Adjustment Disorder



Adjustment Disorder

Dr Jonathan Haverkampf

When a relationship breaks apart, a loved one dies or a job is lost, but also in happy circumstances, such as winning the lottery, people need to adjust to the new circumstances, which may temporarily, and sometimes even in the long run, lead to psychiatric symptoms.

Common symptoms of an adjustment disorder are light to moderate depression, various degrees of anxiety or traumatic stress, or a combination of these. There are a number of different flavours of adjustment disorders, but the underlying problem is the same. The world of the patient has changed, at least subjectively in a very profound way.

The perceived enormity of the change depends on one’s values. Winning the lottery changes the world for someone who values material possessions highly more than that of a Trappist monk. One common observation is that those for whom a particular change is more difficult to process are those with poorly defined value systems, who only have tenuous contact with what they feel is important in their lives. If a change happens, it adds further instability to an already unstable system. The result is anxiety, a state of fear of the unknown and the uncertain.

Working patients on their interests, values and aspirations is especially important in cases of adjustment disorder.

The sense of loss of direction is visible in the typical patient with adjustment disorder: He or she is rather young, has more identified psychosocial and environmental problems and has undergone shorter or no treatment, especially not psychodynamic treatment. However, it can affect people of all ages and from all walks of life. The basic requirement seems to be that the change is outside the reach of their usual coping mechanisms. If someone already has very narrow, rigid or fragile coping mechanisms with little flexibility, they are likely to break down earlier and expose the person to the anxiety of uncertainty and insecurity.

We live in a world where changes in one’s individual situation are the norm rather than the exception. Many cultures and societies have adapted to this by internalizing change (‘change is good’). The more this springs from their basic values and beliefs, the better it works. In this sense a social group is not very different from an individual. The more one is in contact with one’s fundamental values, the less change will affect the person. Values and meaning are not the same. Meaning is if some information is able to bring about a change, however small, in a person. A value is in some ways complementary to meaning. It informs what change is possible and provides a direction for decision-making. Fundamental values are very stable and there is probably a rudimentary biological program for us to have them. Many derivative values are probably formed in childhood.

If one’s world has changed in a fundamental aspect, the sense of certainty and predictability is affected. However, there is a difference between security and certainty. I can face uncertain times but still feel secure. As long as I know I have a system to make decisions that are good for me, I can feel quite secure even if I do not know which decisions I will have to take. The more flexible we are in our perspectives and our outlook on the world the less likely we are to have problems with adjustment in a changing world. But this requires knowing there is a good and solid decision-making system, which is where one’s values, interests and aspirations come into play.

What helps in times of change is to focus on the things that remain constant, our values and interests, our sense of self and who we are. Having a stable sense of self helps in the face of sudden change, whether positive or negative change. Winning the lottery has ripped many from their comfortable paths and actually left them worse off psychologically and financially in the long- and even medium-term.

So, what are these stable components and how can one learn about them? You know what you are interested in because doing it feels god over the long run. Your values are what you get emotional about when they are touched in some way. Our internal and external communication points us to our values by exposing us to messages that resonate or do not. Something may be meaningful to us but does not resonate with our values and interests. Then the message tends to stop with us. In adjustment disorder there is confusion and one can sense that the patient sends out conflicting signals. The reason is that if one is not sure about one’s values everything can potentially be of value. The result is the tendency to try to respond to everything and taking on stress, which actually leads to doing nothing or things that are not really congruous with one’s values.

If there are not many emotions attached to something it may be something your environment wants you to do, but which is not that important to you. You learn about these things by communicating with yourself. Many people have gotten out of touch with themselves because they think they have to have different values and interests. But the truth is that values at least do not change much over time, if at all, because they are too closely linked with who we are and our sense of self. When we do things that are congruous with them we feel ourselves the most.

Self-confidence is about doing things one enjoys. Feeling good is a prerequisite for building self-confidence because it attaches good feelings to what you do and think, and thereby also to yourself. Lasting and stable self-confidence require es activities that are congruous with oneself, but it is very effective as a defence against various kinds of adjustment disorders. So it comes down to identifying one’s values. The interesting thing about values is that they may be formulated and defined in the process of exploration. This is definitely what can be observed in psychodynamic therapy which has as one objective to make one’s personality more authentic and self-actualized. It also helps to create and design better coping mechanisms, because they are rooted in a more stable experience of the self, one’s values, aspirations and interests.

Coping mechanisms are the strategies we use to deal with the emotional consequences of stressors. This means the more experience one has with dealing with changing situations in life the better one may cope with them. Children are thus more likely to suffer from an adjustment disorder in the same situation as an adult, if the changes are not outside usual human experience, such as rape or serious violence. We learn these tools in our interactions with other people. Thus social skills and the ability to communicate helps one deal with adjustment problems. Another advantage is that communication helps one to respond more flexibly to react to changing life situations.

Trauma in the past, especially if they have occurred repeatedly, can increase the risk of adjustment problems. One reason might be that traumata leave more vulnerable coping and defense systems, another that traumata lead to greater rigidity from the experience of a not only hurtful but also unpredictable world. If one’s value system, which gives a sense of stability to the self, is seriously compromised or damaged, this can lead to a variety of self-defeating behaviors. The goal is to reconnect the patient with his or her true values in a therapeutic interaction that affects the internal communication in the patient.

© 2012, 2016 Christian Jonathan Haverkampf. All rights reserved.; Dublin, Ireland

This paper is solely a basis for academic discussion, no medical advice can be given and no medical advice is given. Always consult a professional if you believe you might suffer from a medical condition.

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