The COVID-19 pandemic is a prime example of what can cause an adjustment disorder—here’s what to know.

Often when people start feeling anxious or sad more often than they should, we assume they might be struggling with anxiety or depression. Yet, there’s another mental health disorder that presents with symptoms of anxiety, depression, or sometimes both. Adjustment disorders can look very similar to these other common mental health conditions, but with one important caveat: They’re triggered by a stressful life event.

Though most commonly diagnosed in children, according to the Johns Hopkins Psychiatry Guide, adjustment disorders are becoming more prevalent in adults as we all continue to struggle to adjust with the circumstances COVID-19 has thrown at us.

Here’s what you need to know about adjustment disorders, how to spot the signs in yourself and others, and how to treat it.

What are adjustment disorders?

Adjustment disorders are largely related to high-stress events. When something extremely stressful happens — a divorce, loss of a job, the death of a loved one, an accident that causes you to lose your house or to be seriously injured, or any number of other things — people sometimes cannot bounce back. They might feel symptoms of depression, anxiety, or both. They might start acting out behaviorally or be unable to eat or concentrate on work or life.

“It’s a reaction to a stressful life event that is causing significant disturbance in your life,” Lindsay Henderson, PsyD, a therapist with Amwell, tells Health. While it’s normal to feel sad, restless, or overwhelmed after a big stressor, when suffering from an adjustment disorder those feelings rise to a point that is disproportionate to the stressor itself or last longer than they normally would, Dr. Henderson says.

What are the signs of adjustment disorders?

Often, adjustment disorders look similar to depression or anxiety. “When we look at diagnosing adjustment disorders, we can categorize and say, ‘This is an adjustment disorder with depressed mood,’ or ‘This is an adjustment disorder with anxiety,” or it can be a mix of both depression and anxiety,” Dr. Henderson says.

Yet, “adjustment disorder” is not a term most patients use when they first seek help. Most of the time, people coming into Dr. Henderson’s office will say, “I just can’t seem to get over losing my job,” or “I can’t seem to manage everything in my life the way I used to.”

Commonly, adjustment disorders also show symptoms like trouble concentrating or trouble with memory. Gina Shuster, LMSW, a therapist at Oakland Psychological Clinic, sees patients who say “I’m so forgetful now and I never used to be this way;” “I get so flustered all the time;” or “I can’t find the right words.” With anxiety disorders that present as anxiety or depression, Shuster says, your body is spending so much energy just trying to maintain itself at this heightened emotional state that little things like memory and concentration start to slip. “It’s like juggling a bunch of different balls in the air. Eventually, some things are going to have to be let go,” she says.

How has COVID-19 affected adjustment disorders?

It will come as no surprise to those of us who have lived through the last several months that COVID-19 has been one big stressor. According to Johns Hopkins Psychiatry Guide, triggers for adjustment disorders can be stressors that affect whole communities. And many people have been dealing with additional stressors on top of worrying about the virus: many have lost work, lost loved ones, and been forced to miss out on milestones like high school or college graduation, starting kindergarten, and throwing their weddings.

All of these stressors add up to a surge in people seeking therapy to find a way to cope, as well as greater reports of mental health struggles than ever before.

CDC report published August 14 and examining mental health in the U.S. during one week in June, 2020, found that 40% of adults reported struggling with mental health or substance abuse. More than 25% of the 5,412 people who took the survey reported anxiety symptoms, up from 8% prior to the pandemic, and the prevalence of depression was four times greater than pre-pandemic (24.3% up from 6.5%).

Many of those who now feel anxious or depressed are likely suffering from an adjustment disorder triggered by coronavirus. “I’ve seen more people who are coming in saying that their usual coping skills just aren’t working anymore. They’re feeling overwhelmed and having a hard time managing their lives,” Dr. Henderson says.

Shuster has seen an incredible increase in new patients, as well. “We’re seeing a lot more adjustment disorders because everything is uncertain right now,” she says. “And people are experiencing major losses or have had to cancel things that they’ve been looking forward to for a year or have been unable to celebrate accomplishments that they were so excited and so proud of.”

When talking to these patients, Dr. Henderson’s first step is to try to put their struggles into perspective of the immense stress we’ve all been under both as individuals and as a society. “When you’re living in it, it can sometimes be hard to recognize, appreciate, or really understand just how depleting a global pandemic can be on your internal resources,” she says.

How are adjustment disorders treated?

Adjustment disorders that present as depression, anxiety, or both are treated similarly to those disorders, with the exception that therapy is often focused on the stressor that triggered the adjustment disorder.

“We want to be able to identify triggers, but also be able to identify ways to calm down,” Shuster says. She offers her patients grounding techniques, which are similar to mindfulness practices and are meant to help people who might be close to a panic attack or be lost in depressive thoughts to focus on where they are in the moment.

One popular grounding technique Shuster likes is called “5-4-3-2-1.” It draws on all five senses, and it works like this: When you start to feel overwhelmed, stop wherever you are and look around. Name five things you can see. Then, four things you can touch, three things you can hear, two things you can smell, and, if possible, one thing you can taste.

Coping skills like this exercise help bring people who feel overwhelmed back to the moment. Dr. Henderson also works with patients on cognitive behavioral therapy, which aims to change the way we think and offer coping mechanisms for when our thoughts start to spiral. Often she sees patients who engage in two main forms of negative thinking: catastrophizing and black-and-white thinking.

“Catastrophizing is assuming that the worst is going to happen. So, ‘We’re in economic instability, I’m definitely going to lose my job. I’m not going to be able recover, and we’re going to lose our house,” she says. “While black-and-white thinking is seeing things as all good or all bad, and not allowing for a middle ground.”

Dr. Henderson works with people who have adjustment disorders to examine their thoughts and behaviors and make small changes in their thinking patterns, which can lead to better mood overall.

It’s of course also important to be proactive, rather than simply responding to triggers or already heightened emotions. “The first step in exploring mental health and emotional well-being is making sure that someone is doing the bare minimum to take care of their body and their mind. Eating well and sleeping well. I mean, all the stuff we hear over and over again. But people do need reminding of how important these things are,” Dr. Henderson says.

Right now, in times when everyone is struggling emotionally, Schuster suggests starting a feelings journal to track your mental health. Then, you can look back and see that you’re actually coping much better now than you were a few months ago, and things really are getting better.

Another simple way to boost your own happiness is to do something kind for others. “I’m doing gratitude work,” Shuster says. And research shows that people are happier when they’re helping others. So bake a pie and drop it off to your neighbors, or go grocery shopping for your grandparents, or make a donation to an organization that’s keeping people safe. A little charitable work goes a long way in lifting your mood.


Image by Priscilla Du Preez / Unsplash

It can be incredibly difficult to feel betrayed, hurt, or otherwise wronged by someone, and especially someone you love. Perhaps even harder? Forgiving them.

But forgiveness is just as much a gift to yourself as it is to them, so we asked experts how to forgive someone even when it’s hard.

What does it really mean to forgive someone?

Forgiveness is essentially a letting go—of anger, resentment, or whatever it is you feel toward someone who you feel has wronged you. As psychologist Kristina Hallett, Ph.D., previously explained to mbg, “Merriam-Webster defines forgiveness as ‘to cease to feel resentment against an offender’ or ‘to give up resentment of or claim to requital.’ It’s an internal state of being, and it’s not dependent on anyone but you.”

She adds that your ability to forgive someone often has little to do with that person or what they did and everything to do with whether you can make that shift in your thoughts, feelings, and actions toward the person. And just because you forgive someone doesn’t mean you’re condoning the behavior or even that you’re going to welcome this person back into your life—it just means you’ve made peace with what happened.

According to licensed marriage and family therapist Rachel Zar, LMFT, CST, it’s important to remember that it’s only natural to be averse to forgiving: “It’s a protective thing that we do, it’s fight or flight, and it’s human instinct to want to strike back or punish when we feel like we’ve been deeply wronged and hold on to that weapon we can build in future fights. But there does come a point where you can ask yourself, Is this actually serving me?

To that end, she notes that we tend to conceptualize forgiveness as something we’re giving to someone else when we should really think about it as something we do for ourselves. “It does start to feel like drinking the poison and hoping that somebody else will die,” she explains—which brings us to our next point.

Benefits of forgiveness.

To understand the benefits of forgiveness, you have to understand what happens when you don’t forgive. As Zar explains, “Holding on to a grudge, holding resentment—it’s not good for us. It causes a lot of stress and anxiety, lower mood, and of course, relationship stress.”

Hallett describes not forgiving someone as a mixture of anger, depression, and blame. But most of all, she says, “the opposite of forgiveness is stagnation—it’s getting mired in an emotional place regarding a particular incident, and it prohibits future growth and discovery.”

When we forgive, on the other hand, we’re able to let go of all of the energy we’re spending by not forgiving. “What forgiveness looks like is actually letting go and not giving energy to a situation which you have a very strong reaction to, or an individual that you have a strong reaction to, or relationship with an individual that you have a strong reaction to,” psychotherapist Annette Nuñez, Ph.D., LMFT, tells mbg.

5 steps to forgiveness:

1. Understand why forgiveness is important.

Before you even begin to think about the particular situation you’re facing, take a step back and reflect on your why. Why do you want to forgive, in general? As Nuñez explains, “I always ask my clients, What purpose does holding resentment or anger or sadness toward a situation serve?

Reflect on that question, and some of the previous points mentioned above, and recognize the value of releasing emotional baggage and forgiving people when you’ve been wronged.

2. Assess who/what needs to be forgiven.

From this place of understanding, begin to think about the situation and person in question. Zar explains this is when you’ll begin to start deciding whether you even can forgive them.

“Has that person done enough, or meant enough to you, that you want to see them as more than the thing they’ve done to you? Have they actually atoned? Apologized? Earned your trust back if that’s what’s needed? Have they clarified that their intention wasn’t to hurt you? Do you believe them? That’s really important,” she tells mbg.

She adds that a big aspect of forgiveness is safety, as well, so you can also assess whether you feel safe (emotionally and physically) around this person. When you can begin separating what the action was from who the person is, she says, you’ve begun to ease into forgiveness.

3. Do some inner work around the issue.

Nuñez says forgiveness also requires a degree of inner work, and namely, looking at how holding on to resentment is affecting you and why you’re doing it. As aforementioned, it can be instinctual to not want to forgive, but are you holding on to anger out of fear? Or a grudge? And how is that energy festering in your life?

Part of this step ties back to No. 1 and recognizing that forgiveness is a gift to yourself. Take your understanding of the value of forgiveness and apply it to the situation at hand.

4. Choose to release and forgive.

Once you’ve muddled through all the messy inner work and reflected on the situation, you can choose to release and forgive. And it is, ultimately, a choice. Zar and Nuñez both note that this step can involve a literal declaration of forgiveness, in which you tell the person you forgive them, but it can also be an internal process that you never actually speak about.

“You don’t necessarily have to say, ‘I forgive you.’ You could write it on a piece of paper and let it go. That is just as important as actually telling an individual that you forgive them—it’s very symbolic,” Nuñez says.

Or, if you do want to verbalize your forgiveness, Zar says you can tell the person you are making the choice to let it go (whatever it is), and you understand that their action wasn’t representative of who they are. “It’s important to recognize that forgiveness isn’t the same as letting your dog off the hook or saying what they did was OK, right? You can forgive someone and at the same time say, ‘It’s not OK, and you hurt me, and that’s not acceptable behavior—and I’m choosing to forgive you. I’m choosing for me to move forward,'” she adds.

5. Be prepared for setbacks.

Thought we were done? Not quite. Zar says to anticipate some setbacks along the path of forgiveness, explaining that it’s entirely possible for the issue in question to trigger you in the future.

“Forgiveness doesn’t always happen in a linear fashion, and that’s important to recognize,” she explains. “Sometimes we think we let something go and then something triggers it and it comes back up, and that can be a normal part of the process.”

In this case, notice when you are triggered, and come back to all of these points, remembering your “why,” and further, why you chose to forgive this person initially.

When forgiveness may not be an option + what to do instead.

Sometimes, the hurt is too deep, and we cannot bring ourselves to forgive—or at least not yet. Regardless of what happened, in cases like this, Nuñez notes that it would be a good idea to seek the guidance of a professional to help you work through the negative emotions you’re holding on to.

And even if you can’t necessarily “forgive” this person (or people, or situation), it’s still important to find a degree of acceptance so you’re not harboring negativity unconsciously. “What takeaway did you get from this, even if you’re unable to forgive somebody? How can we grow? How can we better ourselves from it?” she suggests asking yourself.

Whenever somebody feels they’ve been really wronged and forgiveness isn’t an option, she adds, it’s also important to assess how this is showing up in your life and whether it’s eating away at you. “And if you find it’s more negative and nagging than positive, then really seek a therapist to help you figure it out because there may be some deeper issue as to why it’s eating away at you,” Nuñez explains.

Moving forward.

When you’ve reached a place of forgiveness (or even reluctant acceptance), there are still steps to be taken moving forward. And according to Zar, setting firm boundaries is the main one.

Ask yourself what boundaries you need in place and what you need to help yourself move on, she says. If a friend has betrayed your trust, for example, the boundary is that you need more transparency from them. And while you can’t necessarily count on the person in question to honor your boundary, you can count on yourself to hold it.

“In the meantime,” she adds, “you might need some time apart, maybe saying, ‘I’m not going to be coming to social gatherings for a few weeks because I’m working through this myself,’ for example. Or it could also mean fundamentally changing the nature of the relationship.”

Zar tells mbg that depending on the situation, your course of action is going to look different. You may feel it’s best to cut the person off entirely, see them less, or only see them in group settings. It’s up to you to decide what’s best for you given the situation.

“And you can forgive someone and do that at the same time. Forgiveness doesn’t mean acting like nothing ever happened, but it really is about what can you do to get to a place of emotional and physical safety—and then once you’re there, it becomes a lot easier to either accept a change in the relationship dynamic or accept that the person in the relationship is bigger or more important to you than what happened,” she says.

The takeaway.

The bottom line is, forgiveness doesn’t always come easy, but it is so worth it. As they say, anything that costs you your peace is too expensive, and by holding on to anger or resentment, we’re only spending our own peace—not theirs.



The 44-year-old actor said he’s “lucky to be alive” after the flare-up.

Ashton Kutcher is best known for his role on That ’70s Show, but it’s his health that’s been making headlines in recent days.

Kutcher, 44, revealed that he dealt with a “super-rare form of vasculitis” three years ago, which left his vision, hearing, and balance impaired. The actor shared his medical diagnosis in a clip from an upcoming episode of the National Geographic show “Running Wild with Bear Grylls: The Challenge,” first released by Access Hollywood on Monday.

“It took me like a year to build it all back up. You don’t really appreciate it until it’s gone,” Kutcher said in the clip, referencing his vision, hearing and balance impairments. According to the actor, he’s “lucky to be alive,” after his health issues.

Despite experiencing such severe symptoms, Kutcher said on Tuesday that he’s made a full recovery.

“Yes, I had a rare vasculitis episode [three years] ago. (Autoimmune [flare] up),” he wrote on Twitter. “I had some impairments […] right after. I fully recovered. All good. Moving on.”

Here’s what you need to know about this rare disease, how vasculitis can cause symptoms like the ones Kutcher experienced, and how healthcare providers typically treat and manage the disease.

What Is Vasculitis?

Vasculitis is an umbrella term for a family of diseases that all have to do with inflammation of the blood vessels, according to Peter Merkel, MD, MPH, chief of rheumatology, director of the Vasculitis Center, and professor of medicine and epidemiology at the University of Pennsylvania.

“They range from diseases that affect very large arteries such as the aorta—a large artery that comes out of the heart and its branches—to microscopic arteries that feed almost every tissue and organ in the body,” Dr. Merkel told Health.

Kutcher did not reveal which specific type of vasculitis he suffered from, and even knowing his specific symptoms—loss of full hearing, sight, and ability to walk—isn’t enough to say which iteration of the disease he suffers from.

The National Institute of Health (NIH) names 16 different types of vasculitis, all of which affect different areas of the body with varying degrees of severity.

Vasculitis can refer to any blood vessel swelling—caused by an infection or trauma, for example—but the vasculitis Kutcher is talking about is best characterized as an autoimmune disorder, explained Anisha B Dua, MD, MPH, director of the Vasculitis Center and associate professor of medicine at Northwestern University Feinberg School of Medicine.

“Your immune system is set up to protect you and it should be fighting off bacteria, viruses, everything else. And sometimes your immune system basically goes out of whack and it gets overactive, and starts recognizing parts of your own self as a problem and starts attacking it,” Dr. Dua told Health. “With vasculitis, essentially your immune system is overactive, and it’s attacking and causing inflammation of the blood vessels.”

It’s that sustained attack on the body’s blood vessels that make vasculitis so dangerous, and often painful, for those who have the disease.

Once the immune system starts wrongly attacking the blood vessels, Dr. Dua explained, those blood vessels flare up and become damaged. That damage can cause them to scar and narrow, restricting the flow of blood. It can also sometimes weaken the vessel so much that it’ll become floppy and lead to an aneurysm, meaning it can balloon up in the body, she said.

And as you might imagine, when the blood isn’t flowing properly around the body, the consequences can be severe.

“You start getting a lack of oxygen to the tissues wherever those blood vessels are trying to supply blood. So when you don’t have oxygen going then you start getting some of the clinical manifestations that people come in with when they get diagnosed with vasculitis,” Dr. Dua said. “But people can feel really unwell for a while.”

Vasculitis Symptoms Are Wide-Ranging

Because there are so many different kinds of diseases under the umbrella of vasculitis, the symptoms associated with it can be incredibly varied—from a heart attack to joint pain.

“Vasculitis can affect any artery anywhere in the body, from your largest artery, the aorta, down to small arteries that you find in your skin,” Randy Ramcharitar, MD, assistant professor of cardiovascular medicine at the University of Virginia, told Health. “The manifestations can be extremely variable.”

The National Heart, Lung, and Blood Institute (NHLBI) names a whole host of possible symptoms linked to vasculitis:

  • Ear and nose problems (runny nose, sinus infection, dizziness, hearing loss)
  • Eye problems (itching, burning, vision changes)
  • Joint pain
  • Skin rashes
  • Heart palpitations
  • Stroke
  • Heart attack
  • Kidney disease
  • Aneurysm
  • High and low blood pressure

Aneurysms, strokes, and heart attacks are dangerous and even deadly symptoms of vasculitis, especially when the disease affects blood vessels in the brain or in and around the aorta, Dr. Ramcharitar said.

For Kutcher, his symptoms are likely associated with the inflammation of the smaller blood vessels near his eyes and ears, Dr. Dua said.

Vasculitis can cause the blood vessels in numerous parts of the eye to swell or become inflamed and cause intense pressure in the eye, both of which can cause vision loss. The same is true for hearing—people can experience loss of hearing for just some pitches, while others will see their hearing fade in and out, or go completely, she explained. The ear is also connected to balance, which could also relate to Kutcher’s issue of feeling out of equilibrium and having issues walking.

“When your ears are affected or some of the signaling in your ears, you can really feel off balance and unable to focus,” Dr. Dua said. “You get sort of episodes of dizziness and the world spinning. You can’t really sense your place with walking, so it’s hard to sort of function.”

Or, Dr. Merkel added, Kutcher’s trouble walking could be because of inflammation of the blood vessels in the brain or spinal cord.

It’s impossible to know the specifics of Kutcher’s case simply based on what he’s shared with the public at this point, both Dr. Merkel and Dr. Dua agreed. There are so many moving parts when it comes to vasculitis, including how long the symptoms have been going on or which specific type a person is diagnosed with.

Overall, it’s this variability and rarity that makes vasculitis sometimes hard to pin down, Dr. Merkel explained.

“It can be fast and come on very quickly or it can be subtle and slow, which leads to difficulties in diagnosis. The diseases are often missed for a while—sometimes days, sometimes weeks, sometimes years,” he said. “When they’re very bad usually it’s diagnosed more rapidly but these are rare diseases and people can miss them.”

Tools to Manage, But Not Cure Vasculitis

When vasculitis is caused by a faulty immune response, it’s something that can be treated, but can’t necessarily be cured.

“I think of them more like chronic diseases, kind of like diabetes, hypertension, things that you have and they can be managed, but they’re not just gone,” Dr. Dua said.

And that process of managing vasculitis isn’t always simple.

“I think of it like a fire on your blood vessels,” Dr. Dua said. “So you want to shut down that fire and calm things down quickly, as much and as fast as possible to try to prevent damage from happening. And that’s usually that first phase of treatment.”

The next phase, according to Dr. Dua is a maintenance phase “where we just try to keep everything calm and try to prevent any flare-ups of the disease,” she said.

This treatment process—which Dr. Ramcharitar said can take months or even a few years—isn’t easy on the body. In addition to anti-inflammatory drugs, immunosuppressant drugs are used to stop the body’s attack on its own blood vessels. But that leaves the guard down for other problems to creep in.

“You’re always trying to find the perfect balance of how much you need to keep the vasculitis under control, but also make sure that the patients aren’t suffering from multiple side effects from the medication, or getting lots of infections or anything like that,” Dr. Dua said. “Because a lot of medicines we use can be significantly toxic.”

Prevention can also be a struggle for vasculitis doctors. Dr. Ramcharitar said that smoking can sometimes be associated with the disease and that having people quit could help.

There may be some genetic risks involved with developing some kinds of vasculitis, as well as some risks from infections from the hepatitis B and hepatitis C viruses, Dr. Merkel added. However, there’s still research to be done to figure out how people can avoid getting the disease altogether.

With the possibility of relapse, patients and doctors have to be vigilant about keeping an eye out for vasculitis cropping up again, and being as supportive and positive as possible.

“Finding support in whatever avenues you can—whether that’s your provider or other patients with the disease, or whatever it is—just having a positive attitude and trying to get past some of the hurdles, it’s difficult. But I think our patients with vasculitis are really resilient overall,” Dr. Dua said. “The field has come a long way in the last 10 or 20 years, we’ve found a lot more discoveries for how to manage the disease, how to more accurately diagnose the disease.”


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