5. Anxiety Disorders
5.1. Separation Anxiety Disorder
5.2. Selective Mutism
5.3. Specific Phobia
5.4. Social Anxiety Disorder (Social Phobia)
5.5. Panic Disorder
5.6. Panic Attack Specifier
5.7. Agoraphobia
5.8. Generalized Anxiety Disorder
5.9. Substance/Medication-Induced Anxiety Disorder
5.10. Anxiety Disorder Due to Another Medical Condition
Anxiety Disorders include disorders that share features of excessive fear and anxiety
and related behavioral disturbances. Fear is the emotional response to real or perceived
imminent threat, whereas anxiety is anticipation of future threat. Obviously, these
two states overlap, but they also differ, with fear more often associated with surges of autonomic
arousal necessary for fight or flight, thoughts of immediate danger, and escape
behaviors, and anxiety more often associated with muscle tension and vigilance in preparation
for future danger and cautious or avoidant behaviors. Sometimes the level of fear
or anxiety is reduced by pervasive avoidance behaviors. Panic attacks feature prominently
within the anxiety disorders as a particular type of fear response. Panic attacks are not limited
to anxiety disorders but rather can be seen in other mental disorders as well.
The anxiety disorders differ from one another in the types of objects or situations that
induce fear, anxiety, or avoidance behavior, and the associated cognitive ideation. Thus,
while the anxiety disorders tend to be highly comorbid with each other, they can be differentiated
by close examination of the types of situations that are feared or avoided and
the content of the associated thoughts or beliefs.
Anxiety disorders differ from developmentally normative fear or anxiety by being excessive
or persisting beyond developmentally appropriate periods. They differ from transient
fear or anxiety, often stress-induced, by being persistent (e.g., typically lasting 6 months
or more), although the criterion for duration is intended as a general guide with allowance
for some degree of flexibility and is sometimes of shorter duration in children (as in separation
anxiety disorder and selective mutism). Since individuals with anxiety disorders
typically overestimate the danger in situations they fear or avoid, the primary determination
of whether the fear or anxiety is excessive or out of proportion is made by the clinician,
taking cultural contextual factors into account. Many of the anxiety disorders develop in
childhood and tend to persist if not treated. Most occur more frequently in females than in
males (approximately 2:1 ratio). Each anxiety disorder is diagnosed only when the symptoms
are not attributable to the physiological effects of a substance/medication or to another
medical condition or are not better explained by another mental disorder.
The chapter is arranged developmentally, with disorders sequenced according to the
typical age at onset. The individual with separation anxiety disorder is fearful or anxious
about separation from attachment figures to a degree that is developmentally inappropriate.
There is persistent fear or anxiety about harm coming to attachment figures and
events that could lead to loss of or separation from attachment figures and reluctance to go
away from attachment figures, as well as nightmares and physical symptoms of distress. Although
the symptoms often develop in childhood, they can be expressed throughout adulthood
as well.
Selective mutism is characterized by a consistent failure to speak in social situations in
which there is an expectation to speak (e.g., school) even though the individual speaks in
other situations. The failure to speak has significant consequences on achievement in academic
or occupational settings or otherwise interferes with normal social communication.
Individuals with specific phobia are fearful or anxious about or avoidant of circumscribed
objects or situations. A specific cognitive ideation is not featured in this disorder,
as it is in other anxiety disorders. The fear, anxiety, or avoidance is almost always immediately
induced by the phobic situation, to a degree that is persistent and out of proportion
to the actual risk posed. There are various types of specific phobias: animal; natural environment;
blood-injection-injury; situational; and other situations.
In social anxiety disorder (social phobia), the individual is fearful or anxious about or
avoidant of social interactions and situations that involve the possibility of being scrutinized.
These include social interactions such as meeting unfamiliar people, situations in
which the individual may be observed eating or drinking, and situations in which the individual
performs in front of others. The cognitive ideation is of being negatively evaluated
by others, by being embarrassed, humiliated, or rejected, or offending others.
In panic disorder, the individual experiences recurrent unexpected panic attacks and is
persistently concerned or worried about having more panic attacks or changes his or her
behavior in maladaptive ways because of the panic attacks (e.g., avoidance of exercise or of
unfamiliar locations). Panic attacks are abrupt surges of intense fear or intense discomfort
that reach a peak within minutes, accompanied by physical and/or cognitive symptoms.
Limited-symptom panic attacks include fewer than four symptoms. Panic attacks may be
expected, such as in response to a typically feared object or situation, or unexpected, meaning
that the panic attack occurs for no apparent reason. Panic attacks function as a marker and
prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders,
including, but not limited to, the anxiety disorders (e.g., substance use, depressive
and psychotic disorders). Panic attack may therefore be used as a descriptive specifier for
any anxiety disorder as well as other mental disorders.
Individuals with agoraphobia are fearful and anxious about two or more of the following
situations: using public transportation; being in open spaces; being in enclosed places;
standing in line or being in a crowd; or being outside of the home alone in other situations.
The individual fears 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. These situations almost always induce fear or anxiety
and are often avoided and require the presence of a companion.
The key features of generalized anxiety disorder are persistent and excessive anxiety
and worry about various domains, including work and school performance, that the individual
finds difficult to control. In addition, the individual experiences physical symptoms,
including restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating
or mind going blank; irritability; muscle tension; and sleep disturbance.
Substance/medication-induced anxiety disorder involves anxiety due to substance intoxication
or withdrawal or to a medication treatment. In anxiety disorder due to another
medical condition, anxiety symptoms are the physiological consequence of another medical
condition.
Disorder-specific scales are available to better characterize the severity of each anxiety
disorder and to capture change in severity over time. For ease of use, particularly for individuals
with more than one anxiety disorder, these scales have been developed to have
the same format (but different focus) across the anxiety disorders, with ratings of behavioral
symptoms, cognitive ideation symptoms, and physical symptoms relevant to each
disorder.
The essential feature of separation anxiety disorder is excessive fear or anxiety concerning
separation from home or attachment figures. The anxiety exceeds what may be expected
given the person's developmental level (Criterion A). Individuals with separation anxiety
disorder have symptoms that meet at least three of the following criteria: They experience
recurrent excessive distress when separation from home or major attachment figures is anticipated
or occurs (Criterion Al). They worry about the well-being or death of attachment
figures, particularly when separated from them, and they need to know the whereabouts
of their attachment figures and want to stay in touch with them (Criterion A2). They also
worry about untoward events to themselves, such as getting lost, being kidnapped, or
having an accident, that would keep them from ever being reunited with their major attachment
figure (Criterion A3). Individuals with separation anxiety disorder are reluctant
or refuse to go out by themselves because of separation fears (Criterion A4). They have
persistent and excessive fear or reluctance about being alone or without major attachment
figures at home or in other settings. Children with separation anxiety disorder may be unable
to stay or go in a room by themselves and may display "clinging" behavior, staying
close to or "shadowing" the parent around the house, or requiring someone to be with
them when going to another room in the house (Criterion A5). They have persistent reluctance
or refusal to go to sleep without being near a major attachment figure or to sleep
away from home (Criterion A6). Children with this disorder often have difficulty at bedtime
and may insist that someone stay with them until they fall asleep. During the night,
they may make their way to their parents' bed (or that of a significant other, such as a sibling).
Children may be reluctant or refuse to attend camp, to sleep at friends' homes, or to
go on errands. Adults may be uncomfortable when traveling independently (e.g., sleeping
in a hotel room). There may be repeated nightmares in which the content expresses the individual's
separation anxiety (e.g., destruction of the family through fire, murder, or other
catastrophe) (Criterion A7). Physical symptoms (e.g., headaches, abdominal complaints,
nausea, vomiting) are common in children when separation from major attachment figures
occurs or is anticipated (Criterion A8). Cardiovascular symptoms such as palpitations,
dizziness, and feeling faint are rare in younger children but may occur in adolescents and
adults.
The disturbance must last for a period of at least 4 weeks in children and adolescents
younger than 18 years and is typically 6 months or longer in adults (Criterion B). However,
the duration criterion for adults should be used as a general guide, with allowance for
some degree of flexibility. The disturbance must cause clinically significant distress or impairment
in social, academic, occupational, or other important areas of functioning (Criterion
C).
When separated from major attachment figures, children with separation anxiety disorder may exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work or play. Depending on their age, individuals may have fears of animals, monsters, the dark, muggers, burglars, kidnappers, car accidents, plane travel, and other situations that are perceived as presenting danger to the family or themselves. Some individuals become homesick and uncomfortable to the point of misery when away from home. Separation anxiety disorder in children may lead to school refusal, which in turn may lead to academic difficulties and social isolation. When extremely upset at the prospect of separation, children may show anger or occasionally aggression toward someone who is forcing separation. When alone, especially in the evening or the dark, young children may report unusual perceptual experiences (e.g., seeing people peering into their room, frightening creatures reaching for them, feeling eyes staring at them). Children with this disorder may be described as demanding, intrusive, and in need of constant attention, and, as adults, may appear dependent and overprotective. The individual's excessive demands often become a source of frustration for family members, leading to resentment and conflict in the family.
The 12-month prevalence of separation anxiety disorder among adults in the United States is 0.9%-1.9%. In children, 6- to 12-month prevalence is estimated to be approximately 4%. In adolescents in the United States, the 12-month prevalence is 1.6%. Separation anxiety disorder decreases in prevalence from childhood through adolescence and adulthood and is the most prevalent anxiety disorder in children younger than 12 years. In clinical samples of children, the disorder is equally common in males and females. In the community, the disorder is more frequent in females.
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.
Girls manifest greater reluctance to attend or avoidance of school than boys. Indirect expression of fear of separation may be more common in males than in females, for example, by limited independent activity, reluctance to be away from home alone, or distress when spouse or offspring do things independently or when contact with spouse or offspring is not possible.
Separation anxiety disorder in children may be associated with an increased risk for suicide. In a community sample, the presence of mood disorders, anxiety disorders, or substance use has been associated with suicidal ideation and attempts. However, this association is not specific to separation anxiety disorder and is found in several anxiety disorders.
Individuals with separation anxiety disorder often limit independent activities away from
home or attachment figures (e.g., in children, avoiding school, not going to camp, having
difficulty sleeping alone; in adolescents, not going away to college; in adults, not leaving the
parental home, not traveling, not working outside the home).
When encountering other individuals in social interactions, children with selective mutism do not initiate speech or reciprocally respond when spoken to by others. Lack of speech occurs in social interactions with children or adults. Children with selective mutism will speak in their home in the presence of immediate family members but often not even in front of close friends or second-degree relatives, such as grandparents or cousins. The disturbance is often marked by high social anxiety. Children with selective mutism often refuse to speak at school, leading to academic or educational impairment, as teachers often find it difficult to assess skills such as reading. The lack of speech may interfere with social communication, although children with this disorder sometimes use nonspoken or nonverbal means (e.g., grunting, pointing, writing) to communicate and may be willing or eager to perform or engage in social encounters when speech is not required (e.g., nonverbal parts in school plays).
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).
Selective mutism is a relatively rare disorder and has not been included as a diagnostic category in epidemiological studies of prevalence of childhood disorders. Point prevalence using various clinic or school samples ranges between 0.03% and 1% depending on the setting (e.g., clinic vs. school vs. general population) and ages of the individuals in the sample. The prevalence of the disorder does not seem to vary by sex or race/ethnicity. The disorder is more likely to manifest in young children than in adolescents and adults.
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.
Selective mutism may result in social impairment, as children may be too anxious to engage
in reciprocal social interaction with other children. As children with selective mutism
mature, they may face increasing social isolation. In school settings, these children may
suffer academic impairment, because often they do not communicate with teachers regarding
their academic or personal needs (e.g., not understanding a class assignment, not
asking to use the restroom). Severe impairment in school and social functioning, including
that resulting from teasing by peers, is common. In certain instances, selective mutism
may serve as a compensatory strategy to decrease anxious arousal in social encounters.
A key feature of this disorder is that the fear or anxiety is circumscribed to the presence of a
particular situation or object (Criterion A), which may be termed the phobic stimulus. The categories
of feared situations or objects are provided as specifiers. Many individuals fear objects
or situations from more than one category, or phobic stimulus. For the diagnosis of specific
phobia, the response must differ from normal, transient fears that commonly occur in the population.
To meet the criteria for a diagnosis, the fear or anxiety must be intense or severe (i.e.,
"marked") (Criterion A). The amount of fear experienced may vary with proximity to the
feared object or situation and may occur in anticipation of or in the actual presence of the object
or situation. Also, the fear or anxiety may take the form of a full or limited symptom panic attack
(i.e., expected panic attack). Another characteristic of specific phobias is that fear or anxiety
is evoked nearly every time the individual comes into contact with the phobic stimulus
(Criterion B). Thus, an individual who becomes anxious only occasionally upon being confronted
with the situation or object (e.g., becomes anxious when flying only on one out of every
five airplane flights) would not be diagnosed with specific phobia. However, the degree of fear
or anxiety expressed may vary (from anticipatory anxiety to a full panic attack) across different
occasions of encountering the phobic object or situation because of various contextual factors
such as the presence of others, duration of exposure, and other threatening elements such as
turbulence on a flight for individuals who fear flying. Fear and anxiety are often expressed differently
between children and adults. Also, the fear or anxiety occurs as soon as the phobic object
or situation is encountered (i.e., immediately rather than being delayed).
The individual actively avoids the situation, or if he or she either is unable or decides
not to avoid it, the situation or object evokes intense fear or anxiety (Criterion C). Active
avoidance means the individual intentionally behaves in ways that are designed to prevent
or minimize contact with phobic objects or situations (e.g., takes tunnels instead of bridges
on daily commute to work for fear of heights; avoids entering a dark room for fear of spiders;
avoids accepting a job in a locale where a phobic stimulus is more common). Avoidance
behaviors are often obvious (e.g., an individual who fears blood refusing to go to the
doctor) but are sometimes less obvious (e.g., an individual who fears snakes refusing to
look at pictures ihat resemble the form or shape of snakes). Many individuals with specific
phobias have suffered over many years and have changed their living circumstances in
ways designed to avoid the phobic object or situation as much as possible (e.g., an individual
diagnosed with specific phobia, animal, who moves to reside in an area devoid of
the particular feared animal). Therefore, they no longer experience fear or anxiety in their
daily life. In such instances, avoidance behaviors or ongoing refusal to engage in activities
that would involve exposure to the phobic object or situation (e.g., repeated refusal to accept
offers for work-related travel because of fear of flying) may be helpful in confirming
the diagnosis in the absence of overt anxiety or panic.
The fear or anxiety is out of proportion to the actual danger that the object or situation
poses, or more intense than is deemed necessary (Criterion D). Although individuals with
specific phobia often recognize their reactions as disproportionate, they tend to overestimate
the danger in their feared situations, and thus the judgment of being out of proportion
is made by the clinician. The individual's sociocultural context should also be taken
into account. For example, fears of the dark may be reasonable in a context of ongoing
violence, and fear of insects may be more disproportionate in settings where insects are
consumed in the diet. The fear, anxiety, or avoidance is persistent, typically lasting for
6 months or more (Criterion E), which helps distinguish the disorder from transient fears
that are common in the population, particularly among children. However, the duration
criterion should be used as a general guide, with allowance for some degree of flexibility.
The specific phobia must cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning in order for the disorder to be diagnosed
(Criterion F).
Individuals with specific phobia typically experience an increase in physiological arousal in anticipation of or during exposure to a phobic object or situation. However, the physiological response to the feared situation or object varies. Whereas individuals with situational, natural environment, and animal specific phobias are likely to show sympathetic nervous system arousal, individuals with blood-injection-injury specific phobia often demonstrate a vasovagal fainting or near-fainting response that is marked by initial brief acceleration of heart rate and elevation of blood pressure followed by a deceleration of heart rate and a drop in blood pressure. Current neural systems models for specific phobia emphasize the amygdala and related structures, much as in other anxiety disorders.
In the United States, the 12-month community prevalence estimate for specific phobia is approximately 7%-9%. Prevalence rates in European countries are largely similar to those in the United States (e.g., about 6%), but rates are generally lower in Asian, African, and Latin American countries (2%-4%). Prevalence rates are approximately 5% in children and are approximately 16% in 13- to 17-year-olds. Prevalence rates are lower in older individuals (about 3%-5%), possibly reflecting diminishing severity to subclinical levels. Females are more frequently affected than males, at a rate of approximately 2:1, although rates vary across different phobic stimuli. That is, animal, natural environment, and situational specific phobias are predominantly experienced by females, whereas blood-injection-injury phobia is experienced nearly equally by both genders.
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.
Individuals with specific phobia are up to 60% more likely to make a suicide attempt than are individuals without the diagnosis. However, it is likely that these elevated rates are primarily due to comorbidity with personality disorders and other anxiety disorders.
Individuals with specific phobia show similar patterns of impairment in psychosocial
functioning and decreased quality of life as individuals with other anxiety disorders and
alcohol and substance use disorders, including impairments in occupational and interpersonal
functioning. In older adults, impairment may be seen in caregiving duties and
volunteer activities. Also, fear of falling in older adults can lead to reduced mobility and
reduced physical and social functioning, and may lead to receiving formal or informal
home support. The distress and impairment caused by specific phobias tend to increase
with the number of feared objects and situations. Thus, an individual who fears four objects
or situations is likely to have more impairment in his or her occupational and social
roles and a lower quality of life than an individual who fears only one object or situation.
Individuals with blood-injection-injury specific phobia are often reluctant to obtain medical
care even when a medical concern is present. Additionally, fear of vomiting and choking
may substantially reduce dietary intake.
The essential feature of social anxiety disorder is a marked, or intense, fear or anxiety of social
situations in which the individual may be scrutinized by others. In children the fear or
anxiety must occur in peer settings and not just during interactions with adults (Criterion
A). When exposed to such social situations, the individual fears that he or she will be negatively
evaluated. The individual is concerned that he or she will be judged as anxious,
weak, crazy, stupid, boring, intimidating, dirty, or unlikable. The individual fears that
he or she will act or appear in a certain way or show anxiety symptoms, such as blushing,
trembling, sweating, stumbling over one's words, or staring, that will be negatively evaluated
by others (Criterion B). Some individuals fear offending others or being rejected as
a result. Fear of offending others—for example, by a gaze or by showing anxiety symptoms—
may be the predominant fear in individuals from cultures with strong collectivistic
orientations. An individual with fear of trembling of the hands may avoid drinking, eating,
writing, or pointing in public; an individual with fear of sweating may avoid shaking
hands or eating spicy foods; and an individual with fear of blushing may avoid public performance,
bright lights, or discussion about intimate topics. Some individuals fear and
avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or
"shy bladder syndrome").
The social situations almost always provoke fear or anxiety (Criterion C). Thus, an individual
who becomes anxious only occasionally in the social situation(s) would not be diagnosed
with social anxiety disorder. However, the degree and type of fear and anxiety
may vary (e.g., anticipatory anxiety, a panic attack) across different occasions. The anticipatory
anxiety may occur sometimes far in advance of upcoming situations (e.g., worrying
every day for weeks before attending a social event, repeating a speech for days in advance).
In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, or
shrinking in social situations. The individual will often avoid the feared social situations.
Alternatively, the situations are endured with intense fear or anxiety (Criterion D). Avoidance
can be extensive (e.g., not going to parties, refusing school) or subtle (e.g., overpreparing
the text of a speech, diverting attention to others, limiting eye contact).
The fear or anxiety is judged to be out of proportion to the actual risk of being negatively
evaluated or to the consequences of such negative evaluation (Criterion E). Sometimes,
the anxiety may not be judged to be excessive, because it is related to an actual
danger (e.g., being bullied or tormented by others). However, individuals with social anxiety
disorder often overestimate the negative consequences of social situations, and thus
the judgment of being out of proportion is made by the clinician. The individual's sociocultural
context needs to be taken into account when this judgment is being made. For example,
in certain cultures, behavior that might otherwise appear socially anxious may be
considered appropriate in social situations (e.g., might be seen as a sign of respect).
The duration of the disturbance is typically at least 6 months (Criterion F).
This duration
threshold helps distinguish the disorder from transient social fears that are common,
particularly among children and in the community. However, the duration criterion
should be used as a general guide, with allowance for some degree of flexibility. The fear,
anxiety, and avoidance must interfere significantly with the individual's normal routine,
occupational or academic functioning, or social activities or relationships, or must cause
clinically significant distress or impairment in social, occupational, or other important areas
of functioning (Criterion G). For example, an individual who is afraid to speak in public
would not receive a diagnosis of social anxiety disorder if this activity is not routinely
encountered on the job or in classroom work, and if the individual is not significantly distressed
about it. However, if the individual avoids, or is passed over for, the job or education
he or she really wants because of social anxiety symptoms. Criterion G is met.
Individuals with social anxiety disorder may be inadequately assertive or excessively submissive or, less commonly, highly controlling of the conversation. They may show overly rigid body posture or inadequate eye contact, or speak with an overly soft voice. These individuals may be shy or withdrawn, and they may be less open in conversations and disclose little about themselves. They may seek employment in jobs that do not require social contact, although this is not the case for individuals with social anxiety disorder, performance only. They may live at home longer. Men may be delayed in marrying and having a family, whereas women who would want to work outside the home may live a life as homemaker and mother. Self-medication with substances is common (e.g., drinking before going to a party). Social anxiety among older adults may also include exacerbation of symptoms of medical illnesses, such as increased tremor or tachycardia. Blushing is a hallmark physical response of social anxiety disorder.
The 12-month prevalence estimate of social anxiety disorder for the United States is approximately 7%. Lower 12-month prevalence estimates are seen in much of the world using the same diagnostic instrument, clustering around 0.5%-2.0%; median prevalence in Europe is 2.3%. The 12-month prevalence rates in children and adolescents are comparable to those in adults. Prevalence rates decrease with age. The 12-month prevalence for older adults ranges from 2% to 5%. In general, higher rates of social anxiety disorder are found in females than in males in the general population (with odds ratios ranging from 1.5 to 2.2), and the gender difference in prevalence is more pronounced in adolescents and young adults. Gender rates are equivalent or slightly higher for males in clinical samples, and it is assumed that gender roles and social expectations play a significant role in explaining the heightened help-seeking behavior in male patients. Prevalence in the United States is higher in American Indians and lower in persons of Asian, Latino, African American, and Afro-Caribbean descent compared with non-Hispanic whites.
The syndrome of taijin kyofusho (e.g., in Japan and Korea) is often characterized by socialevaluative concerns, fulfilling criteria for social anxiety disorder, that are associated with the fear that the individual makes other people uncomfortable (e.g., "My gaze upsets people so they look away and avoid me"), a fear that is at times experienced with delusional intensity. This symptom may also be found in non-Asian settings. Other presentations of taijin kyofusho may fulfill criteria for body dysmorphic disorder or delusional disorder. Immigrant status is associated with significantly lower rates of social anxiety disorder in both Latino and non-Latino white groups. Prevalence rates of social anxiety disorder may not be in line with self-reported social anxiety levels in the same culture—that is, societies with strong collectivistic orientations may report high levels of social anxiety but low prevalence of social anxiety disorder.
Females with social anxiety disorder report a greater number of social fears and comorbid depressive, bipolar, and anxiety disorders, whereas males are more likely to fear dating, have oppositional defiant disorder or conduct disorder, and use alcohol and illicit drugs to relieve symptoms of the disorder. Paruresis is more common in males.
Social anxiety disorder is associated with elevated rates of school dropout and with decreased
well-being, employment, workplace productivity, socioeconomic status, and quality
of life. Social anxiety disorder is also associated with being single, unmarried, or divorced
and with not having children, particularly among men. In older adults, there may be impairment
in caregiving duties and volunteer activities. Social anxiety disorder also impedes leisure
activities. Despite the extent of distress and social impairment associated with social
anxiety disorder, only about half of individuals with the disorder in Western societies ever
seek treatment, and they tend to do so only after 15-20 years of experiencing symptoms. Not
being employed is a strong predictor for ihe persistence of social aimety disorder.
Panic disorder refers to recurrent unexpected panic attacks (Criterion A). 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 a list of 13 physical and cognitive symptoms occur.
The term recurrent literally means more than one unexpected panic attack. The term unexpected
refers to a panic attack for which there is no obvious cue or trigger at the time of occurrence—
that is, the attack appears to occur from out of the blue, such as when the
individual is relaxing or emerging from sleep (nocturnal panic attack). In contrast, expected
panic attacks are attacks for which there is an obvious cue or trigger, such as a situation in
which panic attacks typically occur. The determination of whether panic attacks are expected
or unexpected is made by the clinician, who makes this judgment based on a combination
of careful questioning as to the sequence of events preceding or leading up to the
attack and the individual's own judgment of whether or not the attack seemed to occur for
no apparent reason. Cultural interpretations may influence the assignment of panic attacks
as expected or unexpected (see section "Culture-Related Diagnostic Issues" for this
disorder). In the United States and Europe, approximately one-half of individuals with
panic disorder have expected panic attacks as well as unexpected panic attacks. Thus, the
presence of expected panic attacks does not rule out the diagnosis of panic disorder. For
more details regarding expected versus unexpected panic attacks, see the text accompanying
panic attacks (pp. 214-217).
The frequency and severity of panic attacks vary widely. In terms of frequency, there
may be moderately frequent attacks (e.g., one per week) for months at a time, or short
bursts of more frequent attacks (e.g., daily) separated by weeks or months without any attacks
or with less frequent attacks (e.g., two per month) over many years. Persons who
have infrequent panic attacks resemble persons with more frequent panic attacks in terms
of panic attack symptoms, demographic characteristics, comorbidity with other disorders,
family history, and biological data. In terms of severity, individuals with panic disorder
may have both full-symptom (four or more symptoms) and limited-symptom (fewer than
four symptoms) attacks, and the number and type of panic attack symptoms frequently
differ from one panic attack to the next. However, more than one unexpected full-symptom
panic attack is required for the diagnosis of panic disorder.
The worries about panic attacks or their consequences usually pertain to physical concerns,
such as worry that panic attacks reflect the presence of life-threatening illnesses
(e.g., cardiac disease, seizure disorder); social concerns, such as embarrassment or fear of
being judged negatively by others because of visible panic symptoms; and concerns about
mental functioning, such as ''going crazy" or losing control (Criterion B). The maladaptive
changes in behavior represent attempts to minimize or avoid panic attacks or their consequences.
Examples include avoiding physical exertion, reorganizing daily life to ensure
that help is available in the event of a panic attack, restricting usual daily activities, and
avoiding agoraphobia-type situations, such as leaving home, using public transportation,
or shopping. If agoraphobia is present, a separate diagnosis of agoraphobia is given.
One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in a state of panic, which differs from panicking after fully waking from sleep). In the United States, this type of panic attack has been estimated to occur at least one time in roughly one-quarter to one-third of individuals with panic disorder, of whom the majority also have daytime panic attacks. In addition to worry about panic attacks and their consequences, many individuals with panic disorder report constant or intermittent feelings of anxiety that are more broadly related to health and mental health concerns. For example, individuals with panic disorder often anticipate a catastrophic outcome from a mild physical symptom or medication side effect (e.g., thinking that they may have heart disease or that a headache means presence of a brain tumor). Such individuals often are relatively intolerant of medication side effects. In addition, there may be pervasive concerns about abilities to complete daily tasks or withstand daily stressors, excessive use of drugs (e.g., alcohol, prescribed medications or illicit drugs) to control panic attacks, or extreme behaviors aimed at controlling panic attacks (e.g., severe restrictions on food intake or avoidance of specific foods or medications because of concerns about physical symptoms that provoke panic attacks).
In the general population, the 12-month prevalence estimate for panic disorder across the United States and several European countries is about 2%-3% in adults and adolescents. In the United States, significantly lower rates of panic disorder are reported among Latinos, African Americans, Caribbean blacks, and Asian Americans, compared with non-Latino whites; American Indians, by contrast, have significantly higher rates. Lower estimates have been reported for Asian, African, and Latin American countries, ranging from 0.1% to 0.8%. Females are more frequently affected than males, at a rate of approximately 2:1. The gender differentiation occurs in adolescence and is already observable before age 14 years. Although panic attacks occur in children, the overall prevalence of panic disorder is low before age 14 years (<0.4%). The rates of panic disorder show a gradual increase during adolescence, particularly in females, and possibly following the onset of puberty, and peak during adulthood. The prevalence rates decline in older individuals (i.e., 0.7% in adults over the age of 64), possibly reflecting diminishing severity to subclinical levels.
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 khyal attacks), to atmospheric wind (associated with trung 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.
The clinical features of panic disorder do not appear to differ between males and females. There is some evidence for sexual dimorphism, with an association between panic disorder and the catechol-O-methyltransferase (COMT) gene in females only.
Agents with disparate mechanisms of action, such as sodium lactate, caffeine, isoproterenol, yohimbine, carbon dioxide, and cholecystokinin, provoke panic attacks in individuals with panic disorder to a much greater extent than in healthy control subjects (and in some cases, than in individuals with other anxiety, depressive, or bipolar disorders without panic attacks). Also, for a proportion of individuals with panic disorder, panic attacks are related to hypersensitive medullary carbon dioxide detectors, resulting in hypocapnia and other respiratory irregularities. However, none of these laboratory findings are considered diagnostic of panic disorder.
Panic attacks and a diagnosis of panic disorder in the past 12 months are related to a higher rate of suicide attempts and suicidal ideation in the past 12 months even when comorbidity and a history of childhood abuse and other suicide risk factors are taken into account.
Panic disorder is associated with high levels of social, occupational, and physical disability;
considerable economic costs; and the highest number of medical visits among the anxiety
disorders, although the effects are strongest with the presence of agoraphobia.
Individuals with panic disorder may be frequently absent from work or school for doctor
and emergency room visits, which can lead to unemployment or dropping out of school.
In older adults, impairment may be seen in caregiving duties or volunteer activities. Fullsymptom
panic attacks typically are associated with greater morbidity (e.g., greater health
care utilization, more disability, poorer quality of life) than limited-symptom attacks.
The essential feature of 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 13 physical and cognitive symptoms occur. Eleven of these 13 symptoms are physical (e.g., palpitations, sweating), while two are cognitive (i.e., fear of losing control or going crazy, fear of dying). 'Tear of going crazy" is a colloquialism often used by individuals with panic attacks and is not intended as a pejorative or diagnostic term. The term within minutes means that the time to peak intensity is literally only a few minutes. A panic attack can arise from either a calm state or an anxious state, and time to peak intensity should be assessed independently of any preceding anxiety. That is, the start of the panic attack is the point at which there is an abrupt increase in discomfort rather than the point at which armety first developed. Likewise, a panic attack can return to either an anxious state or a calm state and possibly peak again. A panic attack is distinguished from ongoing anxiety by its time to peak intensity, which occurs within minutes; its discrete nature; and its typically greater severity. Attacks that meet all other criteria but have fewer than four physical and/or cognitive symptoms are referred to as limited-symptom attacks. There are two characteristic types of panic attacks: expected and unexpected. Expected panic attacks are attacks for which there is an obvious cue or trigger, such as situations in which panic attacks have typically occurred. Unexpected panic attacks are those for which there is no obvious cue or trigger at the time of occurrence (e.g., when relaxing or out of sleep [nocturnal panic attack]). The determination of whether panic attacks are expected or unexpected is made by the clinician, who makes this judgment based on a combination of careful questioning as to the sequence of events preceding or leading up to the attack and the individual's own judgment of whether or not the attack seemed to occur for no apparent reason. Cultural interpretations may influence their determination as expected or unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen; however, such symptoms should not count as one of the four required symptoms. Panic attacks can occur in the context of any mental disorder (e.g., anxiety disorders, depressive disorders, bipolar disorders, eating disorders, obsessive-compulsive and related disorders, personality disorders, psychotic disorders, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal), with the majority never meeting criteria for panic disorder. Recurrent unexpected panic attacks are required for a diagnosis of panic disorder.
One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in a state of panic), which differs from panicking after fully waking from sleep. Panic attacks are related to a higher rate of suicide attempts and suicidal ideation even when comorbidity and other suicide risk factors are taken into account.
In the general population, 12-month prevalence estimates for panic attacks in the United States is 11.2% in adults. Twelve-month prevalence estimates do not appear to differ significantly among African Americans, Asian Americans, and Latinos. Lower 12-month prevalence estimates for European countries appear to range from 2.7% to 3.3%. Females are more frequently affected than males, although this gender difference is more pronounced for panic disorder. Panic attacks can occur in children but are relatively rare until the age of puberty, when the prevalence rates increase. The prevalence rates decline in older individuals, possibly reflecting diminishing severity to subclinical levels.
Cultural interpretations may influence the determination of panic attacks as expected or unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen; however, such symptoms should not count as one of the four required symptoms. Frequency of each of the 13 symptoms varies crossculturally (e.g., higher rates of paresthesias in African Americans and of dizziness in several Asian groups). Cultural syndromes also influence the cross-cultural presentation of panic attacks, resulting in different symptom profiles across different cultural groups. Examples include khyal (wind) attacks, a Cambodian cultural syndrome involving dizziness, tinnitus, and neck soreness; and trunggio (wind-related) attacks, a Vietnamese cultural syndrome associated with headaches. Ataque de nervios (attack of nerves) is a cultural syndrome among Latin Americans that may involve trembling, uncontrollable screaming or crying, aggressive or suicidal behavior, and depersonalization or derealization, and which may be experienced for longer than only a few minutes. Some clinical presentations of ataque de nervios fulfill criteria for conditions other than panic attack (e.g., other specified dissociative disorder). Also, cultural expectations may influence the classification of panic attacks as expected or unexpected, as cultural syndromes may create fear of certain situations, ranging from interpersonal arguments (associated with ataque de nervios), to types of exertion (associated with khyal attacks), to atmospheric wind (associated with trunggio attacks). Clarification of the details of cultural attributions may aid in distinguishing expected and unexpected panic attacks. For more information about cultural syndromes, see "Glossary of Cultural Concepts of Distress" in the Appendix to this manual.
Panic attacks are more common in females than in males, but clinical features or symptoms of panic attacks do not differ between males and females.
In the context of^co-occurring mental disorders, including anxiety disorders, depressive
disorders, bipolar disorder, substance use disorders, psychotic disorders, and personality
disorders, panic attacks are associated with increased symptom severity, higher rates of
comorbidity and suicidality, and poorer treatment response. Also, full-symptom panic attacks
typically are associated with greater morbidity (e.g., greater health care utilization,
more disability, poorer quality of life) than limited-symptom attacks.
The essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the
real or anticipated exposure to a wide range of situations (Criterion A). The diagnosis requires
endorsement of symptoms occurring in at least two of the following five situations:
1) using public transporation, such as automobiles, buses, trains, ships, or planes; 2) being
in open spaces, such as parking lots, marketplaces, or bridges; 3) being in enclosed spaces,
such as shops, theaters, or cinemas; 4) standing in line or being in a crowd; or 5) being outside
of the home alone. The examples for each situation are not exhaustive; other situations
may be feared. When experiencing fear and anxiety cued by such situations, individuals
typically experience thoughts that something terrible might happen (Criterion B). Individuals
frequently believe that escape from such situations might be difficult (e.g., "can't get
out of here") or that help might be unavailable (e.g., "there is nobody to help me") when
panic-like symptoms or other incapacitating or embarrassing symptoms occur. "Panic-like
symptoms" refer to any of the 13 symptoms included in the criteria for panic attack, such as
dizziness, faintness, and fear of dying. "Other incapacitating or embarrassing symptoms"
include symptoms such as vomiting and inflammatory bowel symptoms, as well as, in
older adults, a fear of falling or, in children, a sense of disorientation and getting lost.
The amount of fear experienced may vary with proximity to the feared situation and
may occur in anticipation of or in the actual presence of the agoraphobic situation. Also,
the fear or anxiety may take the form of a full- or limited-symptom panic attack (i.e., an expected
panic attack). Fear or anxiety is evoked nearly every time the individual comes into
contact with the feared situation (Criterion C). Thus, an individual who becomes anxious
only occasionally in an agoraphobic situation (e.g., becomes anxious when standing in line
on only one out of every five occasions) would not be diagnosed with agoraphobia. The individual
actively avoids the situation or, if he or she either is unable or decides not to avoid
it, the situation evokes intense fear or anxiety (Criterion D). Active avoidance means the individual
is currently behaving in ways that are intentionally designed to prevent or minimize
contact with agoraphobic situations. Avoidance can be behavioral (e.g., changing
daily routines, choosing a job nearby to avoid using public transportation, arranging for
food delivery to avoid entering shops and supermarkets) as well as cognitive (e.g., using
distraction to get through agoraphobic situations) in nature. The avoidance can become so
severe that the person is completely homebound. Often, an individual is better able to confront
a feared situation when accompanied by a companion, such as a partner, friend, or
health professional.
The fear, anxiety, or avoidance must be out of proportion to the actual danger posed by
the agoraphobic situations and to the sociocultural context (Criterion E). Differentiating
clinically significant agoraphobic fears from reasonable fears (e.g., leaving the house during
a bad storm) or from situations that are deemed dangerous (e.g., walking in a parking
lot or using public transportation in a high-crime area) is important for a number of reasons.
First, what constitutes avoidance may be difficult to judge across cultures and sociocultural
contexts (e.g., it is socioculturally appropriate for orthodox Muslim women in certain parts
of the world to avoid leaving the house alone, and thus such avoidance would not be considered
indicative of agoraphobia). Second, older adults are likely to overattribute their
fears to age-related constraints and are less likely to judge their fears as being out of proportion
to the actual risk. Third, individuals with agoraphobia are likely to overestimate
danger in relation to panic-like or other bodily symptoms. Agoraphobia should be diagnosed
only if the fear, anxiety, or avoidance persists (Criterion F) and if it causes clinically
significant distress or impairment in social, occupational, or other important areas of functioning
(Criterion G). The duration of "typically lasting for 6 months or more" is meant to
exclude individuals with short-lived, transient problems. However, the duration criterion
should be used as a general guide, with allowance for some degree of flexibility.
In its most severe forms, agoraphobia can cause individuals to become completely homebound, unable to leave their home and dependent on others for services or assistance to provide even for basic needs. Demoralization and depressive symptoms, as well as abuse of alcohol and sedative medication as inappropriate self-medication strategies, are common.
Every year approximately 1.7% of adolescents and adults have a diagnosis of agoraphobia. Females are twice as likely as males to experience agoraphobia. Agoraphobia may occur in childhood, but incidence peaks in late adolescence and early adulthood. Twelve-month prevalence in individuals older than 65 years is 0.4%. Prevalence rates do not appear to vary systematically across cultural/racial groups.
Females have different patterns of comorbid disorders than males. Consistent with gender differences in the prevalence of mental disorders, males have higher rates of comorbid substance use disorders.
Agoraphobia is associated with considerable impairment and disability in terms of role
functioning, work productivity, and disability days. Agoraphobia severity is a strong determinant
of the degree of disability, irrespective of the presence of comorbid panic disorder,
panic attacks, and other comorbid conditions. More than one-third of individuals
with agoraphobia are completely homebound and unable to work.
The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive
expectation) about a number of events or activities. The intensity, duration, or
frequency of the anxiety and worry is out of proportion to the actual likelihood or impact
of the anticipated event. The individual finds it difficult to control the worry and to keep
worrisome thoughts from interfering with attention to tasks at hand. Adults with generalized
anxiety disorder often worry about everyday, routine life circumstances, such as
possible job responsibilities, health and finances, the health of family members, misfortune
to their children, or minor matters (e.g., doing household chores or being late for appointments).
Children with generalized anxiety disorder tend to worry excessively about
their competence or the quality of their performance. During the course of the disorder,
the focus of worry may shift from one concern to another.
Several features distinguish generalized anxiety disorder from nonpathological anxiety.
First, the worries associated with generalized anxiety disorder are excessive and typically interfere
significantly with psychosocial functioning, whereas the worries of everyday life
are not excessive and are perceived as more manageable and may be put off when more
pressing matters arise. Second, the worries associated with generalized anxiety disorder are
more pervasive, pronounced, and distressing; have longer duration; and frequently occur
without precipitants. The greater the range of life circumstances about which a person
worries (e.g., finances, children's safety, job performance), the more likely his or her symptoms
are to meet criteria for generalized anxiety disorder. Third, everyday worries are much
less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up
or on edge). Individuals with generalized anxiety disorder report subjective distress due
to constant worry and related impairment in social, occupational, or other important areas
of functioning.
The anxiety and worry are accompanied by at least three of the following additional
symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty
concentrating or mind going blank, irritability, muscle tension, and disturbed sleep, although
only one additional symptom is required in children.
Associated with muscle tension, there may be trembling, twitching, feeling shaky, and muscle aches or soreness. Many individuals with generalized anxiety disorder also experience somatic symptoms (e.g., sweating, nausea, diarrhea) and an exaggerated startle response. Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of breath, dizziness) are less prominent in generalized anxiety disorder than in other anxiety disorders, such as panic disorder. Other conditions that may be associated with stress (e.g., irritable bowel syndrome, headaches) frequently accompany generalized anxiety disorder.
The 12-month prevalence of generalized anxiety disorder is 0.9% among adolescents and 2.9% among adults in the general community of the United States. The 12-month prevalence for the disorder in other countries ranges from 0.4% to 3.6%. The lifetime morbid risk is 9.0%. Females are twice as likely as males to experience generalized anxiety disorder. The prevalence of the diagnosis peaks in middle age and declines across the later years of life. Individuals of European descent tend to experience generalized anxiety disorder more frequently than do individuals of non-European descent (i.e., Asian, African, Native American and Pacific Islander). Furthermore, individuals from developed countries are more likely than individuals from nondeveloped countries to report that they have experienced symptoms that meet criteria for generalized anxiety disorder in their lifetime.
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.
In clinical settings, generalized anxiety disorder is diagnosed somewhat more frequently in females than in males (about 55%-60% of those presenting with the disorder are female). In epidemiological studies, approximately two-thirds are female. Females and males who experience generalized anxiety disorder appear to have similar symptoms but demonstrate different patterns of comorbidity consistent with gender differences in the prevalence of disorders. In females, comorbidity is largely confined to the anxiety disorders and unipolar depression, whereas in males, comorbidity is more likely to extend to the substance use disorders as well.
Excessive worrying impairs the individual's capacity to do things quickly and efficiently,
whether at home or at work. The worrying takes time and energy; the associated symptoms
of muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrating,
and disturbed sleep contribute to the impairment. Importantly the excessive worrying
may impair the ability of individuals with generalized anxiety disorder to encourage confidence
in their children.
Generalized anxiety disorder is associated with significant disability and distress that is
independent of comorbid disorders, and most non-institutionalized adults with the disorder
are moderately to seriously disabled. Generalized anxiety disorder accounts for 110 million
disability days per annum in the U.S. population.
The essential features of substance/medication-induced anxiety disorder are prominent
symptoms of panic or anxiety (Criterion A) that are judged to be due to the effects of a substance
(e.g., a drug of abuse, a medication, or a toxin exposure). The panic or anxiety symptoms
must have developed during or soon after substance intoxication or withdrawal or
after exposure to a medication, and the substances or medications must be capable of producing
the symptoms (Criterion B2). Substance/medication-induced anxiety disorder
due to a prescribed treatment for a mental disorder or another medical condition must
have its onset while the individual is receiving the medication (or during withdrawal, if a
withdrawal is associated with the medication). Once the treatment is discontinued, the
panic or anxiety symptoms will usually improve or remit within days to several weeks to
a month (depending on the half-life of the substance/medication and the presence of withdrawal).
The diagnosis of substance/medication-induced anxiety disorder should not be
given if the onset of the panic or anxiety symptoms precedes the substance/medication intoxication
or withdrawal, or if the symptoms persist for a substantial period of time (i.e.,
usually longer than 1 month) from the time of severe intoxication or withdrawal. If the
panic or anxiety symptoms persist for substantial periods of time, other causes for the
symptoms should be considered.
The substance/medication-induced anxiety disorder diagnosis should be made instead
of a diagnosis of substance intoxication or substance withdrawal only when the
symptoms in Criterion A are predominant in the clinical picture and are sufficiently severe
to warrant independent clinical attention.
Panic or anxiety can occur in association with intoxication with the following classes of substances: alcohol, caffeine, cannabis, phencyclidine, other hallucinogens, inhalants, stimulants (including cocaine), and other (or unknown) substances. Panic or anxiety can occur in association with withdrawal from the following classes of substances: alcohol; opioids; sedatives, hypnotics, and anxiolytics; stimulants (including cocaine); and other (or unknown) substances. Some medications that evoke anxiety symptoms include anesthetics and analgesics, sympathomimetics or other bronchodilators, anticholinergics, insulin, thyroid preparations, oral contraceptives, antihistamines, antiparkinsonian medications, corticosteroids, antihypertensive and cardiovascular medications, anticonvulsants, lithium carbonate, antipsychotic medications, and antidepressant medications. Heavy metals and toxins (e.g., organophosphate insecticide, nerve gases, carbon monoxide, carbon dioxide, volatile substances such as gasoline and paint) may also cause panic or anxiety symptoms.
The prevalence of substance/medication-induced anxiety disorder is not clear. General
population data suggest that it may be rare, with a 12-month prevalence of approximately
0.002%. However, in clinical populations, the prevalence is likely to be higher.
The essential feature of anxiety disorder due to another medical condition is clinically significant
anxiety that is judged to be best explained as a physiological effect of another medical condition.
Symptoms can include prominent anxiety symptoms or panic attacks (Criterion A).
The judgment that the symptoms are best explained by the associated physical condition must
be based on evidence from the history, physical examination, or laboratory findings (Criterion
B). Additionally, it must be judged that the symptoms are not better accounted for by another
mental disorder, in particular, adjustment disorder, with anxiety, in which the stressor is the
medical condition (Criterion C). In this case, an individual with adjustment disorder is especially
distressed about the meaning or the consequences of the associated medical condition.
By contrast, there is often a prominent physical component to the anxiety (e.g., shortness of
breath) when the anxiety is due to another medical condition. The diagnosis is not made if the
anxiety symptoms occur only during the course of a delirium (Criterion D). The anxiety symptoms
must cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning (Criterion E).
In determining whether the anxiety symptoms are attributable to another medical condition,
the clinician must first establish the presence of the medical condition. Furthermore,
it must be established that anxiety symptoms can be etiologically related to the
medical condition through a physiological mechanism before making a judgment that this
is the best explanation for the symptoms in a specific individual. A careful and comprehensive
assessment of multiple factors is necessary to make this judgment. Several aspects
of the clinical presentation should be considered: 1) the presence of a clear temporal association
between the onset, exacerbation, or remission of the 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); and 3) evidence in the literature that a known physiological
mechanism (e.g., hyperthyroidism) causes anxiety. In addition, the disturbance
must not be better explained by a primary anxiety disorder, a substance/medicationinduced
anxiety disorder, or another primary mental disorder (e.g., adjustment disorder).
A number of medical conditions are known to include anxiety as a symptomatic manifestation. Examples include endocrine disease (e.g., hyperthyroidism, pheochromocytoma, hypoglycemia, hyperadrenocortisolism), cardiovascular disorders (e.g., congestive heart failure, pulmonary embolism, arrhythmia such as atrial fibrillation), respiratory illness (e.g., chronic obstructive pulmonary disease, asthma, pneumonia), metabolic disturbances (e.g., vitamin B^2 deficiency, porphyria), and neurological illness (e.g., neoplasms, vestibular dysfunction, encephalitis, seizure disorders). Anxiety due to another medical condition is diagnosed when the medical condition is known to induce anxiety and when the medical condition preceded the onset of the anxiety.
The prevalence of anxiety disorder due to another medical condition is unclear. There appears to be an elevated prevalence of anxiety disorders among individuals with a variety of medical conditions, including asthma, hypertension, ulcers, and arthritis. However, this increased prevalence may be due to reasons other than the anxiety disorder directly causing the medical condition.