Anxiety Disorders

Panic Disorder Duration

≥ 1 month

Panic Attack Duration

minutes - 1 hr

Panic Attack Prevalence

~1/7-1/3 lifetime

Panic Disorder Core Features

• ≥ 4 symptoms from DSM-5

• Recurrent unexpected panic attacks followed by persistent worry about additional attacks or maladaptive change in behavior

• Distinguish from specific phobia, which only happen in a predictable context

Panic Disorder Comorbidities

Mood disorders, SUDs, other anxiety/trauma-related disorders

Panic Disorder Epidemiology

• 1/25 lifetime (~4%)

• Onset: late teens-20s

• 2x in females vs males

Panic Disorder Treatment

• First-line: SSRI/SNRI

• CBT (psychoeducation, interoceptive/situational exposure, cognitive work)

• BZDs: short-acting, controlling abrupt symptoms (dependence and risks concern)

• Others: psychodynamic (limited evidence)

Agoraphobia Duration

≥6 month

Agoraphobia Core Features

Out of proportion fear and avoidance of ≥2 out of 5 situations: public transportation, open spaces, enclosed spaces, standing in line/being in a crowd, being outside of the home alone

• Occurs w/ or w/o panic attacks

• Somatic symptoms: "panic-like," GI/autonomic complaints

Common safety behaviors in agoraphobia

Mapping exits, sitting near doors, requiring a companion, online shopping only, homebound in severe cases

Agoraphobia Epidemiology

• Onset: late teens–early 20s

• Women > men

Agoraphobia Treatment

• First-line: CBT

• SSRI/SNRI

• CBT + SSRI/SNRI (when severe)

• Avoid long-term use of BZDs

Agoraphobia Comorbidities

Anxiety disorders (>50%)

Depression (~33-53%, higher w/ panic attacks)

Social Anxiety Disorder Duration

≥6 month

• often chronic

• relapse common after med discontinuation

Social Anxiety Disorder Core Features

Out of proportion fear about ≥1 social situations where the individual is exposed to possible scrutiny by others

• ***In children, anxiety must occur in peer settings, not just w/ adults

• Avoid or endure social situations

Social Anxiety Disorder Epidemiology

US: ~8% 12-month, ~13% lifetime

Onset: early teens

Women > men

Social Anxiety Disorder Comorbidities

Depression, other anxiety disorders, SUDs (self-medication), Elevated suicide risk (always assess)

Social Anxiety Disorder Treatment

• First-line: CBT

• SSRI/SNRI (start low, go slow)

  • maintain 6-12 months after response before tapering

• Combination (CBT+SSRI/SNRI) for moderate-severe cases

• Performance social anxiety disorder: beta-blocker PRN for physical symptoms (avoid w/ asthma or bradycardia)

  • Ex. propranolol

• Avoid long-term use of BZDs

Specific Phobia Duration

≥6 month

Specific Phobia Core Features

Out of proportion fear/anxiety about a specific object or situation

Many have >1 phobic stimulus

Specific Phobia Epidemiology

Lifetime prevalence ~9% (US data)

• Teens have the highest prevalence

Onset: childhood/teen years

• Animal and natural environments earlier

• Situation/BII (Blood-injection injury) later

Women > men

Blood-Injection-Injury (BII) specific phobia subtype

Unique vasovagal pattern

• Bradycardia/hypotension → fainting

Treatment: Teach applied tension

• Repeated 10-15 sec. muscle tensing to prevent syncope

Specific Phobia Treatment

Exposure-based CBT

• BII = applied tension + exposure

• Tools: imaginal exposure (ex. VR)

No routine meds

GAD Duration

≥6 month

GAD Core Features

• Excessive, difficult to control worry about multiple life domains (ex. work, school performance) causing distress/impairment

• ≥ 3 of 6 symptoms:

  • Restlessness or feeling keyed up or on edge

  • Easily fatigued

  • Difficulty concentrating or mind going blank

  • Irritability

  • Muscle tension

  • Sleep disturbances

GAD Epidemiology

Lifetime ≈ 5%

Onset: early and older adulthood

Women > men

GAD Comorbiditities

MDD, other anxiety disorders, SUDs

GAD Treatment

• First-line: CBT; psychoeducation; relaxation/breathing

• SSRI/SNRI (start low, go slow)

  • reassess 4-6 weeks

  • continue ~12 months after remission before slow taper (relapse is common)

Selective Mutism Duration

>1 month (not just 1st month of school)

Selective Mutism Core Features

Consistent failure to speak in specific social settings (ex. school) despite speaking normally in other settings (ex. home)

Selective Mutism Epidemiology

~1% of children

Onset: before age 5

Girls ≳ boys

Selective Mutism Comorbidities

Social anxiety disorder

Can also overlap with developmental/communication disorders

Selective Mutism Treatment

• First-line: Behavioral/CBT-based interventions (often school + family)

  • Positive reinforcement: remove pressure to speak

  • Address comorbid social anxiety w/ CBT skills

• SSRI (fluoxetine/sertraline) may help moderate-severe cases or when CBT access/response is limited

Separation Anxiety Disorder Duration

≥4 weeks in children

≥6 months in adults

Separation Anxiety Disorder Core Features

Excessive fear about separation

≥3 symptoms:

• Distress w/ separation

• Worries about harm/events

• Refusal to go out/sleep away

• Being along

• Nightmare

• Somatic complaints (headache, stomachache, nausea)

Separation Anxiety Disorder Epidemiology

Lifetime ≈ 4.8%

Onset: adult (43%)

• Similar in males and females

Onset: childhood

• girls > boys

Separation Anxiety Disorder Cormorbidities

MDD, BPD, OCD, social anxiety, specific phobia

Separation Anxiety Disorder Treatment

• first-line: CBT w/ family/systems involvement

• SSRI can be considered as adjuncts when CBT is unavailable/insufficient (evidence in adults is limited, pediatrics is mixed)