Anxiety Disorders

According to the American Psychiatric Association, anxiety is a normal response to stress and can even be useful in some situations, such as increasing attention and focus on what we are doing. By contrast, anxiety disorders differ from temporary feelings of anxiousness or nervousness with more intense feelings of fear or anxiety.

Anxiety Disorder Types: Generalized anxiety disorder, Social anxiety disorder, Panic disorder, Separation anxiety disorder and Substance or medication-induced anxiety disorder.

The Diagnostic and Statistical Manual (DSM-5) specifically describes anxiety as excessive worry and apprehensive expectations, occurring more days than not for at least 6 months, about a number of events or activities.

Generalized Anxiety Disorder, DSM-5 criteria:

1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
2. The person finds it difficult to control the worry.
3. The anxiety and worry are associated with three or more of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months):

1.    Restlessness or feeling keyed up or on edge

2.    Being easily fatigued

3.    Difficulty concentrating or mind going blank

4.    Irritability

5.    Muscle tension

6.    Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

D. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder). The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

Social anxiety disorder, DSM-5:

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).

Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

B. The social situations almost always provoke fear or anxiety.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

C. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

H. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

I. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if: Performance only: if the fear is restricted to speaking or performing in public.

Panic disorder (anxiety disorder) is considered a feature of the specific disorder in which the panic attack/agoraphobia occurs. DSM-5:

• An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of the following symptoms occur:
• Agoraphobia: A marked fear or anxiety about two (or more) of the following five situations:
• Using public transportation
• Being in open spaces
• Being in enclosed spaces (e.g., shops, theaters, cinemas)
• Standing in line or being in a crowd
• Being outside the home alone.
• The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.
• The agoraphobic situations almost always provoke fear or anxiety.
• The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
• The fear, anxiety or avoidance is persistent, typically lasting 6 months or more.
• The fear, anxiety, or avoidance causes clinically significant distress or impairment in important areas of functioning.
• The anxiety or phobic avoidance is not better accounted for by another mental disorder.
• The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms.
• If an associated general medical condition is present, the fear described in Criterion A is clearly in excess of that usually associated with the condition.
• Recurrent and unexpected panic attacks. One or more attacks have been followed by 1 month or more of 1 or both of the following:

              1) Persistent concern about additional attacks or their consequences

              2) A significant maladaptive change in behavior related to the attacks

• The panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse or a medication) or a general medical condition.
• The panic attacks are not better accounted for by another mental disorder.

Phobias, anxiety disorder:

• Marked fear or anxiety about a specific object or situation (e.g. bugs, height, water, blood…).

• The phobic object or situation almost always provokes immediate fear or anxiety.

• The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.

• The phobic object or situation is actively avoided or endured with intense fear or anxiety.

• The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

• The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

• Specify type: Animal Type (e.g., spiders, insects, dogs)

• Specify type: Natural Environment Type (e.g., heights, storms, water)

• Specify type: Blood-Injection-Injury Type (e.g., needles, invasive medical procedures) 

• Specify type: Situational Type (e.g., airplanes, elevators, enclosed places)

Other Type (e.g., phobic avoidance of situations that may lead to choking, vomiting or contracting an illness; in children, avoidance of loud sounds or costumed characters)

DSM-5 Separation Anxiety Disorder Comparison

1. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:
2. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
3. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
4. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
5. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
6. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
7. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
8. Repeated nightmares involving the theme of separation
9. Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
10. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
11. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
12. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.

Substance/medication-induced anxiety disorder is diagnosed after an individual uses a substance (e.g., drug abuse, medication or a toxin exposure) that leads to prominent symptoms of panic or anxiety:

• Panic or anxiety can occur in association with intoxication with the following substances: alcohol, caffeine, cannabis, phencyclidine, other hallucinogens, inhalants, and stimulants.

• Panic or anxiety can occur in association with withdrawal from the following classes of substances: alcohol, opioids, sedatives, hypnotics, anxiolytics, stimulants (including cocaine)

Medications that can cause anxiety symptoms include:

• Anesthetics, analgesics, sympathomimetics, bronchodilators (e.g. – theophylline), anticholinergics, insulin, thyroid replacement, oral contraceptives, antihistamines, antiparkinsonian medications, corticosteroids, antihypertensives, cardiovascular medications, anticonvulsants, lithium, antipsychotics, and antidepressants.

• Heavy metals and toxins can also cause panic or anxiety symptoms, including:

• Oganophosphate insecticide, nerve gases, carbon monoxide, carbon dioxide, and volatile substances (e.g. – gasoline, paint).