Quiz 2: Anxiety Disorders Flashcards Preview

Adult Psychopathology Erin > Quiz 2: Anxiety Disorders > Flashcards

Flashcards in Quiz 2: Anxiety Disorders Deck (30):
1

Separation Anxiety Disorder Criteria

A. 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:
1. Recurrent excessive distress when anticipating or experiencing separation from
home or from major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or about possible
harm to them, such as illness, injury, disasters, or death.
3. 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.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or
elsewhere because of fear of separation.
5. Persistent and excessive fear of or reluctance about being alone or without major
attachment figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without
being near a major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea,
vomiting) when separation from major attachment figures occurs or is anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting AT LEAST 4 WEEKS in children and
adolescents and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social, academic,
occupational, or other important areas of functioning.
D. 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

2

Associated Features Supporting Diagnosis: SEPARATION ANXIETY DISORDER

-when separated - show social withdrawal, apathy, sadness, difficultly with work or play; fear situations that present danger to family or themselves; extreme homesickness; refuse school; leads to resentment and conflict in family bc of dependance

3

Course: Separation Anxiety Disorder

Onset of separation
anxiety disorder may be as early as preschool age and may occur at any time during childhood
and more rarely in adolescence. Typically there are periods of exacerbation and remission.
In some cases, both the anxiety about possible separation and the avoidance of
situations involving separation from the home or nuclear fam.; majority of children with separation anxiety disorder are free of impairing anxiety disorders
over their lifetimes. Many adults with separation anxiety disorder do not recall a
childhood onset of separation anxiety disorder, although they may recall symptoms.
The manifestations of separation anxiety disorder vary with age. Younger children are
more reluctant to go to school or may avoid school altogether. Younger children may not
express worries 6r specific fears of definite threats to parents, home, or themselves, and the
anxiety is manifested only when separation is experienced. As children age, worries
emerge; these are often worries about specific dangers (e.g., accidents, kidnapping, mugging,
death) or vague concerns about not being reunited with attachment figures. In adults,
separation anxiety disorder may limit their ability to cope with changes in circumstances
(e.g., moving, getting married). Adults with the disorder are typically overconcemed about
their offspring and spouses and experience marked discomfort when separated from them.
They may also experience significant disruption in work or social experiences because of
needing to continuously check on the whereabouts of a significant other.

4

Culture: Separation Anxiety Disorder

There are cultural variations in the degree to which it is considered desirable to tolerate
separation, so that demands and opportunities for separation between parents and children
are avoided in some cultures. For example, there is wide variation across countries
and cultures with respect to the age at which it is expected that offspring should leave the
parental home. It is important to differentiate separation anxiety disorder from the high
value some cultures place on strong interdependence among family members.

5

Differential Diagnosis: Separation Anxiety Disorder

Generalized anxiety disorder. Separation anxiety disorder is distinguished from generalized
anxiety disorder in that the anxiety predominantly concerns separation from attachment
figures, and if other worries occur, they do not predominate the clinical picture.
Panic disorder. Threats of separation may lead to extreme anxiety and even a panic attack.
In separation anxiety disorder, in contrast to panic disorder, the anxiety concerns the
possibility of being away from attachment figures and worry about untoward events befalling
them, rather than being incapacitated by an unexpected panic attack.
Agoraphobia. Unlike individuals with agoraphobia, those with separation anxiety disorder
are not anxious about being trapped or incapacitated in situations from which escape
is perceived as difficult in the event of panic-like symptoms or other incapacitating
symptoms.
Conduct disorder. School avoidance (truancy) is common in conduct disorder, but anxiety
about separation is not responsible for school absences, and the child or adolescent
usually stays away from, rather than returns to, the home.
Social anxiety disorder. School refusal may be due to social anxiety disorder (social phobia).
In such instances, the school avoidance is due to fear of being judged negatively by others
rather than to worries about being separated from the attachment figures.
Posttraumatic stress disorder. Fear of separation from loved ones is common after traumatic
events such as a disasters, particularly when periods of separation from loved ones
were experienced during the traumatic event. In posttraumatic stress disorder (PTSD), the
central symptoms concern intrusions about, and avoidance of, memories associated with
the traumatic event itself, whereas in separation anxiety disorder, the worries and avoidance
concern the well-being of attachment figures and separation from them.
Illness anxiety disorder. Individuals with illness anxiety disorder worry about specific
illnesses they may have, but the main concern is about the medical diagnosis itself, not
about being separated from attachment figures.
Bereavement. Intense yearning or longing for the deceased, intense sorrow and emotional
pain, and preoccupation with the deceased or the circumstances of the death are expected
responses occurring in bereavement, whereas fear of separation from other
attachment figures is central in separation anxiety disorder.
Depressive and bipolar disorders. These disorders may be associated with reluctance
to leave home, but the main concern is not worry or fear of untoward events befalling attachment
figures, but rather low motivation for engaging with the outside world. However,
individuals with separation anxiety disorder may become depressed while being
separated or in anticipation of separation.
Oppositional defiant disorder. Children and adolescents with separation anxiety disorder
may be oppositional in the context of being forced to separate from attachment figures.
Oppositional defiant disorder should be considered only when there is persistent oppositional
behavior unrelated to the anticipation or occurrence of separation from attachment
figures.
Psychotic disorders. Unlike the hallucinations in psychotic disorders, the unusual perceptual
experiences that may occur in separation anxiety disorder are usually based on a
misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and
are reversed by the presence of an attachment figure.
Personality disorders. Dependent personality disorder is characterized by an indiscriminate
tendency to rely on others, whereas separation anxiety disorder involves concern
about the proximity and safety of main attachment figures. Borderline personality
disorder is characterized by fear of abandonment by loved ones, but problems in identity,
self-direction, interpersonal functioning, and impulsivity are additionally central to that
disorder, whereas they are not central to separation anxiety disorder.

6

SELECTIVE MUTISM Criteria

A. Consistent failure to speak in specific social situations in which there is an expectation
for speaking (e.g., at school) despite speaking in other situations.
B. The disturbance interferes with educational or occupational achievement or with social
communication.
C. The duration of the disturbance is at least 1 month (not limited to the first month of
school).
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the
spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder (e.g., childhoodonset
fluency disorder) and does not occur exclusively during the course of autism
spectrum disorder, schizophrenia, or another psychotic disorder.

7

Associated features: SELECTIVE MUTISM

Associated features of selective mutism may include excessive shyness, fear of social embarrassment,
social isolation and withdrawal, clinging, compulsive traits, negativism,
temper tantrums, or mild oppositional behavior. Although children with this disorder
generally have normal language skills, there may occasionally be an associated communication
disorder, although no particular association with a specific communication disorder
has been identified. Even when these disorders are present, anxiety is present as
well. In clinical settings, children with selective mutism are almost always given an additional
diagnosis of another anxiety disorder—most commonly, social anxiety disorder (social
phobia).

8

Risk and Prognostic factors: SELECTIVE MUTISM

Temperamental. Temperamental risk factors for selective mutism are not well identified.
Negative affectivity (neuroticism) or behavioral inhibition may play a role, as may
parental history of shyness, social isolation, and social anxiety. Children with selective
mutism may have subtle receptive language difficulties compared with their peers, although
receptive language is still within the normal range.
Environmental. Social inhibition on the part of parents may serve as a model for social
reticence and selective mutism in children. Furthermore, parents of children with selective
mutism have been described as overprotective or more controlling than parents of children
with other anxiety disorders or no disorder.
Genetic and physiological factors. Because of the significant overlap between selective
mutism and social anxiety disorder, there may be shared genetic factors between these
conditions.

9

Risk and Prognostic Factors: SEPARATION ANXIETY DISORDER

Environmental. Separation anxiety disorder often develops after life stress, especially a
loss (e.g., the death of a relative or pet; an illness of the individual or a relative; a change of
schools; parental divorce; a move to a new neighborhood; immigration; a disaster that involved
periods of separation from attachment figures). In young adults, other examples of
life stress include leaving the parental home, entering into a romantic relationship, and becoming
a parent. Parental overprotection and intrusiveness may be associated with separation
anxiety disorder.
Genetic and physiological. Separation anxiety disorder in children may be heritable.
Heritability was estimated at 73% in a community sample of 6-year-old twins, with higher
rates in girls. Children with separation anxiety disorder display particularly enhanced
sensitivity to respiratory stimulation using C02-enriched air.

10

culture: selective mutism

Children in families who have immigrated to a country where a different language is spoken
may refuse to speak the new language because of lack of knowledge of the language.
If comprehension of the new language is adequate but refusal to speak persists, a diagnosis
of selective mutism may be warranted

11

Differential Diagnosis: SELECTIVE MUTISM

Communication disorders. Selective mutism should be distinguished from speech disturbances
that are better explained by a communication disorder, such as language
disorder, speech sound disorder (previously phonological disorder), childhood-onset
fluency disorder (stuttering), or pragmatic (social) communication disorder. Unlike selective
mutism, the speech disturbance in these conditions is not restricted to a specific social
situation.
Neurodevelopmental disorders and schizophrenia and other psychotic disorders.
Individuals with an autism spectrum disorder, schizophrenia or another psychotic disorder,
or severe intellectual disability may have problems in social communication and be
unable to speak appropriately in social situations. In contrast, selective mutism should be
diagnosed only when a child has an established capacity to speak in some social situations
(e.g., typically at home).
Social anxiety disorder (social phobia). The social anxiety and social avoidance in social
anxiety disorder may be associated with selective mutism. In such cases, both diagnoses
may be given.

12

SPECIFIC PHOBIA Criteria

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals,
receiving an injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing,
or clinging.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object
or situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
G. 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 if:
Code based on the phobic stimulus:
300.29 (F40.218) Animal (e.g., spiders, insects, dogs).
300.29 (F40.228) Natural environment (e.g., heights, storms, water).
300.29 (F40.23X) Blood-injection-injury (e.g., needles, invasive medical procedures).
Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood;
F40.231 fear of injections and transfusions; F40.232 fear of other medical care; or
F40.233 fear of injury.
300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed places).
300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting: in children,
e.g., loud sounds or costumed characters).
Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes
that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal, and
F40.248 specific phobia, situational).
**75% have more than one and would diagnose each separately with different specifier

13

Risk and prognostic factors: Specific Phobia

Temperamental. Temperamental risk factors for specific phobia, such as negative affectivity
(neuroticism) or behavioral inhibition, are risk factors for other anxiety disorders as
well.
Environmental. Environmental risk factors for specific phobias, such as parental overprotectiveness,
parental loss and separation, and physical and sexual abuse, tend to predict
other anxiety disorders as well. As noted earlier, negative or traumatic encounters
with the feared object or situation sometimes (but not always) precede the development of
specific phobia.
Genetic and physiological. There may be a genetic susceptibility to a certain category of
specific phobia (e.g., an individual with a first-degree relative with a specific phobia of animals
is significantly more likely to have the same specific phobia than any other category
of phobia). Individuals with blood-injection-injury phobia show a unique propensity to
vasovagal syncope (fainting) in the presence of the phobic stimulus.

14

Culture: Specific Phobia

In the United States, Asians and Latinos report significantly lower rates of specific phobia
than non-Latino whites, African Americans, and Native Americans. In addition to having
lower prevalence rates of specific phobia, some countries outside of the United States, particularly
Asian and African countries, show differing phobia content, age at onset, and
gender ratios.

15

Differential Diagnosis: Specific Phobia

Agoraphobia. Situational specific phobia may resemble agoraphobia in its clinical presentation,
given the overlap in feared situations (e.g., flying, enclosed places, elevators). If
an individual fears only one of the agoraphobia situations, then specific phobia, situational,
may be diagnosed. If two or more agoraphobic situations are feared, a diagnosis of
agoraphobia is likely warranted. For example, an individual who fears airplanes and elevators
(which overlap with the '"public transportation" agoraphobic situation) but does
not fear other agoraphobic situations would be diagnosed with specific phobia, situational,
whereas an individual who fears airplanes, elevators, and crowds (which overlap
with two agoraphobic situations, "using public transportation" and "standing in line and
or being in a crowd") would be diagnosed with agoraphobia. Criterion B of agoraphobia
(the situations are feared or avoided "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") can also be useful in differentiating agoraphobia
from specific phobia. If the situations are feared for other reasons, such as fear of being
harmed directly by the object or situations (e.g., fear of the plane crashing, fear of the animal
biting), a specific phobia diagnosis may be more appropriate.
Social anxiety disorder. If the situations are feared because of negative evaluation, social
anxiety disorder should be diagnosed instead of specific phobia.
Separation anxiety disorder. If the situations are feared because of separation from a
primary caregiver or attachment figure, separation anxiety disorder should be diagnosed
instead of specific phobia.
Panic disorder. Individuals with specific phobia may experience panic attacks when confronted
with their feared situation or object. A diagnosis of specific phobia would be given if
the panic attacks only occurred in response to the specific object or situation, whereas a diagnosis
of panic disorder would be given if the individual also experienced panic attacks
that were unexpected (i.e., not in response to the specific phobia object or situation).
Obsessive-compulsive disorder. If an individual's primary fear or anxiety is of an object
or situation as a result of obsessions (e.g., fear of blood due to obsessive thoughts about
contamination from blood-borne pathogens [i.e., HIV]; fear of driving due to obsessive images
of harming others), and if other diagnostic criteria for obsessive-compulsive disorder
are met, then obsessive-compulsive disorder should be diagnosed.
Trauma- and stressor-related disorders. If the phobia develops following a traumatic
event, posttraumatic stress disorder (PTSD) should be considered as a diagnosis. However,
traumatic events can precede the onset of PTSD and specific phobia. In this case, a diagnosis
of specific phobia would be assigned only if all of the criteria for PTSD are not met.
Eating disorders. A diagnosis of specific phobia is not given if the avoidance behavior is
exclusively limited to avoidance of food and food-related cues, in which case a diagnosis
of anorexia nervosa or bulimia nervosa should be considered.
Schizophrenia spectrum and other psychotic disorders. When the fear and avoidance
are due to delusional thinking (as in schizophrenia or other schizophrenia spectrum and
other psychotic disorders), a diagnosis of specific phobia is not warranted

16

SOCIAL ANXIETY DISORDER Criteria

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.
B. 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).
C. 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.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation
and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. 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.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another
mental disorder, such as panic disorder, body dysmoφhic disorder, or autism spectrum
disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from bums
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.

17

risk prognostic factors: SOCIAL ANXIETY DISORDER

Temperamental. Underlying traits that predispose individuals to social anxiety disorder
include behavioral inhibition and fear of negative evaluation.
Environmental. There is no causative role of increased rates of childhood maltreatment or
other early-onset psychosocial adversity in the development of social anxiety disorder. However,
childhood maltreatment and adversity are risk factors for social anxiety disorder.
Genetic and physiological. Traits predisposing individuals to social anxiety disorder,
such as behavioral inhibition, are strongly genetically influenced. The genetic influence is
subject to gene-environment interaction; that is, children with high behavioral inhibition
are more susceptible to environmental influences, such as socially anxious modeling by
parents. Also, social anxiety disorder is heritable (but performance-only anxiety less so).
First-degree relatives have a two to six times greater chance of having social anxiety disorder,
and liability to the disorder involves the interplay of disorder-specific (e.g., fear of
negative evaluation) and nonspecific (e.g., neuroticism) genetic factors.

18

Differential Diagnosis: SOCIAL ANXIETY DISORDER

Normative shyness. Shyness (i.e., social reticence) is a common personality trait and is
not by itself pathological. In some societies, shyness is even evaluated positively. However,
when there is a significant adverse impact on social, occupational, and other important
areas of functioning, a diagnosis of social anxiety disorder should be considered, and
when full diagnostic criteria for social anxiety disorder are met, the disorder should be diagnosed.
Only a minority (12%) of self-identified shy individuals in the United States have
symptoms that meet diagnostic criteria for social anxiety disorder.
Agoraphobia. Individuals with agoraphobia may fear and avoid social situations (e.g., going
to a movie) because escape might be difficult or help might not be available in the event of
incapacitation or panic-like symptoms, whereas individuals with social anxiety disorder are
most fearful of scrutiny by others. Moreover, individuals with social anxiety disorder are likely
to be calm when left entirely alone, which is often not the case in agoraphobia.
Panic disorder. Individuals with social anxiety disorder may have panic attacks, but the
concern is about fear of negative evaluation, whereas in panic disorder the concern is
about the panic attacks themselves.
Generalized anxiety disorder. Social worries are common in generalized anxiety disorder,
but the focus is more on the nature of ongoing relationships rather than on fear of negative
evaluation. Individuals with generalized anxiety disorder, particularly children, may have excessive
worries about the quality of their social performance, but these worries also pertain to
nonsocial performance and when the individual is not being evaluated by others. In social anxiety
disorder, the worries focus on social performance and others' evaluation.
Separation anxiety disorder. Individuals with separation anxiety disorder may avoid
social settings (including school refusal) because of concerns about being separated from
attachment figures or, in children, about requiring the presence of a parent when it is not
developmentally appropriate. Individuals with separation anxiety disorder are usually
comfortable in social settings when their attachment figure is present or when they are at
home, whereas those with social anxiety disorder may be uncomfortable when social situations
occur at home or in the presence of attachment figures.
Specific phobias. Individuals with specific phobias may fear embarrassment or humiliation
(e.g., embarrassment about fainting when they have their blood drawn), but they do
not generally fear negative evaluation in other social situations.
Selective mutism. Individuals with selective mutism may fail to speak because of fear of
negative evaluation, but they do not fear negative evaluation in social situations where no
speaking is required (e.g., nonverbal play).
Major depressive disorder. Individuals with major depressive disorder may be concerned
about being negatively evaluated by others because they feel they are bad or not
worthy of being liked. In contrast, individuals with social anxiety disorder are worried
about being negatively evaluated because of certain social behaviors or physical symptoms.
Body dysmorphic disorder. Individuals with body dysmorphic disorder are preoccupied
with one or more perceived defects or flaws in their physical appearance that are not
observable or appear slight to others; this preoccupation often causes social anxiety and
avoidance. If their social fears and avoidance are caused only by their beliefs about their
appearance, a separate diagnosis of social anxiety disorder is not warranted.
Delusional disorder. Individuals with delusional disorder may have nonbizarre delusions
and/or hallucinations related to the delusional theme that focus on being rejected by
or offending others. Although extent of insight into beliefs about social situations may
vary, many individuals with social anxiety disorder have good insight that their beliefs are
out of proportion to the actual threat posed by the social situation.
Autism spectrum disorder. Social anxiety and social communication deficits are hallmarks
of autism spectrum disorder. Individuals with social anxiety disorder typically
have adequate age-appropriate social relationships and social communication capacity,
although they may appear to have impairment in these areas when first interacting with
unfamiliar peers or adults.
Personality disorders. Given its frequent onset in childhood and its persistence into and
through adulthood, social anxiety disorder may resemble a personality disorder. The most
apparent overlap is with avoidant personality disorder. Individuals with avoidant personality
disorder have a broader avoidance pattern than those with social anxiety disorder.
Nonetheless, social anxiety disorder is typically more comorbid with avoidant personality
disorder than with other personality disorders, and avoidant personality disorder is more
comorbid with social anxiety disorder than with other anxiety disorders.
Other mental disorders. Social fears and discomfort can occur as part of schizophrenia,
but other evidence for psychotic symptoms is usually present. In individuals with an eating
disorder, it is important to determine that fear of negative evaluation about eating
disorder symptoms or behaviors (e.g., purging and vomiting) is not the sole source of social
anxiety before applying a diagnosis of social anxiety disorder. Similarly, obsessivecompulsive
disorder may be associated with social anxiety, but the additional diagnosis of
social anxiety disorder is used only when social fears and avoidance are independent of
the foci of the obsessions and compulsions.
Other medical conditions. Medical conditions may produce symptoms that may be embarrassing
(e.g. trembling in Parkinson's disease). When the fear of negative evaluation
due to other medical conditions is excessive, a diagnosis of social anxiety disorder should
be considered.
Oppositional defiant disorder. Refusal to speak due to opposition to authority figures
should be differentiated from failure to speak due to fear of negative evaluation.

19

PANIC DISORDER Criteria

A. Recurrent unexpected panic attacks. A panic attack is 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;
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable
screaming or crying) may be seen. Such symptoms should not count as one of
the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of
the following:
1. Persistent concern or worry about additional panic attacks or their consequences
(e.g., losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors
designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar
situations).
C. 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, cardiopulmonary
disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks
do not occur only in response to feared social situations, as in social anxiety disorder:
in response to circumscribed phobic objects or situations, as in specific phobia:
in response to obsessions, as in obsessive-compulsive disorder: in response to reminders
of traumatic events, as in posttraumatic stress disorder: or in response to separation
from attachment figures, as in separation anxiety disorder).

20

Risk and Prognostic factors: SOCIAL ANXIETY DISORDER

Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing negative
emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of
anxiety are harmful) are risk factors for the onset of panic attacks and, separately, for
worry about panic, although their risk status for the diagnosis of panic disorder is unknown.
History of "fearful spells" (i.e., limited-symptom attacks that do not meet full criteria
for a panic attack) may be a risk factor for later panic attacks and panic disorder.
Although separation anxiety in childhood, especially when severe, may precede the later
development of panic disorder, it is not a consistent risk factor.
Environmental. Reports of childhood experiences of sexual and physical abuse are more
common in panic disorder than in certain other anxiety disorders. Smoking is a risk factor
for panic attacks and panic disorder. Most individuals report identifiable stressors in the
months before their first panic attack (e.g., interpersonal stressors and stressors related to
physical well-being, such as negative experiences with illicit or prescription drugs, disease,
or death in the family).
Genetic and physiological. It is believed that multiple genes confer vulnerability to panic
disorder. However, the exact genes, gene products, or functions related to the genetic regions
implicated remain unknown. Current neural systems models for panic disorder emphasize
the amygdala and related structures, much as in other anxiety disorders. There is
an increased risk for panic disorder among offspring of parents with anxiety, depressive,
and bipolar disorders. Respiratory disturbance, such as asthma, is associated with panic
disorder, in terms of past history, comorbidity, and family history.

21

CULTURE: SOCIAL PHOBIA

The rate of fears about mental and somatic symptoms of anxiety appears to vary across
cultures and may influence the rate of panic attacks and panic disorder. Also, cultural expectations
may influence the classification of panic attacks as expected or unexpected. For
example, a Vietnamese individual who has a panic attack after walking out into a windy
environment (trilng gio; "hit by the wind") may attribute the panic attack to exposure to
wind as a result of the cultural syndrome that links these two experiences, resulting in classification
of the panic attack as expected. Various other cultural syndromes are associated
with panic disorder, including ataque de nervios ("attack of nerves") among Latin Americans
and khyal attacks and "soul loss" among Cambodians. Ataque de nervios may involve
trembling, uncontrollable screaming or crying, aggressive or suicidal behavior, and depersonalization
or derealization, which may be experienced longer than the few minutes typical
of panic attacks. Some clinical presentations of ataque de nervios fulfill criteria for conditions
other than panic attack (e.g., other specified dissociative disorder). These syndromes
impact the symptoms and frequency of panic disorder, including the individual's attribution
of unexpectedness, as cultural syndromes may create fear of certain situations, ranging
from interpersonal arguments (associated with ataque de nervios), to types of exertion
(associated with khyâl attacks), to atmospheric wind (associated with trùng gio attacks).
Clarification of the details of cultural attributions may aid in distinguishing expected and
unexpected panic attacks. For more information regarding cultural syndromes, refer to the
"Glossary of Cultural Concepts of Distress" in the Appendix.
The specific worries about panic attacks or their consequences are likely to vary from
one culture to another (and across different age groups and gender). For panic disorder,
U.S. community samples of non-Latino whites have significantly less functional impairment
than African Americans. There are also higher rates of objectively defined severity in
non-Latino Caribbean blacks with panic disorder, and lower rates of panic disorder overall
in both African American and Afro-Caribbean groups, suggesting that among individuals
of African descent, the criteria for panic disorder may be met only when there is
substantial severity and impairment.

22

Differential Diagnosis: SOCIAL ANXIETY DISORDER

other specified anxiety disorder or unspecified anxiety disorder. Panic disorder should
not be diagnosed if full-symptom (unexpected) panic attacks have never been experienced. In
the case of only limited-symptom unexpected panic attacks, an other specified anxiety disorder
or unspecified anxiety disorder diagnosis should be considered.
Anxiety disorder due to another medical condition. Panic disorder is not diagnosed if
the panic attacks are judged to be a direct physiological consequence of another medical
condition. Examples of medical conditions that can cause panic attacks include hyperthyroidism,
hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders,
and cardiopulmonary conditions (e.g., arrhythmias, supraventricular tachycardia,
asthma, chronic obstructive pulmonary disease [COPD]). Appropriate laboratory tests
(e.g., serum calcium levels for hyperparathyroidism; Holter monitor for arrhythmias) or
physical examinations (e.g., for cardiac conditions) may be helpful in determining the etiological
role of another medical condition.
Substance/medication-induced anxiety disorder. Panic disorder is not diagnosed if
the panic attacks are judged to be a direct physiological consequence of a substance. Intoxication
with central nervous system stimulants (e.g., cocaine, amphetamines, caffeine)
or cannabis and withdrawal from central nervous system depressants (e.g., alcohol, barbiturates)
can precipitate a panic attack. However, if panic attacks continue to occur outside
of the context of substance use (e.g., long after the effects of intoxication or withdrawal
have ended), a diagnosis of panic disorder should be considered. In addition, because
panic disorder may precede substance use in some individuals and may be associated
with increased substance use, especially for purposes of self-medication, a detailed history
should be taken to determine if the individual had panic attacks prior to excessive substance
use. If this is the case, a diagnosis of panic disorder should be considered in addition
to a diagnosis of substance use disorder. Features such as onset after age 45 years or the
presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness,
loss of bladder or bowel control, slurred speech, armiesia) suggest the possibility that another
medical condition or a substance may be causing the panic attack symptoms.
Other mental disorders with panic attacks as an associated feature (e.g., other anxiety
disorders and psychotic disorders). Panic attacks that occur as a symptom of other anxiety
disorders are expected (e.g., triggered by social situations in social anxiety disorder, by
phobic objects or situations in specific phobia or agoraphobia, by worry in generalized anxiety
disorder, by separation from home or attachment figures in separation anxiety disorder)
and thus would not meet criteria for panic disorder. (Note: Sometimes an unexpected panic
attack is associated with the onset of another anxiety disorder, but then the attacks become
expected, whereas panic disorder is characterized by recurrent unexpected panic attacks.) If
the panic attacks occur only in response to specific triggers, then only the relevant anxiety
disorder is assigned. However, if the individual experiences unexpected panic attacks as
well and shows persistent concern and worry or behavioral change because of the attacks,
then an additional diagnosis of panic disorder should be considered.

23

Panic Attack Specifier Criteria

Note: Symptoms are presented for the purpose of identifying a panic attaclcontext of any anxiety disorder as well as other mental disorders (e.g., depressive disorders,
posttraumatic stress disorder, substance use disorders) and some medical conditions
(e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic
attack is identified, it should be noted as a specifier (e.g., “posttraumatic stress disorder
with panic attacks”). For panic disorder, the presence of panic attack is contained within
the criteria for the disorder and panic attack is not used as a specifier.
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:
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chilis or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable
screaming or crying) may be seen. Such symptoms should not count as one of the four
required symptoms.

24

Differential Diagnosis: PANIC ATTACK SPECIFIER

Other paroxysmal episodes (e.g., “anger attacks”). Panic attacks should not be diagnosed
if the episodes do not involve the essential feature of an abrupt surge of intense fear
or intense discomfort, but rather other emotional states (e.g., anger, grief).
Anxiety disorder due to another medical condition. Medical conditions that can cause
or be misdiagnosed as panic attacks include hyperthyroidism, hyperparathyroidism, pheochromocytoma,
vestibular dysfunctions, seizure disorders, and cardiopulmonary conditions
(e.g., arrhythmias, supraventricular tachycardia, asthma, chronic obstructive
pulmonary disease). Appropriate laboratory tests (e.g., serum calcium levels for hyperparathyroidism;
Holter monitor for arrhythmias) or physical examinations (e.g., for cardiac conditions)
may be helpful in determining the etiological role of another medical condition.
Substance/medication-induced anxiety disorder. Intoxication with central nervous
system stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis and withdrawal
from central nervous system depressants (e.g., alcohol, barbiturates) can precipitate a
panic attack. A detailed history should be taken to determine if the individual had panic
attacks prior to excessive substance use. Features such as onset after age 45 years or the
presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness,
loss of bladder or bowel control, slurred speech, or amnesia) suggest the possibility that a
medical condition or a substance may be causing the panic attack symptoms.
Panic disorder. Repeated unexpected panic attacks are required but are not sufficient for
the diagnosis of panic disorder (i.e., full diagnostic criteria for panic disorder must be met).

25

AGORAPHOBIA Criteria

A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. 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 (e.g., fear of falling in the elderly;
fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion,
or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic
situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease)
is present, the fear, anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental
disorder—for example, the symptoms are not confined to specific phobia, situational
type; do not involve only social situations (as in social anxiety disorder): and are not related
exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects
or flaws in physical appearance (as in body dysmoφhic disorder), reminders of traumatic
events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety
disorder).
Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s
presentation meets criteria for panic disorder and agoraphobia, both diagnoses
should be assigned

26

Differential Diagnosis: AGORAPHOBIA

When diagnostic criteria for agoraphobia and another disorder are fully met, both diagnoses
should be assigned, unless the fear, anxiety, or avoidance of agoraphobia is attributable to the
other disorder. Weighting of criteria and clinical judgment may be helpful in some cases.
Specific phobia, situational type. Differentiating agoraphobia from situational specific
phobia can be challenging in some cases, because these conditions share several symptom
characteristics and criteria. Specific phobia, situational type, should be diagnosed versus agoraphobia
if the fear, anxiety, or avoidance is limited to one of the agoraphobic situations.
Requiring fears from two or more of the agoraphobic situations is a robust means for differentiating
agoraphobia from specific phobias, particularly the situational subtype. Additional differentiating
features include the cognitive ideation. Thus, if the situation is feared for reasons
other than panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fears
of being directly harmed by the situation itself, such as fear of the plane crashing for individuals
who fear flying), then a diagnosis of specific phobia may be more appropriate.
Separation anxiety disorder. Separation anxiety disorder can be best differentiated
from agoraphobia by examining cognitive ideation. In separation anxiety disorder, the
thoughts are about detachment from significant others and the home environment (i.e.,
parents or other attachment figures), whereas in agoraphobia the focus is on panic-like
symptoms or other incapacitating or embarrassing symptoms in the feared situations.
Social anxiety disorder (social phobia). Agoraphobia should be differentiated from social
anxiety disorder based primarily on the situational clusters that trigger fear, anxiety,
or avoidance and the cognitive ideation. In social anxiety disorder, the focus is on fear of
being negatively evaluated.
Panic disorder. When criteria for panic disorder are met, agoraphobia should not be diagnosed
if the avoidance behaviors associated with the panic attacks do not extend to avoidance
of two or more agoraphobic situations.
Acute stress disorder and posttraumatic stress disorder. Acute stress disorder and
posttraumatic stress disorder (PTSD) can be differentiated from agoraphobia by examining
whether the fear, anxiety, or avoidance is related only to situations that remind the
individual of a traumatic event. If the fear, anxiety, or avoidance is restricted to trauma reminders,
and if the avoidance behavior does not extend to two or more agoraphobic situations,
then a diagnosis of agoraphobia is not warranted.
Major depressive disorder. In major depressive disorder, the individual may avoid leaving
home because of apathy, loss of energy, low self-esteem, and anhedonia. If the avoidance
is unrelated to fears of panic-like or other incapacitating or embarrassing symptoms,
then agoraphobia should not be diagnosed.
Other medical conditions. Agoraphobia is not diagnosed if the avoidance of situations
is judged to be a physiological consequence of a medical condition. This determination is
based on history, laboratory findings, and a physical examination. Other relevant medical
conditions may include neurodegenerative disorders with associated motor disturbances
(e.g., Parkinson's disease, multiple sclerosis), as well as cardiovascular disorders. Individuals
with certain medical conditions may avoid situations because of realistic concerns
about being incapacitated (e.g., fainting in an individual with transient ischemic attacks)
or being embarrassed (e.g., diarrhea in an individual with Crohn's disease). The diagnosis
of agoraphobia should be given only when the fear or avoidance is clearly in excess of that
usually associated with these medical conditions.

27

Generalized anxiety Disorder (GAD) Criteria

A. 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).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms
(with at least some symptoms having been present for more days than not for the
past 6 months);
Note: Only one item is required in children.
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 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).
F. 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).

28

Culture GAD

There is considerable cultural variation in the expression of generalized anxiety disorder.
For example, in some cultures, somatic symptoms predominate in the expression of the
disorder, whereas in other cultures cognitive symptoms tend to predominate. This difference
may be more evident on initial presentation than subsequently, as more symptoms
are reported over time. There is no information as to whether the propensity for excessive
worrying is related to culture, although the topic being worried about can be culture specific.
It is important to consider the social and cultural context when evaluating whether
worries about certain situations are excessive.

29

Differential Diagnosis: GAD

Anxiety disorder due to another medical condition. The diagnosis of anxiety disorder
associated with another medical condition should be assigned if the individual's anxiety
and worry are judged, based on history, laboratory findings, or physical examination, to
be a physiological effect of another specific medical condition (e.g., pheochromocytoma,
hyperthyroidism).
Substance/medication-induced anxiety disorder. A substance/medication-induced
anxiety disorder is distinguished from generalized anxiety disorder by the fact that a substance
or medication (e.g., a drug of abuse, exposure to a toxin) is judged to be etiologically
related to the anxiety. For example, severe anxiety that occurs only in the context of heavy
coffee consumption would be diagnosed as caffeine-induced anxiety disorder.
Social anxiety disorder. Individuals with social anxiety disorder often have anticipatory
anxiety that is focused on upcoming social situations in which they must perform or
be evaluated by others, whereas individuals with generalized anxiety disorder worry,
whether or not they are being evaluated.
Obsessive-compulsive disorder. Several features distinguish the excessive worry of
generalized anxiety disorder from the obsessional thoughts of obsessive-compulsive disorder.
In generalized anxiety disorder the focus of the worry is about forthcoming problems,
and it is the excessiveness of the worry about future events that is abnormal. In
obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of
intrusive and unwanted thoughts, urges, or images.
Posttraumatic stress disorder and adjustment disorders. Anxiety is invariably present
in posttraumatic stress disorder. Generalized anxiety disorder is not diagnosed if the
anxiety and worry are better explained by symptoms of posttraumatic stress disorder.
Anxiety may also be present in adjustment disorder, but this residual category should be
used only when the criteria are not met for any other disorder (including generalized anxiety
disorder). Moreover, in adjustment disorders, the anxiety occurs in response to an
identifiable stressor within 3 months of the onset of the stressor and does not persist for
more than 6 months after the termination of the stressor or its consequences.
Depressive, bipolar, and psychotic disorders. Generalized anxiety/worry is a common
associated feature of depressive, bipolar, and psychotic disorders and should not be diagnosed
separately if the excessive worry has occurred only during the course of these
conditions.

30

OTHER SPECIFIED ANXIETY DISORDER Criteria

This category applies to presentations in which symptoms characteristic of an anxiety disorder
that cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning predominate but do not meet the full criteria for any of the
disorders in the anxiety disorders diagnostic class. The other specified anxiety disorder
category is used in situations in which the clinician chooses to communicate the specific
reason that the presentation does not meet the criteria for any specific anxiety disorder.
This is done by recording “other specified anxiety disorder” followed by the specific reason
(e.g., “generalized anxiety not occurring more days than not”).
Examples of presentations that can be specified using the “other specified” designation
include the following;
1. Limited-symptom attacks.
2. Generalized anxiety not occurring more days than not.
3. Khyâl cap (wind attacks): See “Glossary of Cultural Concepts of Distress” in the Appendix.
4. Ataque de nervios (attack of nerves): See “Glossary of Cultural Concepts of Distress”
in the Appendix.