Adjustment Disorders in Midlife and Beyond
Most people in midlife and later life have developed a considerable capacity for coping. Decades of navigating difficulty, whether that’s work pressures, relationship changes, health challenges, or loss, tend to produce resilience, perspective, the ability to cope adaptively, and keep going when things are hard.
And then something happens. A diagnosis. A redundancy. A retirement that does not feel like relief. A bereavement. A marriage ending. A child leaving. A parent who can no longer live independently. Something that arrives with enough weight that the usual coping strategies such as keeping busy, talking to a friend, giving it time, are not quite enough.
What follows is not depression in the clinical sense, and not anxiety as it is typically understood. It is something more specific: a struggle to adapt to a significant change that has disrupted the person’s sense of themselves and their life. Persistent, distressing, and more disabling than the circumstances seem to others to warrant; which is often part of what makes it hardest to name, and hardest to seek help for.
This is what psychologists call an adjustment disorder. And in midlife and later life, it is one of the most common mental health presentations and one of the most undertreated.
The space between coping and not coping
There is a vast and underacknowledged space between coping well and clinical depression or anxiety. Most people in psychological difficulty are not at either extreme; they are somewhere in between: managing on the surface, struggling underneath, and unsure whether what they are experiencing is serious enough to warrant help.
Adjustment disorder exists in that space. It is a clinical condition recognised in both the DSM-5 and the ICD-11, the two diagnostic systems used globally but it sits at a lower threshold of severity than major depression or anxiety disorder. Its hallmark is not severity but specificity: the distress is directly tied to an identifiable stressor, is disproportionate to what most people would experience in similar circumstances, and significantly affects daily functioning.
For people in midlife and later life, this experience is both extremely common and, in a culture that prizes stoicism and resilience, extremely difficult to acknowledge. There is a pervasive expectation that major life changes, such as retirement, bereavement, health challenges, are simply part of getting older, and should be absorbed without too much fuss. This expectation is both unrealistic and harmful. The psychological challenge of adapting to major life transitions is real, and it deserves real support.
What is an adjustment disorder?
How adjustment disorder is defined
An adjustment disorder is a clinically significant emotional or behavioural response to an identifiable life stressor that is either disproportionate in intensity to the severity of the stressor, or causes marked impairment in social, occupational, or other areas of functioning (American Psychiatric Association, 2013).
The ICD-11 — the most recent international diagnostic system, released by the World Health Organisation in 2018 and now used in Australia — describes adjustment disorder as a failure to adapt to a stressor, characterised by preoccupation with the stressor and its consequences, alongside difficulty accepting and adjusting to what has changed (World Health Organisation, 2018). This formulation is clinically useful because it captures something important: the problem is not just the presence of distress, but the person’s difficulty moving through it.
Key diagnostic features include:
Symptoms develop within three months of the onset of the stressor
Symptoms cause clinically significant distress or functional impairment
Symptoms do not meet criteria for another mental health disorder
Symptoms do not represent normal bereavement
Symptoms typically resolve within six months once the stressor has resolved though in the presence of ongoing stressors, adjustment disorder can persist for longer
The last point is particularly relevant in midlife and later life, where the stressors are frequently ongoing, for example a chronic illness or condition, a long-term family carer role, a sustained period of financial strain, rather than single acute events that resolve neatly.
The subtypes
The DSM-5 recognises six subtypes of adjustment disorder, reflecting the range of ways the condition presents:
With depressed mood: characterised by low mood, tearfulness, and hopelessness
With anxiety: characterised by worry, nervousness, or fear
With mixed anxiety and depressed mood: the most commonly diagnosed subtype in clinical practice
With disturbance of conduct: characterised by behavioural changes such as impulsivity or recklessness
With mixed disturbance of emotions and conduct: combining emotional and behavioural symptoms
Unspecified: for presentations that do not fit neatly into the above categories
In midlife and later life, adjustment disorder with anxiety, with depressed mood, and with mixed anxiety and depressed mood are the presentations most frequently seen, reflecting the emotional complexity of the transitions and losses that typically trigger the condition in this age group (Zapata-Ospina et al., 2020).
What adjustment disorder is not
It is worth being explicit about what adjustment disorder is not, because the boundaries matter both diagnostically and therapeutically.
Adjustment disorder is not depression, although it shares some features. The key distinctions are the direct relationship to an identifiable stressor, the lower severity of symptoms, and the expectation that it will resolve as the person adapts. A 2022 systematic review by Kelber et al. noted that adjustment disorder and major depressive disorder share symptom profiles but differ in severity and prognosis with adjustment disorder characterised by lower depressive symptom scores and a better prognosis (Kelber et al., 2022).
Adjustment disorder is not the same as grief, though grief can trigger it. Normal grief, even when intense, is not pathological. Adjustment disorder is diagnosed when the response is clearly disproportionate or when it significantly disrupts functioning in ways that normal grief does not.
And adjustment disorder is not ‘just stress.’ The clinical threshold of significant distress and functional impairment means that many people who are stressed, and coping, do not meet criteria. The diagnosis is for those whose capacity to adapt has been genuinely overwhelmed.
Why midlife and later life are periods of particular vulnerability
Adjustment disorders can occur at any age and in response to any significant stressor. But midlife and later life are periods of distinctive vulnerability for several reasons.
First, the sheer density of potential stressors increases in the second half of life. People in their fifties, sixties, and seventies are frequently navigating multiple concurrent changes, their own health, their partner’s health, ageing parents, career transitions, changing family structures, in ways that rarely have parallels in younger adulthood. The cumulative load of these changes can overwhelm adaptive capacity even in people with considerable psychological resources.
Second, a 2020 study by Zelviene et al. found that older age was itself a risk factor for adjustment disorder in a general population sample exposed to life stressors, suggesting that the biological and psychological changes of ageing may reduce the buffer against stress responses, independent of the severity of the stressor (Zelviene et al., 2020).
Third, the stressors of later life are often specifically the kind that adjustment disorder research identifies as highest risk: health-related stressors. A 2025 nationwide survey by Chu et al. found that health-related stressors were significantly more common in adults over 60 with adjustment disorder than in younger adults, affecting 67.8% of older adults with the condition compared to 51.3% of younger adults (Chu et al., 2025). And anxiety symptoms were the strongest predictor of adjustment disorder in the older adult group, with a substantially larger effect than in younger populations.
Fourth, and perhaps most importantly, the cultural scaffolding for navigating these transitions is thin. There is relatively little social permission for midlife and later-life adults to say, openly, that they are struggling to adapt, and relatively few structures to support them when they do.
The stressors that most commonly trigger adjustment disorders in midlife and later life
Retirement
Retirement is often assumed to be a positive transition. And for many people, eventually, it is. But the period of adjustment, particularly in the first year or two, can be psychologically demanding in ways that few people anticipate. The loss of work identity, daily structure, social connection, and sense of purpose can combine to produce a genuine adaptive challenge. A 2020 meta-analysis by van der Heide et al. found that the psychological impact of retirement was highly variable, with those who had not developed a sense of self beyond their work role at particular risk of adjustment difficulties (van der Heide et al., 2020).
Health diagnoses: your own or someone you love
A significant health diagnosis such as cancer, cardiac disease, dementia, chronic pain, a neurological condition, represents what researchers call a biographical disruption: the sense that the life story being written has been interrupted, and that a new narrative must now be found (Bury, 1982). The psychological challenge of adapting to a diagnosis is not simply one of managing symptoms. It is one of reconstructing a sense of self and future. This process takes time, and when it stalls, adjustment disorder is a common result.
Bereavement and loss
The losses of midlife and later life accumulate, whether partners, parents, siblings, friends, or peers. Each loss requires a period of adaptation that is real, time-consuming, and psychologically demanding. When the response to bereavement is clearly disproportionate to what is socially and culturally expected, or when it significantly disrupts functioning, an adjustment disorder may be the appropriate clinical framing, although care is needed to distinguish this from normal grief, which is not pathological and does not require clinical treatment.
Relationship breakdown
The end of a long-term relationship, whether through separation, divorce, or the gradual estrangement of a partnership, is one of the most significant life stressors any person can face, and in midlife and later life it carries particular weight. The loss of the shared life, of identity, of social networks built over decades, and of anticipated futures can be genuinely destabilising. Research consistently identifies relationship breakdown as one of the most common triggers for adjustment disorder across the lifespan (Kelber et al., 2022).
Career change, redundancy, or financial disruption
Involuntary career change, through redundancy, organisational change, or the forced reconfiguration of a career that has been central to identity for decades, can produce an adjustment response that is more severe than the external circumstances appear to warrant. When work has been a primary source of identity, structure, and social connection, its loss or transformation requires a genuine adaptive process that is frequently underestimated.
Becoming a carer
Taking on a significant carer role, for a partner with dementia, a parent with a serious illness, or an adult child with complex needs, involves not only practical demands but a profound shift in identity, relationship, and life orientation. A major analysis by Ye et al. in 2023, found significant psychological distress among informal carers of people with chronic health conditions, with anxiety and depression the most commonly reported outcomes (Ye et al., 2023). For carers who do not meet the threshold for depression or anxiety disorder, adjustment disorder is frequently the more accurate diagnosis.
Empty nest and shifting family roles
The departure of the last child from the family home or the gradual shift from active parent to less central figure in adult children’s lives can prompt a reevaluation of self-identity, which for some people is more destabilising than they expected. Research by Mitchell (2010) found that the empty nest transition prompted identity reassessment in both mothers and fathers, with many describing a need to reconnect with parts of themselves that had been set aside during the intensive parenting years.
How adjustment disorder presents, and why it often goes unrecognised
One of the reasons adjustment disorder is so frequently undertreated is that it often does not look like what most people think of as a mental health problem. It tends to present quietly, as a persistent low mood that doesn’t quite lift, as a worry that won’t settle, as a difficulty concentrating or sleeping or finding motivation, as an irritability that is out of character, as a pulling back from social life that is explained as tiredness or busyness.
What makes it clinically identifiable is the combination of these symptoms with a clear triggering stressor, and the persistence and functional impact that distinguishes it from an ordinary stress response.
In older adults specifically, adjustment disorder is frequently masked by somatic symptoms, such as physical complaints including fatigue, headaches, pain, and gastrointestinal disturbance, which send people to their GP for physical investigation rather than psychological support. A 2020 review found that adjustment disorder with anxiety in older adults was a significantly disabling cause of anxiety symptoms that was routinely underrecognised and undertreated in primary care settings (Nguyen et al., 2020).
There is also the issue of attribution: both the person experiencing adjustment disorder and the people around them tend to attribute the symptoms to the stressor itself (“of course they’re struggling; look at what’s happened”) rather than recognising that the response has moved beyond what the adaptive process typically involves. This attribution, which is partly accurate, and partly a normalisation of what is, in fact, a treatable condition, is one of the primary reasons people don’t seek help.
The risk of pushing through
Adjustment disorder is generally considered a time-limited condition, one that resolves as the person adapts to the stressor. But this outcome is not guaranteed, and the assumption that it will resolve on its own can be harmful.
Research suggests that untreated adjustment disorder significantly increases the risk of developing a more severe disorder, particularly major depression and anxiety disorder, over time. A 2022 systematic review found that adjustment disorder symptoms were a significant predictor of subsequent depression, particularly in the presence of ongoing stressors and when the person had limited social support (Kelber et al., 2022). In other words: the window in which adjustment disorder can be addressed at a relatively lower threshold of severity is a clinically important one. Waiting until it becomes depression is not a neutral strategy.
There are also the immediate costs of untreated adjustment disorder to consider: the impact on relationships, work performance, physical health, and quality of life that accumulates during a period of sustained adaptive difficulty. These costs are significant, and they are not an inevitable consequence of the stressor itself, but instead a consequence of struggling to adapt without support.
What the evidence says helps
It is important to be honest about where the evidence base for adjustment disorder treatment currently stands. The research is less extensive than for major depression or anxiety disorders, partly because the condition has been harder to define precisely and partly because it is often regarded as less severe. However, several approaches are supported by the available evidence, and clinical consensus is strong.
Psychological therapy: CBT and related approaches
Cognitive Behavioural Therapy (CBT) is the most researched psychological intervention for adjustment disorder, and the results are promising — though the evidence base is still emerging. A 2023 review identified a small but growing body of studies finding CBT effective for reducing adjustment disorder symptoms, including a randomised controlled trial finding that both face-to-face and internet-delivered CBT produced significant symptom improvements in adults with adjustment disorder (Shafierizi et al., 2023). A 2023 pre-post intervention trial also found a significant and large reduction in psychosocial symptoms following individual CBT across treatment conditions, with a large effect size (Van Wijk, 2023).
The caveat the evidence demands is honesty: the methodological quality of existing studies is variable, and the evidence is not yet as robust as for other conditions. What can be said confidently is that CBT is showing meaningful promise, is well-matched to the nature of adjustment disorder — which frequently involves unhelpful thinking patterns and avoidant coping, and is the approach most supported by the available literature.
Acceptance and Commitment Therapy
ACT is particularly well-suited to adjustment disorder because so much of what makes adjustment difficult is the struggle against what has happened, the resistance to accepting what cannot be changed, rather than the stressor itself. ACT directly targets this resistance, helping people develop a more flexible relationship with unwanted thoughts and feelings while clarifying what matters and taking steps toward it.
A 2024 qualitative study by Willi et al. found that ACT practitioners viewed it as well-suited to bereavement support, one of the most common adjustment disorder triggers, because of its focus on present-moment awareness, acceptance of loss, and values-guided action (Willi et al., 2024). A 2023 meta-analysis by Ye et al. found ACT effective for improving psychological health in informal carers of people with chronic health conditions — another high-risk group for adjustment disorder (Ye et al., 2023). And a 2021 systematic review by Lappalainen et al. found ACT effective for older adults across outcomes including anxiety, depression, and quality of life (Lappalainen et al., 2021).
Social support and connection
Social support is one of the most robust protective factors against adjustment disorder, and its absence is one of the strongest risk factors. People who are navigating major life transitions with strong, genuine social networks, including people who understand and share aspects of their experience, adapt more successfully than those who are doing so alone. Actively maintaining and building social connection during periods of transition is not merely a comfort measure but rather a therapeutic intervention.
Meaning-making and life review
For adjustment disorders triggered by transitions that carry existential weight, including retirement, health diagnosis, major bereavement, meaning-making approaches are particularly relevant. Research consistently shows that the ability to make sense of difficult experiences, or to find meaning, however partial, in what has happened, is a central mechanism of successful adaptation (Park, 2010). Life review therapy provides a structured context for this process, helping people integrate difficult transitions into a coherent and sustaining life narrative. A 2024 integrative review by Jiang et al. found life review associated with improved life satisfaction and reduced depression and anxiety in older adults, with meaning-making identified as a key mediating mechanism (Jiang et al., 2024).
Physical activity
Physical activity is a well-established intervention for depression and anxiety, and there is reasonable evidence for its value in adjustment disorder — operating through its effects on mood regulation, stress physiology, sleep quality, and social connection when activity is undertaken in social contexts. A 2021 meta-analysis by Stubbs et al. found aerobic exercise significantly reduced anxiety symptoms in older adults, with effects comparable to pharmacological treatment in mild-to-moderate anxiety (Stubbs et al., 2021). For people whose adjustment disorder is centred on a health diagnosis or physical change, finding forms of activity that are adapted to current capacity is both practically and psychologically important.
What about medication?
Medication is not a first-line treatment for adjustment disorder and is not recommended as a primary intervention. Because adjustment disorder is by definition a time-limited response to a stressor, rather than a chronic condition driven by underlying neurobiological changes, the evidence base for pharmacological treatment is limited.
Where medication may play a role is in the management of specific symptoms, particularly sleep disruption or severe anxiety, that are severe enough to significantly impede the person’s capacity to engage with psychological treatment or daily functioning. In these cases, short-term, targeted medication under GP supervision may be appropriate as an adjunct to psychological treatment.
The risk to avoid is the substitution of medication for psychological support; a pattern that is particularly common in older adults presenting to GPs with adjustment-related symptoms, and that addresses the symptoms without supporting the underlying adaptive process.
Frequently asked questions
How do I know if what I’m experiencing is an adjustment disorder rather than depression?
The clearest distinguishing features are the presence of a specific triggering stressor and the expectation that the condition will resolve as you adapt. Depression can exist without a clear stressor, and tends to involve a more pervasive and severe lowering of mood, energy, and motivation. In practice, the distinction is not always clean, and it matters less than the willingness to seek help. A psychologist or GP can help you understand what you are experiencing and what support is most appropriate.
Can adjustment disorder resolve on its own?
Sometimes, but not always, and not inevitably. Research suggests that untreated adjustment disorder carries a meaningful risk of progressing to more severe depression or anxiety, particularly in the presence of ongoing stressors or limited social support (Kelber et al., 2022). The window in which it can be addressed at a lower threshold of severity is clinically important, and waiting to see if it resolves on its own is not a neutral strategy. Psychological support in the early stages of adjustment difficulty is more effective than waiting until the condition has become more entrenched.
Is adjustment disorder a serious diagnosis?
It is a real diagnosis with real functional consequences, including effects on relationships, work, physical health, sleep, and quality of life. Its lower threshold of severity compared to major depression does not mean it is trivial or should be minimised. The fact that it often resolves with appropriate support is a reason to seek help, not a reason to dismiss it.
How long does treatment for adjustment disorder take?
Treatment is typically shorter than for more complex conditions; often in the range of six to twelve sessions, with many people experiencing significant improvement within that period. A 2023 study found significant and large reductions in psychosocial symptoms across twelve weeks of individual CBT (Van Wijk, 2023). Because the condition is directly tied to a specific stressor, treatment is often more focused and more quickly effective than for chronic mood or anxiety disorders.
What if the stressor is ongoing, like a family member’s illness?
This is an important question and a very common situation. When the stressor is ongoing, such as a carer role that continues, a chronic illness or condition, a financial strain that has not resolved, adjustment disorder can still be found beyond the typical six-month window. In these situations, treatment focuses not on waiting for the stressor to resolve but on developing a more sustainable relationship with a situation that is not going to change; building psychological flexibility, coping strategies, and meaning-making that allow life to be lived well alongside ongoing difficulty. ACT is particularly well-suited to this kind of presentation.
How do I get started at Upside Stories?
The easiest first step is a free 20-minute consultation. This gives you an opportunity to meet Bruce, describe what you are experiencing, and find out whether individual online therapy, the Rewrite Your Story program, or the Carers’ Compass program is the right fit for you.
Do I need a GP referral?
No referral is needed to book. If you have a GP referral with a Mental Health Treatment Plan, Medicare rebates apply, which reduces the cost of sessions significantly. A GP visit is also a useful first step to rule out any physical contributors to your symptoms and to discuss whether a Mental Health Treatment Plan is appropriate.
What the research tells us
Adjustment disorder is a clinically significant emotional or behavioural response to an identifiable life stressor, characterised by distress that is disproportionate to the stressor or causes marked functional impairment (APA, 2013; WHO, 2018).
Health-related stressors are significantly more common triggers for adjustment disorder in adults over 60 than in younger adults, and anxiety symptoms are a stronger predictor of adjustment disorder in older adults (Chu et al., 2025).
Older age is itself a risk factor for adjustment disorder in people exposed to significant life stressors, independent of stressor severity (Zelviene et al., 2020).
Adjustment disorder with mixed anxiety and depressed mood is the most commonly diagnosed subtype in clinical practice (Kelber et al., 2022).
Untreated adjustment disorder significantly increases the risk of progressing to major depression or anxiety disorder, particularly in the presence of ongoing stressors (Kelber et al., 2022).
In older adults, adjustment disorder is frequently underrecognised due to presentation with somatic rather than psychological symptoms (Nguyen et al., 2020).
CBT is the most researched treatment for adjustment disorder and shows promising results, though the evidence base is still emerging and methodological quality is variable (Shafierizi et al., 2023; Van Wijk, 2023).
ACT is particularly well-suited to adjustment disorder involving ongoing stressors, including bereavement, caring, and chronic illness (Willi et al., 2024; Ye et al., 2023; Lappalainen et al., 2021).
Life review is associated with improved life satisfaction and reduced depression and anxiety in older adults navigating major transitions, with meaning-making as a key mechanism (Jiang et al., 2024).
Social connection is a significant protective factor against adjustment disorder, and its absence is a significant risk factor (Kelber et al., 2022).
You are not overreacting, and you do not have to wait until it gets worse
One of the most common things people say, looking back on a period of adjustment difficulty they did not seek help for, is: I thought I was overreacting. I thought I should be able to handle it. I thought I should give it more time.
The cultural messages that encourage this kind of stoicism are particularly strong for people in midlife and later life, who have, after all, managed plenty of difficulty before, and who are surrounded by a culture that expects them to keep managing. These messages are understandable. They are also, in this context, a form of ageism: the assumption that later-life struggles should simply be absorbed, because struggle is part of getting older.
The research does not support this view. Adjustment disorder is a real clinical condition that responds to psychological support — and that, untreated, carries real risks of progressing to more severe difficulty. The appropriate response is not to wait longer or push harder. It is to seek support at a level that is proportionate to what you are experiencing, not because you are weak, but because adapting to a genuinely significant life change is hard work, and hard work is done better with the right help.
At Upside Stories, we believe that a longer life should mean more joy, not more resignation. And that includes the wisdom to recognise when adapting to what has changed requires more than time alone.
You don’t have to push through this alone. Book a free 20-minute consult today, to discuss your therapy needs.
References & reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425596
Bury, M. (1982). Chronic illness as biographical disruption. Sociology of Health & Illness, 4(2), 167–182. https://doi.org/10.1111/1467-9566.ep11339939
Chu, S. H., Park, S., Kang, H., & Kim, O. (2025). Adjustment disorder in older adults: Insights from a nationwide survey. Innovation in Aging, 9(Suppl 1), igaf122.3043. https://doi.org/10.1093/geroni/igaf122.3043
Jiang, V., Galin, A., & Lea, X. (2024). Life review for older adults: An integrative review. Psychogeriatrics, 24(6), 1402–1417. https://doi.org/10.1111/psyg.13194
Kelber, M. S., Chard, K. M., Dondanville, K. A., Borah, E. V., Brockman, J., & Stefanovics, E. A. (2022). Systematic review and meta-analysis of predictors of adjustment disorders in adults. Journal of Affective Disorders, 304, 43–58. https://doi.org/10.1016/j.jad.2022.02.032
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Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136(2), 257–301. https://doi.org/10.1037/a0018301
Shafierizi, S., Faramarzi, M., Esmailzadeh, S., Chehrazi, M., Ghofrani, F., & Nasiri-Amiri, F. (2023). Comparing the effect of face-to-face and internet-based cognitive behavioral therapy on adjustment disorder symptoms: A randomized controlled trial. International Journal of Clinical and Health Psychology, 23(1), Article 100339. https://doi.org/10.1016/j.ijchp.2022.100339
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van der Heide, I., van Rijn, R. M., Robroek, S. J. W., Burdorf, A., & Proper, K. I. (2020). Is retirement good for your health? A systematic review of longitudinal studies. BMC Public Health, 13(1), Article 1180. https://doi.org/10.1186/1471-2458-13-1180
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Willi, N., Pancoast, A., Drikaki, I., Gu, X., Gillanders, D., & Finucane, A. (2024). Practitioner perspectives on the use of acceptance and commitment therapy for bereavement support: A qualitative study. BMC Palliative Care, 23, Article 58. https://doi.org/10.1186/s12904-024-01390-x
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Zapata-Ospina, J. P., Rodríguez, N., Rodríguez, A. M., García-Valencia, J., Jiménez-Benítez, M., & Martínez-Ramos, N. (2020). Adjustment disorder with anxiety in old age: Comparing prevalence and clinical management in primary care and mental health care. European Psychiatry, 26(1), 54–59. https://doi.org/10.1016/j.eurpsy.2010.09.004
Zelviene, P., Kazlauskas, E., & Maercker, A. (2020). Risk factors of ICD-11 adjustment disorder in the Lithuanian general population exposed to life stressors. European Journal of Psychotraumatology, 11(1), Article 1708617. https://doi.org/10.1080/20008198.2019.1708617
