ANXIETY DISORDERS
Anxiety Disorders
Overview of Anxiety Disorders
Include:
Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder
Panic Disorder
Panic Attack Specifier
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder
Fear vs. Anxiety
Fear:
Emotional response to real or perceived imminent threat.
Associated with:
Surges of autonomic arousal necessary for fight or flight.
Immediate danger thoughts.
Escape behaviors.
Anxiety:
Anticipation of future threat.
Associated with:
Muscle tension.
Vigilance in preparation for future danger.
Cautious or avoidant behaviors.
Separation Anxiety Disorder (Diagnostic Criteria 309.21/F93.0)
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from major attachment figures, evidenced by at least 3 of the following:
1. Recurrent excessive distress when anticipating or experiencing separation from home or major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or harm to them (e.g., illness, injury, disasters).
3. Persistent worry about experiencing events that could lead to separation (e.g., getting lost, being kidnapped).
4. Persistent reluctance or refusal to leave home or other places due to fear of separation.
5. Persistent fear of being alone or without attachment figures.
6. Reluctance or refusal to sleep away from home or without attachment figures nearby.
7. Repeated nightmares involving the theme of separation.
8. Physical complaints (e.g., headaches, stomachaches, nausea) when separation occurs or is anticipated.
B. Fear/anxiety/avoidance lasts at least 4 weeks in children/adolescents and typically 6 months or more in adults.
C. Causes clinically significant distress or impairment in functioning (social, academic, occupational).
D. Not better explained by another mental disorder.
Selective Mutism (Diagnostic Criteria 312.23/F94.0)
A. Consistent failure to speak in specific social situations where there is an expectation to speak (e.g., at school), despite speaking in other settings.
B. Disturbance interferes with educational, occupational achievement, or social communication.
C. Duration is at least 1 month (not limited to the first month of school).
D. Failure to speak is not due to unfamiliarity or discomfort with the spoken language required.
E. Not better explained by a communication disorder or during course of autism/psychotic disorders.
Specific Phobia (Diagnostic Criteria)
A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals).
In children, fear may be expressed by crying, tantrums, freezing, or clinging.
B. Phobic object/situation almost always provokes immediate fear or anxiety.
C. Phobic object/situation is either avoided or endured with intense fear.
D. Fear/anxiety is disproportionate to actual danger and sociocultural context.
E. Fear/anxiety/avoidance persists for 6 months or more.
F. Causes clinically significant distress or impairment in functioning.
G. Not better explained by symptoms of another mental disorder.
Specify based on phobic stimulus:
300.29 (F40.218) Animal (e.g., spiders, insects).
300.29 (F40.228) Natural environment (e.g., heights, storms).
300.29 (F40.23X) Blood-injection-injury (e.g., needles).
300.29 (F40.248) Situational (e.g., airplanes, elevators).
300.29 (F40.298) Other (e.g., choking, loud sounds).
Social Anxiety Disorder (Social Phobia) (Diagnostic Criteria 300.23/F40.10)
A. Marked fear or anxiety about social situations where the individual may be scrutinized (e.g., conversations, being observed).
In children, anxiety must occur in peer settings, not just by interactions with adults.
B. Individual fears being negatively evaluated (humiliated, rejected).
C. Social situations almost always provoke fear or anxiety.
In children, expressed by crying, tantrums, etc.
D. Avoidance of social situations or enduring them with intense fear/anxiety.
E. Fear/anxiety is out of proportion to the actual threat posed and sociocultural context.
F. Persistent fear/anxiety lasting for 6 months or more.
G. Causes clinically significant distress or impairment in functioning.
H. Not attributable to substance effects or another medical condition.
I. Not better explained by symptoms of another mental disorder.
J. If another medical condition is present, fear/anxiety/avoidance is excessive.
Specify if performance only: Fear is restricted to public speaking/performing.
Panic Disorder (Diagnostic Criteria 300.01/F41.0)
A. Recurrent unexpected panic attacks (surge of intense fear/discomfort that peaks within minutes).
Symptoms include:
1. Palpitations or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath and smothering.
5. Feeling of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling).
11. Derealization or depersonalization.
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., neck soreness) may be present but do not count as required symptoms.
B. Attacks followed by 1 month or more of one or both:
1. Persistent concern about additional attacks (e.g., losing control).
2. Significant maladaptive change in behavior (e.g., avoidance of triggers).
C. Not attributable to substance effects or another medical condition.
D. Not better explained by another mental disorder or phobia.
Panic Attack Specifier
Panic attacks can occur in various mental disorders but panic attack itself is not a mental disorder (cannot be coded).
Symptoms identify panic attacks; specify if present in other diagnoses like posttraumatic stress disorder.
Agoraphobia (Diagnostic Criteria 300.22/F40.00)
A. Marked fear/anxiety about two or more of the following:
1. Using public transport.
2. Being in open spaces.
3. Being in enclosed places.
4. Standing in line or being in a crowd.
5. Being outside of home alone.
B. Fears arise from concerns that escape might be difficult, or help unavailable if panic-like symptoms arise.
C. Situations almost always provoke fear or anxiety.
D. Situations avoided, require companion presence, or endured with intense fear.
E. Anxiety is out of proportion to actual danger posed and sociocultural context.
F. Persistent avoidance usually lasting 6 months or more.
G. Causes significant distress or impairment in functioning.
H. If another medical condition is present, fears are excessive.
I. Not better explained by symptoms of another mental disorder.
Generalized Anxiety Disorder (Diagnostic Criteria 300.02/F41.1)
A. Excessive anxiety and worry occurring more days than not for at least 6 months about various events or activities.
B. Difficulty controlling the worry.
C. Anxiety/worry associated with three or more of the following:
1. Restlessness or feeling keyed up.
2. Being easily fatigued.
3. Difficulty concentrating.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance.
Note: Only one symptom needed in children.
D. Causes clinically significant distress or impairment in functioning.
E. Not attributable to substance effects or another medical condition.
F. Not better explained by another mental disorder.
Substance/Medication-Induced Anxiety Disorder (Diagnostic Criteria)
A. Panic attacks or anxiety is predominant in the clinical picture.
B. Evidence from history, exam, or labs of:
1. Symptoms developed during or shortly after substance use or withdrawal.
2. The substance/medication capable of producing these symptoms.
C. Not better explained by a separate anxiety disorder.
Evidence of independent anxiety could include symptoms preceding substance use or continuing post withdrawal.
D. Not occurring exclusively during a delirium.
E. Causes clinically significant distress or impairment in functioning.
Specify if:
With onset during intoxication, withdrawal, or after medication use.
Anxiety Disorder Due to Another Medical Condition (Diagnostic Criteria 293.84/F06.4)
A. Panic attacks or anxiety is predominant.
B. Evidence that disturbance is a direct consequence of another medical condition.
C. Not better explained by another mental disorder.
D. Not during a delirium.
E. Causes clinically significant distress or impairment in functioning.
Other Specified Anxiety Disorder (Diagnostic Criteria 300.09/F41.8)
Applies to symptoms characteristic of anxiety disorders causing distress but not meeting full criteria for specific disorders.
Used when: clinician specifies the reason it does not meet criteria for any specific anxiety disorder.
Examples of specified presentations:
Limited-symptom attacks.
Generalized anxiety not occurring more days than not.
Cultural concepts (e.g., Khyal cap, Ataque de nervios).
Unspecified Anxiety Disorder (Diagnostic Criteria 300.00/F41.9)
Applies to anxiety disorder symptoms causing distress but do not meet full criteria for any specific anxiety disorder.
Used when: clinician chooses not to specify reason or lacks sufficient information for specific diagnosis (e.g., emergency situations).