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Anxiety Disorders

Christen Zulli and Maria Martin
by

Maria Martin

on 20 September 2012

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Transcript of Anxiety Disorders

Specific Substances Anxiety Disorders can occur in association with intoxication with the following classes of substances: alcohol; amphetamine and related substances; caffeine; cannabis; cocaine; hallucinogens; inhalants; phencyclidine and related substances; and other or unknown substances.

Anxiety Disorders can occur in association with withdrawal from the following classes of substances: alcohol; cocaine; sedatives, hypnotics, and anxiolytics; and other or unknown substances. Diagnostic Criteria A. Prominent anxiety, Panic Attacks, or obsessions or compulsions predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
(1) the symptoms in Criterion A developed during, or within 1 month of, Substance Intoxication or Withdrawal
(2) medication use is etiologically related to the disturbance
C. It is not better accounted for by an Anxiety Disorder that is not substance induced. Evidence that
the symptoms are better accounted for by an Anxiety Disorder that is not substance induced might
include the following:
- the symptoms precede the onset of the substance use (or medication use);
- the symptoms persist for a substantial period of time (e.g., about a month) after the
cessation of acute withdrawal or severe intoxication or are substantially in excess of what
would be expected given the type or amount of the substance used or the duration of use;
- There is other evidence suggesting the existence an independent non-substance-induced
Anxiety Disorder (e.g., a history of recurrent non-substance-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning. Differential Diagnosis The diagnosis is Anxiety Disorder Due to a General Medical Condition if the anxiety symptoms are a direct physiological consequence of a specific general medical condition (e.g., pheochromocytoma, hyperthyroidism)

A Substance-Induced Anxiety Disorder is distinguished from Generalized Anxiety Disorder by the fact that a substance (i.e., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the anxiety disturbance

When another Axis I disorder is present, diagnosis Generalized Anxiety Disorder should be made only when the focus of the anxiety and worry is unrelated to the other disorder, that is, the excessive worry is not restricted to having a Panic Attack (Panic Disorder), being embarrassed in public (Social Phobia), being contaminated (Obsessive-Compulsive Disorder), gaining weight (Anorexia Nervosa), having a serious illness (Hypochondriasis) D. The focus of the anxiety and worry is not confined to features of an Axis I disorder. The
anxiety is not about having a Panic Attack (as in Panic Disorder), being embarrassed in
public (as in Social Phobia), being contaminated (as in Obsessive- Compulsive Disorder),
being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight
(as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder),
or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur
exclusively during Posttraumatic Stress Disorder.
E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
F. Not due to the effects of a substance (e.g., a drug of abuse, a medication) or medical
condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a
Psychotic Disorder, or a Pervasive Developmental Disorder. Differential Diagnosis Adjustment Disorder, the stressor can be of any severity (not life-threatening like ptsd), for situations in which the symptom pattern of PTSD occurs in response to a stressor that is not extreme (e.g., spouse leaving, being fired).

Symptoms of avoidance, numbing, and increased arousal that are present before exposure to the stressor do not meet criteria for the diagnosis of PTSD and require consideration of other diagnoses (e.g., a Mood Disorder or another Anxiety Disorder).

Acute Stress Disorder is distinguished from PTSD because the symptom pattern in Acute Stress Disorder must occur within 4 weeks of the traumatic event and resolve within that 4-week period

In Obsessive-Compulsive Disorder, there are recurrent intrusive thoughts, but these are experienced as inappropriate and are not related to an experienced traumatic event.

Flashbacks in PTSD must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in Schizophrenia, other Psychotic Disorders, Mood Disorder With Psychotic Features, a delirium, Substance-Induced Disorders, and Psychotic Disorders Due to a General Medical Condition. Specifiers The following specifiers may be used to specify onset and duration of the symptoms of PTSD:
Acute. This specifier should be used when the duration of symptoms is less than 3 months.
Chronic. This specifier should be used when the symptoms last 3 months or longer.
With Delayed Onset. This specifier indicates that at least 6 months have passed between the traumatic event and the onset of the symptoms. Diagnostic Criteria (2) C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Differential Diagnosis Individuals with both Panic Attacks and social avoidance sometimes present a potentially difficult diagnostic problem.

Panic Disorder With Agoraphobia is characterized by the initial onset of unexpected Panic Attacks and avoidance of situations thought to be likely triggers of the Panic Attacks.

Avoidance of situations because of a fear of possible humiliation is highly prominent in Social Phobia, but may also at times occur in Panic Disorder and Agoraphobia. The situations avoided in Social Phobia are limited to those involving possible scrutiny by other people. Fears in Agoraphobia typically involve characteristic clusters of situations that may or may not involve scrutiny by others.

Children with Separation Anxiety Disorder may avoid social settings due to concerns about being separated from their caretaker, concerns about being embarrassed by needing to leave prematurely to return home, or concerns about requiring the presence of a parent when it is not developmentally appropriate.

Although fear of embarrassment or humiliation may be present in Generalized Anxiety Disorder or Specific Phobia (e.g., embarrassment about fainting when having blood drawn), this is not the main focus of the individual's fear or anxiety.

Social anxiety and avoidance of social situations are associated features of many other mental disorders (e.g., Major Depressive Disorder, Schizophrenia, Body Dysmorphic Disorder). If the symptoms of social anxiety or avoidance occur only during the course of another mental disorder and are judged to be better accounted for by that disorder, the additional diagnosis of Social Phobia is not made Culture In certain cultures (e.g., Japan and Korea), individuals with Social Phobia may develop fears of giving offense to others in social situations, instead of being embarrassed. Etreme anxiety that blushing, eye-to-eye contact, or one's body odor will be offensive to others (taijin kyofusho in Japan). In children, crying, tantrums, freezing, clinging or staying close to a familiar person, and inhibited interactions to the point of mutism may be present.

Unlike adults, children with Social Phobia usually do not have the option of avoiding feared situations altogether and may be unable to identify the nature of their anxiety. There may be a decline in classroom performance, school refusal, or avoidance of age-appropriate social activities and dating. To make the diagnosis in children, there must be evidence of capacity for social relationships with familiar people and the social anxiety must occur in peer settings, not just in interactions with adults

Cmmunity-based studies suggest that Social Phobia is more common in women than in men. In most clinical samples, however, the sexes are either equally represented or the majority are male. Diagnostic Criteria A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible
scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur
in peer settings, not just in interactions with adults.

B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of situationally bound or situationally
predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with
unfamiliar people.

C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent. Differential Diagnosis Agoraphobia w/out History of Panic Disorder is distinguished from Panic Disorder With Agoraphobia by the absence of a history of recurrent unexpected Panic Attacks.
In Social Phobia, individuals avoid social or performance situations in which they fear that they might act in a way that is humiliating or embarrassing.
In Specific Phobia, the individual avoids a specific feared object or situation.
In Major Depressive Disorder, the individual may avoid leaving home due to apathy, loss of energy, and anhedonia.
Persecutory fears (as in Delusional Disorder) and fears of contamination (as in Obsessive-Compulsive Disorder) can also lead to widespread avoidance.
In Separation Anxiety Disorder, children avoid situations that take them away from home or close relatives. Diagnostic Criteria A. The presence of Agoraphobia related to fear of
developing panic-like symptoms (e.g., dizziness or
diarrhea).
B. Criteria have never been met for Panic Disorder.
C. The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition.
D. 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. Differential Diagnosis Panic Disorder is not diagnosed if the Panic Attacks are a direct consequence of a general medical condition, in which case an Anxiety Disorder Due to a General Medical Condition is diagnosed.

Panic Disorder is not diagnosed if the Panic Attacks are a direct consequence of a substance (i.e., a drug of abuse, a medication), Substance-Induced Anxiety Disorder is diagnosed.

Panic Disorder must be distinguished from other mental disorders (e.g., other Anxiety Disorders and Psychotic Disorders) that have Panic Attacks as an associated feature. Culture In some cultures, Panic Attacks may involve intense fear of witchcraft or magic. Some cultural or ethnic groups restrict the participation of women in public life, and this must be distinguished from Agoraphobia.

Panic Disorder Without Agoraphobia is diagnosed twice as often and Panic Disorder With Agoraphobia three times as often in women as in men. Diagnostic Criteria A. Both (1) and (2):
(1) recurrent unexpected Panic Attacks
(2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
(a) persistent concern about having additional attacks
(b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
(c) a significant change in behavior related to the attacks

B. The presence of Agoraphobia.

C. The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse,
a medication) or a general medical condition (e.g., hyperthyroidism).

D. The Panic Attacks are not better accounted for by another mental disorder, such as:
Social Phobia (e.g., occurring on exposure to feared social situations),
Specific Phobia (e.g., on exposure to a specific phobic situation),
Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about
contamination),
Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or
Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

Diagnostic Criteria A. Both (1) and (2):
(1) recurrent unexpected Panic Attacks
(2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
(a) persistent concern about having additional attacks
(b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
(c) a significant change in behavior related to the attacks

B. Absence of Agoraphobia.

C. The Panic Attacks are not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition (e.g.,
hyperthyroidism).

D. The Panic Attacks are not better accounted for by another mental disorder, such as:
Social Phobia (e.g., occurring on exposure to feared social situations),
Specific Phobia (e.g., on exposure to a specific phobic situation),
Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about
contamination),
Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or
Separation Anxiety Disorder (e.g., in response to being away from home or close relatives). Defining Terms A Panic Attack is a discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom.
During these attacks, symptoms such as shortness of breath, palpitations, chest pain or discomfort, choking or smothering sensations, and fear of "going crazy" or losing control are present.
Agoraphobia is anxiety about, or avoidance of, places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a Panic Attack or panic-like symptoms. Differential Diagnosis Anxiety symptoms commonly occur in Substance Intoxication and Substance Withdrawal. The diagnosis of the substance-specific intoxication or substance-specific withdrawal will usually suffice to categorize the symptom presentation.

If substance-induced anxiety symptoms occur exclusively during the course of a delirium, the anxiety symptoms are considered to be an associated feature of the delirium and are not diagnosed separately.

In substance-induced presentations that contain a mix of different types of symptoms (e.g., mood, psychotic, and anxiety), the specific type of Substance-Induced Disorder to be diagnosed depends on which type of symptoms predominates in the clinical presentation. Specifiers The following specifiers can be used to indicate which symptom presentation predominates:

With Generalized Anxiety.
With Panic Attacks.
With Obsessive-Compulsive Symptoms.
With Phobic Symptoms. Culture There is cultural variation in the expression of anxiety (e.g., in some cultures, anxiety is expressed predominantly through somatic symptoms, in others through cognitive symptoms).

In children and adolescents with GAD he anxieties and worries often concern the quality of their performance or competence at school or in sporting events, even when their performance is not being evaluated by others. There may be excessive concerns about punctuality. They may also worry about catastrophic events such as earthquakes or nuclear war.

Children with the disorder may be overly conforming, perfectionist, and unsure of themselves and tend to redo tasks because of excessive dissatisfaction. They typically seek approval and require excessive reassurance about their performance and their other worries.

In clinical settings, the disorder is diagnosed somewhat more frequently in women than in men (about 55%-60% of those presenting with the disorder are female). In epidemiological studies, the sex ratio is approximately two-thirds female. Diagnostic 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 person 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 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) Culture Individuals who recently emigrated from areas of considerable social unrest and civil conflict may have elevated rates of PTSD

In younger children, distressing dreams of the event may, within several weeks, change into generalized nightmares of monsters, of rescuing others, or of threats to self or others. Reliving of the trauma may occur through repetitive play

It may be difficult for children to report diminished interest in significant activities and constriction of affect, these symptoms should be carefully evaluated with reports from parents, teachers, and other observers.

Children may also exhibit various physical symptoms, such as stomachaches and headaches. Diagnostic Criteria (1) A. The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's
normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical
condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety
Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).

H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering,
trembling in Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.

Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder) Culture Some cultural or ethnic groups restrict the participation of women in public life, and this must be distinguished from Agoraphobia.

This disorder is diagnosed far more often in females than in males. Panic Disorder Without Agoraphobia 300.01 With Agoraphobia 300.21 Anxiety
Disorders Social Phobia 300.23 Agoraphobia Without History
of Panic Disorder 300.22 PTSD 309.81 Generalized Anxiety
Disorder 300.02 Substance Induced
Anxiety Disorder Christen Zulli and Maria Martin Specific Phobia 300.29 Obsessive Compulsive Disorder 300.3 Acute Stress Disorder 308.3 Anxiety Disorder Due to a General Medical Condition 293.84 Anxiety Disorder NOS 300.00 DSM V Changes Panic Disorder w/out Agoraphobia
Panic Disorder w/ Agoraphobia
Agoraphobia w/out Panic Disorder
Specific Phobia
Social Phobia
OCD
PTSD
Acute Stress Disorder
Generalized Anxiety Disorder
Anxiety Disorder due to Medical Cond.
Substance Induced Anxiety Disorder
Anxiety Disorder NOS Separation Anxiety
Panic Disorder
Agoraphobia
Specific Phobia
Social Anxiety Disorder
Obsessive-Compulsive and Related Disorders
Trauma and Stressor Related Disorders
Generalized Anxiety Disorder
Anxiety Disorder Attributed to Another Med. Condition
Substance Induced Anxiety Disorder
Anxiety Disorder Not Elsewhere Classified DSM IV DSM V Now included as an Anxiety Disorder
No longer included under Anxiety Disorder With Generalized Anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation

With Panic Attacks: if Panic Attacks (see p. 432) predominate in the clinical presentation

With Obsessive-Compulsive Symptoms: if obsessions or compulsions predominate in the clinical presentation

Coding note: Include the name of the general medical condition on Axis I, e.g., 293.84 Anxiety Disorder Due to Pheochromocytoma, With Generalized Anxiety; also code the general medical condition on Axis 111 (see Appendix G for codes).  Specify If… Endocrine conditions (e.g., hyper- and hypothyroidism, pheochromocytoma, hypoglycemia, hyperadrenocorticism)
Cardiovascular conditions (e.g., congestive heart failure, pulmonary embolism, arrhythmia)
Respiratory conditions (e.g., chronic obstructive pulmonary disease, pneumonia, hyperventilation)
Metabolic conditions (e.g., vitamin B12 deficiency, porphyria)
Neurological conditions (e.g., neoplasms, vestibular dysfunction, encephalitis). Associated General Medical Conditions The essential feature of Anxiety Disorder Due to a General Medical Condition is clinically Significant anxiety that is judged to be due to the direct physiological effects of a general medical condition. Symptoms can include prominent, generalized anxiety symptoms, Panic Attacks, or obsessions or compulsions (Criterion A) AND There must be evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition (Criterion B) 293.84 Anxiety Disorder Due to a General Medical Condition A. The person has been exposed to a traumatic event in which both of the following were present:
(1)  the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2)  the person's response involved intense fear, helplessness, or horror
B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
(1)  a subjective sense of numbing, detachment, or absence of emotional responsiveness
(2)  a reduction in awareness of his or her surroundings (e.g., "being in a daze")
(3)  derealization
(4)  depersonalization
(5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
C. The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
H. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.  308.3 Acute Stress Disorder Diagnostic Criteria
~ The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.
~ If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g.. preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic ~
~ Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).
~ The disturbance is not due to the direct physiological effects of a substance (e.g.. a drug of abuse, a medication) or a general medical condition. Four factors can be helpful in making this judgment:

The Focus of Fear
The Type and Number of Panic Attacks
The Number of Situations Avoided
The Level of Intercurrent Anxiety
This category includes disorders with prominent anxiety or phobic avoidance that do not meet criteria for any specific Anxiety Disorder, Adjustment Disorder With Anxiety, Or Adjustment Disorder With Mixed Anxiety and Depressed Mood.  300.00 Anxiety Disorder Not Otherwise Specified [Indicate the General Medical Condition]
Prominent anxiety, Panic Attacks, or obsessions or compulsions predominate in the clinical picture.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
The disturbance is not better accounted for by another mental disorder (e.g., Adjustment Disorder With Anxiety in which the stressor is a serious general medical condition).
The disturbance does not occur exclusively during the course of a delirium.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Diagnostic criteria for 293.84 Anxiety Disorder Due to… Establish the presence of a general medical condition.

Establish that the anxiety symptoms are etiologically related to the general medical condition through a physiological mechanism. A careful and comprehensive assessment of multiple factors is necessary to make this judgment. 

Note: Although there are no infallible guidelines for determining whether the relationship between the anxiety symptoms and the general medical condition is etiological, several considerations provide some guidance in this area.

1. The presence of a temporal association between the onset, exacerbation, or remission of the general medical condition and the anxiety symptoms.
2. The presence of features that are atypical of a primary Anxiety Disorder (e.g., atypical age at onset or course, or absence of family history).  Steps To Making a Diagnosis 
Only be considered if the symptoms last at least 2 days and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning or impair the individual's ability to pursue some necessary task (e.g., obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience).

Must be distinguished from a Mental Disorder Due to a General Medical Condition (e.g., head trauma) (see p. 181) and from a Substance- Induced Disorder (e.g., related to Alcohol Intoxication) (see p. 209), which may be common consequences of exposure to an extreme stressor.

In some individuals, psychotic symptoms may occur following an extreme stressor. In such cases, Brief Psychotic Disorder is diagnosed instead of Acute Stress Disorder.

If a Major Depressive Episode develops after the trauma, a diagnosis of Major Depressive Disorder should be considered in addition to a diagnosis of Acute Stress Disorder. A separate diagnosis of Acute Stress Disorder should not be made if the symptoms are an exacerbation of a preexisting mental disorder.

Appropriate only for symptoms that occur within 1 month of the extreme stressor. Because Posttraumatic Stress Disorder requires more than 1 month of symptoms, this diagnosis cannot be made during this initial I-month period. For individuals with the diagnosis of Acute Stress Disorder whose symptoms persist for longer than 1 month, the diagnosis of Posttraumatic Stress Disorder should be considered. For individuals who have an extreme stressor but who develop a symptom pattern that does not meet criteria for Acute Stress Disorder, a diagnosis of Adjustment Disorder should be considered.

Malingering must be ruled out in those situations in which financial remuneration, benefit eligibility, or forensic determinations play a role.  Differential Diagnosis Although some events are likely to be universally experienced as traumatic, the severity and pattern of response may be modulated by cultural differences in the implications of loss. There may also be culturally prescribed coping behaviors that are characteristic of particular cultures. For example, dissociative symptoms may be a more prominent part of the acute stress response in cultures in which such behaviors are sanctioned. For further discussion of cultural factors related to traumatic events, see p.465.  Specific Cultural Features Obsessive-Compulsive Disorder must be distinguished from Anxiety Disorder Due to a General Medical Condition.
The diagnosis is Anxiety Disorder Due to a General Medical Condition when the obsessions or compulsions are judged to be a direct physiological consequence of a specific general medical condition (see p. 476).
Determination is based on history, laboratory findings. or physical examination. A Substance-Induced Anxiety Disorder is distinguished from Obsessive-Compulsive Disorder by the fact that a substance (i.e., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the obsessions or compulsions (see p.479). 
Recurrent or intrusive thoughts, impulses, images, or behaviors may occur in the context of many other mental disorders
Not diagnosed if the content of the thoughts or the activities is exclusively related to another mental disorder (e.g., preoccupation with appearance in Body Dysmorphic Disorder preoccupation with a feared object or situation specific or Social Phobia, hair pulling in Trichotillomania).
Additional diagnosis of Obsessive-Compulsive Disorder may stilI be warranted if there are obsessions or compulsions whose content is unrelated to the other mental disorder. Differential Diagnosis Culturally prescribed ritual behavior is not in itself indicative of Obsessive-Compulsive Disorder UNLESS:
* It exceeds cultural norms
* Occurs at times and places judged inappropriate by others of the same culture
* Interferes with social role functioning.
Note:
~ Religious and cultural beliefs may influence the themes of obsessions and compulsions (e.g., Orthodox Jews with religious compulsions may have symptoms focusing on dietary practices).
~ Important life transitions and mourning may lead to an intensification of ritual behavior that may appear to be an obsession
~ Presentations of Obsessive-Compulsive Disorder in children are generally similar to those in adulthood. Washing, checking, and ordering rituals are particularly common in children. Children generally do not request help, and the symptoms may not be ego-dystonic. More often the problem is identified by parents, who bring the child in for treatment. Gradual declines in schoolwork secondary to impaired ability to concentrate have been reported. Like adults, children are more prone to engage in rituals at home than in front of peers, teachers, or strangers. For a small subset of children, Obsessive-Compulsive Disorder rna}' be associated with Group A beta-hemolytic streptococcal infection (e.g., scarlet fever and "strep throat"). This form of Obsessive-Compulsive Disorder is characterized by prepubertal onset, associated neurological abnormalities (e.g., choreiform movements and motoric hyperactivity) and an abrupt onset of symptoms or an episodic course in which exacerbations are temporally related to the streptococcal infections. Older adults tend to show more obsessions concerning morality and washing rituals compared with other types of symptoms. In adults, this disorder is equally common in males and females. However, in childhood-onset Obsessive-Compulsive Disorder, the disorder is more common in boys than in girls. 

Obsessive Compulsive Disorder
Specific culture, age and gender
features Either Obsessions or Compulsions

Obsessions as defined by (1), (2), (3), and (4):

(1)  recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
(2)  the thoughts, impulses, or images are not simply excessive worries about real- life problems
(3)  the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
(4)  the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).

Compulsions as defined by (1) and (2):
(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive Diagnostic Criteria for
300.3 Obsessive·Compulsive Disorder Specific Phobias differ from most other Anxiety Disorders in levels of intercurrent anxiety. Typically, individuals with Specific Phobia, unlike those with Panic Disorder With Agoraphobia, do not present with pervasive anxiety, because their fear is limited to specific, circumscribed objects or situations. However, generalized anxious anticipation may emerge under conditions in which encounters with the phobic stimulus become more likely (e.g., when a person who is fearful of snakes moves to a desert area) or when life events force immediate confrontation with the phobic stimulus (e.g., when a person who is fearful of flying is forced by circumstances to fly).
Differentiation of Specific Phobia, Situational Three, from Panic Disorder With Agoraphobia may be particularly difficult because both disorders may include Panic At- tacks and avoidance of similar types of situations (e.g., driving, flying, public transportation, and enclosed places).
Prototypically, Panic Disorder With Agoraphobia is characterized by the initial onset of unexpected Panic Attacks and the subsequent avoidance of multiple situations thought to be likely triggers of the Panic Attacks.
Prototypically, Specific Phobia, Situational Type, is characterized by situational avoidance in the absence of recurrent unexpected Panic Attacks. Some presentations fall between these prototypes and require clinical judgment in the selection of the most appropriate diagnosis. Differential Diagnosis Animal Type. This subtype should be specified if the fear is cued by animals or insects. This subtype generally has a childhood onset
Natural Environment Type. This subtype should be specified if the fear is cued by objects in the natural environment, such as storms, heights, or water. This subtype generally has a childhood onset.
Blood-Injection-Injury Type. nus subtype should be specified if the fear is cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure. This subtype is highly familial and is often characterized by a strong vasovagal response.
Situational Type. This subtype should be specified if the fear is cued by a specific situation such as public transportation, tunnels, bridges, elevators, flying, driving, or enclosed places. This subtype has a bimodal age-at-onset distribution, with one peak in childhood and another peak in the mid-20s. nus subtype appears to be similar to Panic Disorder With Agoraphobia in its characteristic sex ratios, familial aggregation pattern, and age at onset.
Other Type. This subtype should be specified if the (ear is cued by other stimuli. These stimuli might include the fear of choking, vomiting, or contracting an illness; "space" phobia (Le., the individual is afraid of falling down if away from walls or other means of physical support); and children's fears of loud sounds or costumed characters.
The frequency of the subtypes in adult clinical settings, from most to least frequent, is Situational; Natural Environment; Blood-Injection-Injury; and Animal. Studies of community samples show a slightly different pattern, with phobias of heights and of spiders, mice, and insects most common, and phobias of other animals and other elements of the natural environment, such as storms, thunder, and lightening, least common. Phobias of closed-in situations (a Situational Type of phobia) may be more common in the elderly. In many cases, more than one subtype of Specific Phobia is present. Having one phobia of a specific subtype tends to increase the likelihood of having another phobia from within the same subtype (e.g., fear of cats and snakes). When more than one subtype applies, they should all be noted (e.g., Specific Phobia, Animal and Natural Environment Types).  Subtypes A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)
B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.
C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
D. The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive- Compulsive Disorder (e.g., fear of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), Separation Anxiety Disorder (e.g., avoidance of school), Social Phobia (e.g., avoidance of social situations because of fear of embarrassment), Panic Disorder With Agoraphobia, or Agoraphobia Without History of Panic Disorder. Diagnostic criteria for 300.29 Specific Phobia Persistent fear of clearly discernable, circumscribed objects or situations
Response to the phobic stimulus almost invariably provokes an immediate anxiety response
Most stimulus is avoided or endured with dread
Diagnosed only when avoidance, fear, or anxious anticipation of encountering the phobic stimulus interferes significantly with the persons daily routine, occupational functioning, or social life or if the person is markedly distressed about having the phobia
Individuals under 18 the symptoms must have persisted for at least 6 months
May also involve concerns of about losing control, panicking, somatic manifestations of anxiety or fear (increased heart rate or shortness of breath), or fainting when exposed to the feared a object
Level of anxiety or fear varies as a function of both degree of proximity to the stimulus and the degree to which escape from the stimulus is limited
Sometimes full blown panic attacks are experienced Diagnostic Features Formerly Simple Phobia 300.29 Specific Phobia 1. Mixed anxiety-depressive disorder: clinically significant symptoms of anxiety and depression, but the criteria are not met for either a specific Mood Disorder or a specific Anxiety Disorder (see p.780 for suggested research criteria) 

2. Clinically significant social phobic symptoms that are related to the social impact of having a general medical condition or mental disorder (e.g., Parkinson's disease, dermatological conditions, Stuttering, Anorexia Nervosa, Body Dysmorphic Disorder)

3. Situations in which the disturbance is severe enough to warrant a diagnosis of an Anxiety Disorder but the individual fails to report enough symptoms for the full criteria for any specific Anxiety Disorder to have been met; for example, an individual who reports all of the features of Panic Disorder Without Agoraphobia except that the Panic Attacks are are limited-symptom attacks

4. Situations in which the clinician has concluded that an Anxiety Disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced  Examples In the DSM V the required duration is at least 3 months. A. Marked fear or anxiety about at least one situation from two or more of the following five groups of situations:
1. public transportation (e.g., traveling in automobiles, buses, trains, ships, or planes)
2. open spaces (e.g., parking lots, market places, or bridges)
3. being in shops, theaters, or cinemas
4. standing in line or being in a crowd
5. being outside of the home alone in other situations
B. The individual fears these situations due to thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms or other incapacitating symptoms (e.g., sense of falling in the elderly, incontinence, etc.)
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 marked fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations.
NOTE: Out of proportion refers to the sociocultural context; see text.
F. The fear, anxiety, or avoidance is persistent, typically lasting six or more months
G. The fear, anxiety, and avoidance cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The disturbance is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse or a medication) or another medical condition (e.g., cardiopulmonary disorders).
I. The disturbance is not better accounted for by another mental disorder (e.g., anxiety about circumscribed objects or situations in Specific Phobia-Situational Specifier , social situations in Social Anxiety Disorder or Body Dysmorphic Disorder, objects or situations related to obsessions in Obsessive-Compulsive Disorder, reminders of traumatic events in Posttraumatic Stress Disorder, or separation from attachment figures in Separation Anxiety Disorder). DSM V Diagnosis Name: Social Anxiety Disorder (Social Phobia)

The fear, anxiety, or avoidance is persistent, typically lasting six or more months

Specify if: Performance Only: If the fear is restricted to speaking or performing in public

Specify if: Selective Mutism: 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 DSM V Changes DSM V Changes
A. Excessive anxiety and worry (apprehensive expectation) about two (or more) domains of activities or events (e.g., family, health, finances, and school/work difficulties).
B. The excessive anxiety and worry occurs on more days than not, for 3 months or more
C. The anxiety and worry are associated with one or more of the following symptoms:
1. restlessness or feeling keyed up or on edge
2. muscle tension
D. The anxiety and worry are associated with one (or more) of the following behaviors:
1. marked avoidance of activities or events with possible negative outcomes
2. marked time and effort preparing for activities or events with possible negative outcomes
3. marked procrastination in behavior or decision-making due to worries
4. repeatedly seeking reassurance due to worries
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
G. The disturbance is not better accounted for by another mental disorder (e.g., anxiety about Panic Attacks in Panic Disorder, negative evaluation in Social Anxiety Disorder, 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, or having a serious illness in Illness Anxiety Disorder). DSM V Changes New Name: Anxiety Disorder Attributable to Another Medical Condition

Diagnostic Criteria:
A.Prominent anxiety or Panic Attacks predominate in the clinical picture.
B.There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of another medical condition.
C.The disturbance is not better accounted for by another DSM-5 disorder (e.g., Adjustment Disorder with Anxiety in which the stressor is a serious medical condition).
D.The disturbance does not occur exclusively during the course of Delirium.
E.The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if:
With Generalized Anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation

With Panic Attacks: if Panic Attacks predominate in the clinical presentation A presentation that conforms to the guidelines for a mental disorder and is characterized by prominent anxiety, fear, or phobic avoidance that does not meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with Mixed Anxiety and Depressed Mood. There are four situations in which the diagnosis may be appropriate:

1. Atypical presentation

2. Other specific syndrome not listed in DSM-5

3. Insufficient information to place the presentation in another Anxiety Disorder category DSM V Changes DSM V Changes No longer included under Anxiety Disorders

Trauma and Stressor Related Disorders DSM V Changes No longer included in Anxiety Disorders

Trauma and Stressor Related Disorders Social Phobia is characterized by clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior. DSM V
Mixed Anxiety/Depression The new criteria ensure that the patient has both sorts of symptoms and the requirement for depressive symptoms is tightened up compared to the previous definition. A. Patient has 3 or 4 major depression symptoms (which must include depressed mood and/or anhedonia), and they are accompanied by anxious distress. Must have lasted two 2 weeks. B. Anxious Distress is defined as having two or more of the following:
Feeling nervous and anxious
Not being able to control worrying
Having difficulty relaxing
Restlessness to the point it is difficult to keep still and a fear that something awful might happen. C. Patient is NOT suffering from any other mental disorder in DSM-V
D. The disturbance causes marked distress or significant impairment At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.
* Note: This does not apply to children. A. A disturbance that meets full criteria for a relevant anxiety disorder.

B. There is evidence from the history, physical examination, or laboratory findings of (1) and (2):
1. the symptoms of the anxiety disorder developed during or within a month after severe intoxication or withdrawal.
2. the involved substance is capable of producing the anxiety disorder.

C. The anxiety disorder is not better accounted for by a disorder that is not substance-induced. Such evidence of an independent anxiety disorder includes the following
(1) the anxiety disorder preceded the onset of severe intoxication or withdrawal; or
(2) the full anxiety disorder persisted for a substantial period of time (e.g., about a month) after the cessation of severe intoxication or withdrawal.

D. The anxiety disorder does not occur exclusively during the course of a Delirium.

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

Note: this diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the symptoms fulfill criteria for a DSM-5 disorder and when the disorder is sufficiently severe to warrant clinical attention.

Code: [Specific Substance]-Induced Anxiety Disorder: Alcohol; Amphetamine; Cocaine; Hallucinogen; Sedative, Hypnotic or Anxiolytic; Caffeine; Cannabis; other (or Unknown) Substance.

Specify: With Onset during Intoxication
With Onset during Withdrawal
DSM V
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