World Health Organization. (2024b). Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders (CDDR). https://www.who.int/publications/i/item/9789240077263

Peer reviewed articles

Arends, I., Bruinvels, D. J., Rebergen, D. S., Nieuwenhuijsen, K., Madan, I., Neumeyer-Gromen, A., Bültmann, U., & Verbeek, J. H. (2012). Interventions to facilitate return to work in adults with adjustment disorders. Cochrane Database of Systematic Reviews, 2012(12), Article CD006389. https://doi.org/10.1002/14651858.CD006389.pub2

Bachem, R., & Casey, P. (2018). Adjustment disorder: A diagnosis whose time has come. Journal of Affective Disorders, 227, 243–253. https://doi.org/10.1016/j.jad.2017.10.034

Bachem, R., & Maercker, A. (2016). Self-help interventions for adjustment disorder problems: A randomized waiting-list controlled study in a sample of burglary victims. Cognitive Behaviour Therapy, 45(5), 397–413. https://doi.org/10.1080/16506073.2016.1191083

Ben-Ezra, M., Mahat-Shamir, M., Lorenz, L., Lavenda, O., & Maercker, A. (2018). Screening of adjustment disorder: Scale based on the ICD-11 and the Adjustment Disorder New Module. Journal of Psychiatric Research, 103, 91–96. https://doi.org/10.1016/j.jpsychires.2018.05.011

Ben-Itzhak, S., Bluvstein, I., Schreiber, S., Aharonov-Zaig, I., Maor, M., Lipnik, R., & Bloch, M. (2012). The effectiveness of brief versus intermediate duration psychodynamic psychotherapy in the treatment of adjustment disorder. Journal of Contemporary Psychotherapy, 42(4), 249–256. https://doi.org/10.1007/s10879-012-9208-6 [David to verify findings]

Casey, P. (2014). Adjustment disorder: New developments. Current Psychiatry Reports, 16(6), Article 451. https://doi.org/10.1007/s11920-014-0451-2

Casey, P., Jabbar, F., O'Leary, E., & Doherty, A. M. (2015). Suicidal behaviours in adjustment disorder and depressive episode. Journal of Affective Disorders, 174, 441–446. https://doi.org/10.1016/j.jad.2014.12.003

Clauss-Ehlers, C. S., Chiriboga, D. A., Hunter, S. J., Roysircar, G., & Tummala-Narra, P. (2019). APA Multicultural Guidelines executive summary: Ecological approach to context, identity, and intersectionality. American Psychologist, 74(2), 232–244. https://doi.org/10.1037/amp0000382

Cornelius, L. R., Brouwer, S., de Boer, M. R., Groothoff, J. W., & van der Klink, J. J. (2014). Development and validation of the Diagnostic Interview Adjustment Disorder (DIAD). International Journal of Methods in Psychiatric Research, 23(2), 192–207. https://doi.org/10.1002/mpr.1418

Cowansage, K. P., Milligan, T., Morgan, M. A., Boyd, C., Bellanti, D. M., Nair, R., Shank, L. M., Smolenski, D., Evatt, D. P., & Kelber, M. S. (2025). Treatments for adjustment disorder: A systematic review and meta-analysis of randomized controlled trials. Psychiatry Research, 353, Article 116739. https://doi.org/10.1016/j.psychres.2025.116739

Einsle, F., Köllner, V., Dannemann, S., & Maercker, A. (2010). Development and validation of a self-report for the assessment of adjustment disorders. Psychology, Health & Medicine, 15(5), 584–595. https://doi.org/10.1080/13548506.2010.487107

Fernández-Buendía, S., Miguel, C., Dumarkaite, A., Kazlauskas, E., Cuijpers, P., & Quero, S. (2024). Technology-supported treatments for adjustment disorder: A systematic review and preliminary meta-analysis. Journal of Affective Disorders, 347, 29–38. https://doi.org/10.1016/j.jad.2023.11.059

Ferrer, L., & Kirchner, T. (2014). Suicidal tendency in a sample of adolescent outpatients with adjustment disorder: Gender differences. Comprehensive Psychiatry, 55(6), 1342–1349. https://doi.org/10.1016/j.comppsych.2014.04.017

Kazlauskas, E., Gegieckaite, G., Eimontas, J., Zelviene, P., & Maercker, A. (2018). A brief measure of the International Classification of Diseases-11 adjustment disorder: Investigation of psychometric properties in an adult help-seeking sample. Psychopathology, 51(1), 10–15. https://doi.org/10.1159/000484415

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

Kryzhanovskaya, L., & Canterbury, R. (2001). Suicidal behavior in patients with adjustment disorders. Crisis, 22(3), 125–131. https://doi.org/10.1027//0227-5910.22.3.125

Lorenz, L., Bachem, R. C., & Maercker, A. (2016). The Adjustment Disorder–New Module 20 as a screening instrument: Cluster analysis and cut-off values. International Journal of Occupational and Environmental Medicine, 7(4), 215–220. https://doi.org/10.15171/ijoem.2016.775

Maercker, A., Forstmeier, S., Pielmaier, L., Spangenberg, L., Brähler, E., & Glaesmer, H. (2012). Adjustment disorders: Prevalence in a representative nationwide survey in Germany. Social Psychiatry and Psychiatric Epidemiology, 47(11), 1745–1752. https://doi.org/10.1007/s00127-012-0493-x

Maina, G., Forner, F., & Bogetto, F. (2005). Randomized controlled trial comparing brief dynamic and supportive therapy with waiting list condition in minor depressive disorders. Psychotherapy and Psychosomatics, 74(1), 43–50. https://doi.org/10.1159/000082026

Mitchell, A. J., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C., & Meader, N. (2011). Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. The Lancet Oncology, 12(2), 160–174. https://doi.org/10.1016/S1470-2045(11)70002-X

Nakagawa, A., Mitsuda, D., Umegaki, Y., Bachem, R., Nogami, W., Higuchi, R., Ito, A., & Kocha, H. (2025). Development and cross-cultural validation of the Japanese version of the Adjustment Disorder-New Module-20. PCN Reports, 4(2), Article e70104. https://doi.org/10.1002/pcn5.70104

O'Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 16(14), Article 2537. https://doi.org/10.3390/ijerph16142537

O'Donnell, M. L., Alkemade, N., Creamer, M., McFarlane, A. C., Silove, D., Bryant, R. A., Felmingham, K., Steel, Z., & Forbes, D. (2016). A longitudinal study of adjustment disorder after trauma exposure. American Journal of Psychiatry, 173(12), 1231–1238. https://doi.org/10.1176/appi.ajp.2016.16010071

O'Donnell, M. L., Metcalf, O., Watson, L., Phelps, A., & Varker, T. (2018). A systematic review of psychological and pharmacological treatments for adjustment disorder in adults. Journal of Traumatic Stress, 31(3), 321–331. https://doi.org/10.1002/jts.22295

Portzky, G., Audenaert, K., & van Heeringen, K. (2005). Adjustment disorder and the course of the suicidal process in adolescents. Journal of Affective Disorders, 87(2–3), 265–270. https://doi.org/10.1016/j.jad.2005.04.009

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia–Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266–1277. https://doi.org/10.1176/appi.ajp.2011.10111704

Quero, S., Rachyla, I., Molés, M., Mor, S., Tur, C., Cuijpers, P., López-Montoyo, A., & Botella, C. (2019). Can between-session homework be delivered digitally? A pilot randomized clinical trial of CBT for adjustment disorders. International Journal of Environmental Research and Public Health, 16(20), Article 3842. https://doi.org/10.3390/ijerph16203842

Shevlin, M., Hyland, P., Ben-Ezra, M., Karatzias, T., Cloitre, M., Vallières, F., Bachem, R., & Maercker, A. (2020). Measuring ICD-11 adjustment disorder: The development and initial validation of the International Adjustment Disorder Questionnaire. Acta Psychiatrica Scandinavica, 141(3), 265–274. https://doi.org/10.1111/acps.13126

Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256–264. https://doi.org/10.1016/j.cbpra.2011.01.001

Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900. https://doi.org/10.1001/jamapsychiatry.2018.1776

van der Klink, J. J., & van Dijk, F. J. (2003). Dutch practice guidelines for managing adjustment disorders in occupational and primary health care. Scandinavian Journal of Work, Environment & Health, 29(6), 478–487. https://doi.org/10.5271/sjweh.756

Yue, R., & Lau, B. H. P. (2025). The pains amidst starting a new life: Investigating adjustment disorder in Hong Kong migrants' transition to the UK. Scientific Reports, 15(1), Article 40545. https://doi.org/10.1038/s41598-025-24311-1 [David to verify before citing aloud]

Zelviene, P., & Kazlauskas, E. (2018). Adjustment disorder: Current perspectives. Neuropsychiatric Disease and Treatment, 14, 375–381. https://doi.org/10.2147/NDT.S121072

Secondary citations (cited as reported in O'Donnell et al., 2019; primary papers not reviewed)

Strain, J. J., Smith, G. C., Hammer, J. S., McKenzie, D. P., Blumenfield, M., Muskin, P., Newstadt, G., Wallack, J., Wilner, A., & Schleifer, S. S. (1998). Adjustment disorder: A multisite study of its utilization and interventions in the consultation-liaison psychiatry setting. General Hospital Psychiatry, 20(3), 139–149. https://doi.org/10.1016/S0163-8343(98)00020-6

Taggart, C., O'Grady, J., Stevenson, M., Hand, E., McClelland, R., & Kelly, C. (2006). Accuracy of diagnosis at routine psychiatric assessment in patients presenting to an accident and emergency department. General Hospital Psychiatry, 28(4), 330–335. https://doi.org/10.1016/j.genhosppsych.2006.05.002

Hospital patient education (non peer reviewed; used for clinical examples only)

Boston Children's Hospital. (n.d.). Adjustment disorders. Retrieved November 4, 2026, from https://www.childrenshospital.org/conditions-treatments/adjustment-disorders

Johns Hopkins Medicine. (n.d.). Adjustment disorders. Retrieved November 4, 2026, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/adjustment-disorders

Videos (all checked November 4, 2026: public, embeddable, title and description on topic)

Beck Institute for Cognitive Behavior Therapy. (2019, January 4). Structure of a CBT session [Video]. YouTube. https://www.youtube.com/watch?v=5XmaYUrIceI

Grande, T. [Dr. Todd Grande]. (2018, April 12). What is adjustment disorder? [Video]. YouTube. https://www.youtube.com/watch?v=l44wfxM0Sk0

Hartstein, J. [DrJenHartstein]. (2025, January 2). Analyzing adjustment disorder: Dr. Jennifer Hartstein [Video]. YouTube. https://www.youtube.com/watch?v=yDurtPX0ngM

MGH Clay Center for Young Healthy Minds [MGHClayCenter]. (2017, October 26). Ellen and Gene on adjustment disorders in kids [Video]. YouTube. https://www.youtube.com/watch?v=ajZ_tSMkfY0

Medcom, Inc. (2018, March 1). 31201 - Adjustment disorder series: Adolescent adjustment disorder, case 1: Kramer (disc 1 of 2) [Video]. YouTube. https://www.youtube.com/watch?v=jAlUvEN9gww

Nasjonal kompetansetjeneste ROP. (2019, September 6). Andreas Maercker: Introduction to adjustment disorder (ICD-11) [Video]. YouTube. https://www.youtube.com/watch?v=wj0IKOVm0Ss

Symptom Media. (2019a, March 25). Adjustment disorder with mixed disturbance example, DSM-5-TR video case [Video]. YouTube. https://www.youtube.com/watch?v=tB6AydhozO8

Symptom Media. (2019b, November 19). Adjustment disorder with depressed mood case study (DSM-5-TR) [Video]. YouTube. https://www.youtube.com/watch?v=q5oV1uKjiFg

Symptom Media. (2020a, April 27). Adjustment disorder with mixed anxiety & depressed mood clinical case [Video]. YouTube. https://www.youtube.com/watch?v=nWQ4u8A8Ye4

Symptom Media. (2020b, April 28). Adjustment disorder with anxiety video, DSM-5-TR case, diagnosis training [Video]. YouTube. https://www.youtube.com/watch?v=SkX7LCq8NYg

Veterans Health Administration. (2024, June 11). Introduction to problem solving therapy [Video]. YouTube. https://www.youtube.com/watch?v=e87Vk8TNB0Y

Full APA 7 list, also saved as references.md. Scroll inside the slide with the mouse or trackpad.

Items still flagged for me to verify before Monday:

Exact chapter listing of Trauma and Stressor Related Disorders in your DSM-5-TR copy (slide 4).
DSM-5-TR Prevalence text: about 5 to 20 percent of outpatient principal diagnoses and up to about 50 percent in hospital psychiatric consultation, with page number (slide 19).
DSM-5-TR Risk and Prognostic Factors wording on disadvantaged life circumstances (slide 20).
DSM-5-TR text on age differences (conduct symptoms in teens, depressive symptoms in adults); currently supported only by hospital patient education pages (slides 10, 24, 25).
DSM-5-TR wording on examples for the Unspecified specifier (slide 12).
Exact ICD-11 6B43 wording on the WHO browser, which did not load for automated checking (slide 14).
ADNM-4 cut off score, ADNM licensing and permission terms, and whether a validated Spanish ADNM or IADQ exists (slides 23, 32).
Whether any medication has an FDA indication specifically for adjustment disorder (slide 31).
Page numbers for the Cultural Formulation Interview and cultural concepts of distress in DSM-5-TR Section III (slide 32).
Pasadena, TX demographics from U.S. Census QuickFacts (slide 32).
Comfort showing the Medcom commercial preview clip, which depicts suicidal ideation (slide 25).
Ben-Itzhak et al. (2012) findings; Yue and Lau (2025) before citing aloud.
Problem solving therapy step names against a PST manual (slide 29).
Current local job loss resources such as Texas Workforce Commission before naming them to clients (slide 35).
Your own clinical impression that mixed anxiety and depressed mood is the most common presentation in your caseload (slide 9).

Adjustment Disorders

Goals for today

Why adjustment matters

What I see in practice

What the literature says

Where adjustment disorders sit in DSM-5-TR

DSM-5-TR criteria A to C

DSM-5-TR criteria D and E

What changed in the text revision

Coding

Specifier 1: With depressed mood (F43.21)

Clinical picture

Specifier 2: With anxiety (F43.22)

Clinical picture

Specifier 3: With mixed anxiety and depressed mood (F43.23)

Clinical picture

Specifier 4: With disturbance of conduct (F43.24)

Clinical picture

Specifier 5: With mixed disturbance of emotions and conduct (F43.25)

Clinical picture

Specifier 6: Unspecified (F43.20)

Clinical picture

Acute vs persistent (chronic)

Acute

Persistent (chronic)

The ICD-11 view

DSM-5-TR and ICD-11 side by side

Differential 1: Normal stress reaction

Expected stress

Adjustment disorder

Differential 2: PTSD and acute stress disorder

Differential 3: Major depression and GAD

Major depressive disorder

Generalized anxiety disorder

Prevalence across settings

Risk factors and course

Common triggers and risks

Course

Suicide risk: what the research shows

Safety assessment in practice

Ask and understand

Plan together

Assessment tools

Across the lifespan: children

Across the lifespan: adolescents

Across the lifespan: adults

Treatment: what the evidence says

Cognitive behavioral therapy

Problem solving therapy

Brief psychodynamic and supportive therapy

Brief psychodynamic

Supportive therapy

Medication notes and referral

When I refer to a prescriber or PCP

Cultural considerations

Fictional composite case: presentation

"Marco," 41

Screening at intake

Fictional composite case: formulation

Fictional composite case: treatment plan

Plan

Measure and review

Discussion questions for supervision

Key takeaways

References

Diagnostic manuals and guidelines

Peer reviewed articles

Secondary citations (cited as reported in O'Donnell et al., 2019; primary papers not reviewed)

Hospital patient education (non peer reviewed; used for clinical examples only)

Videos (all checked November 4, 2026: public, embeddable, title and description on topic)

Speaker notes