DSM-5-TR - Anxiety Disorders

Separation Anxiety Disorder

Excessive, developmentally inappropriate fear of separation from attachment figures

≥3 symptoms: distress on separation, worry about harm/loss of figures, worry about events causing separation, reluctance to go out, fear of being alone, refusal to sleep away, nightmares of separation, physical complaints with/anticipating separation

Duration: ≥4 weeks (children), typically ≥6 months (adults)

Causes distress/impairment

Not better explained by other disorders

Features:

Clinging, refusal to leave home, trouble sleeping alone

Adults: discomfort traveling, frequent checking on loved ones

Physical complaints in children (headache, stomachache, nausea)

Prevalence:

Children: ~4% (girls > boys in community)

Adolescents: ~1.6%

Adults: 0.9-1.9% (higher in women)

Global adult 12-month prevalence ~1%

Course:

Onset often preschool; may persist into adulthood

Fluctuating course with remissions/exacerbations

Early onset → school refusal; adults → difficulty with independence

Risk Factors:

Environmental: loss, parental divorce, illness, bullying, overprotective parenting

Genetic/physiological: heritable (~73% in twins), CO₂ sensitivity, family aggregation

Functional Impact:

Children: school refusal, academic/social problems

Adults: impaired work/social functioning, dependence on proximity/contact

Differential Dx:

GAD (general worries vs. separation-specific)

Panic disorder (unexpected attacks vs. separation-triggered)

Agoraphobia (fear of escape difficulty vs. separation from safety figures)

Social anxiety disorder (fear of judgment vs. separation)

PTSD, illness anxiety disorder, prolonged grief, depressive/bipolar disorders, ODD, psychotic disorders, dependent/borderline PDs

Comorbidity:

Children: GAD, specific phobia

Adults: specific phobia, PTSD, panic disorder, GAD, social anxiety, OCD, grief disorder, Cluster C PDs, depression, bi

Social Anxiety Disorder

Core: Marked fear of social situations with possible scrutiny; fears negative evaluation.

Symptoms: Situations almost always provoke anxiety; avoided or endured with distress; out of proportion.

Duration: ≥6 months.

Impairment: Significant distress/functional impairment.

Specifier: Performance only (restricted to public speaking/performing).

Features: Blushing, trembling, sweating, anticipatory anxiety, self-medication. In kids → crying, clinging, freezing.

Prevalence: US 12-mo ~7%; worldwide 0.5-2%; onset ~13 yrs; persistent course.

Risk factors: Behavioral inhibition, fear of negative evaluation, maltreatment, bullying, genetic risk (2-6× in relatives).

Functional impact: School/work avoidance, low SES, impaired relationships, single/divorced, reduced QoL.

Diff Dx: Shyness, agoraphobia (escape vs. scrutiny), panic disorder (uncued vs. cued), GAD, separation anxiety, specific phobia, selective mutism, MDD, BDD, autism, avoidant PD.

Comorbidity: Other anxiety disorders, MDD, substance use, BDD, avoidant PD (esp. generalized type), selective mutism, autism (children).

Panic Disorder

Recurrent unexpected panic attacks (abrupt surge of intense fear/discomfort peaking in minutes).

Symptoms: ≥4 of palpitations, sweating, trembling, SOB, choking, chest pain, nausea, dizziness, chills/heat, paresthesias, derealization/depersonalization, fear of losing control/"going crazy," fear of dying.

At least 1 attack followed by ≥1 month of worry about more attacks or maladaptive behavioral changes (avoidance).

Not due to substances/medical condition.

Not better explained by another mental disorder.

Features: Attacks can occur from calm or anxious states; nocturnal attacks common; avoidance of exertion or situations; frequent health-related fears (heart attack, seizures); self-medication common.

Prevalence: US/EU adults ~2-3% (12-mo); lifetime ~2-3%; women > men (2:1); onset usually 20-24 yrs; rare before age 14; declines after 55.

Course: Chronic, waxing/waning; some episodic with remission; few achieve full remission without relapse.

Risk Factors:

Temperamental: high neuroticism, anxiety sensitivity, harm avoidance.

Environmental: stress, trauma, parental overprotection, low warmth, smoking.

Genetic/physiological: family history of anxiety/mood disorders; CO₂ sensitivity, respiratory disorders (e.g., asthma).

Functional Impact: High disability, ER visits, missed work/school, high medical costs, impaired QoL; often leads to agoraphobia.

Diff Dx:

Limited-symptom panic attacks (don't meet full criteria)

Anxiety disorder due to medical condition (e.g., thyroid, arrhythmia, COPD)

Substance/medication-induced (stimulants, withdrawal)

Other anxiety disorders (attacks are expected, tied to triggers)

Comorbidity: Very high (~80% lifetime). Common with agoraphobia, MDD, bipolar I/II, anxiety disorders, substance use (esp. alcohol), also associated with medical conditions (cardiac, thyroid, respiratory, GI).

Generalized Anxiety Disorder

Core: Excessive anxiety/worry about multiple events/activities, more days than not, ≥6 months.

Criteria:

Difficulty controlling worry

≥3 of: restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance (≥1 in children)

Causes distress/impairment

Not due to substances/medical condition

Not better explained by another disorder

Features: Constant worry, shifting topics, physical tension (trembling, aches), autonomic symptoms less prominent than panic disorder; often with IBS, headaches.

Prevalence: US adults ~2.9% (12-mo); adolescents ~0.9%; worldwide ~1.3%; lifetime risk ~9%. Women ≥2× men. Onset usually ~30s (later than other anxiety disorders). Chronic, waxing/waning; low remission rates.

Risk Factors:

Temperamental: behavioral inhibition, neuroticism, harm avoidance

Environmental: childhood adversity, overprotective parenting

Genetic: ~1/3 heritability, overlaps with depression/anxiety

Functional Impact: Impaired efficiency at work/home; fatigue, sleep issues; 110 million disability days annually in US; reduced QoL, higher medical use, coronary risk.

Diff Dx:

Medical/substance-induced anxiety (e.g., thyroid, caffeine)

Social anxiety (focus on social evaluation)

Separation anxiety (separation-specific)

Panic disorder (unexpected attacks)

Illness anxiety/somatic symptom disorder (health-specific worry)

OCD (intrusive obsessions vs. excessive general worry)

PTSD/adjustment disorder (linked to identifiable stressor/trauma)

Depression, bipolar, psychosis (if worry severe → comorbid GAD possible)

Comorbidity: Very high with other anxiety and unipolar depression; less common with substance use, conduct, psychotic, or neurocognitive disorders.

Substance/Medication-Induced Anxiety Disorder

Core: Prominent panic/anxiety symptoms developing during/soon after substance intoxication, withdrawal, or medication use.

Criteria:

Substance/medication is capable of producing anxiety.

Not better explained by independent anxiety disorder (e.g., symptoms preceded use, or persist >1 month after stopping).

Not exclusive to delirium.

Causes distress/impairment.

Onset Specifiers:

With onset during intoxication

With onset during withdrawal

With onset after medication use

Coding: Based on substance class (alcohol, cannabis, stimulants, opioids, sedatives, hallucinogens, etc.) and presence/absence of comorbid substance use disorder (mild, moderate/severe, or none).

Features: Symptoms improve once substance is discontinued (days-weeks, depending on half-life). Anxiety must be predominant and severe enough to warrant separate clinical attention.

Associated Substances:

Intoxication: alcohol, caffeine, cannabis, stimulants (cocaine, amphetamines), hallucinogens, inhalants.

Withdrawal: alcohol, opioids, sedatives/hypnotics/anxiolytics, stimulants.

Medications: bronchodilators, thyroid hormones, corticosteroids, antihypertensives, antidepressants, antipsychotics, lithium, anticonvulsants, oral contraceptives.

Toxins: CO, CO₂, heavy metals, pesticides, solvents.

Prevalence: Rare in general population (~0.002% US 12-mo), higher in clinical settings.

Differential Dx:

Substance intoxication/withdrawal (diagnose only if anxiety is predominant/severe).

Independent anxiety disorder (if anxiety precedes use or persists >1 month after cessation).

Delirium (not diagnosed separately if only during delirium).

Anxiety disorder due to another medical condition (if symptoms due to illness, not medication).