Anxiety and Related Disorders

May be associated with intoxication or withdrawal from any of the following substances

uAlcohol, sedatives, hypnotics, or anxiolytics uAmphetamines or cocaine uHallucinogens uCaffeine uCannabis uOthers

uSpecific Phobia

A persistent, intensely felt, and irrational fear of a specific object, activity, or situation that results in a compelling desire to avoid the feared stimulus Responses typically include intense anxiety or panic attacks ICD-10 code depends on specific phobia Agoraphobia and social phobia (i.e. social anxiety disorder) are so common, they get their own sections in the DSM-5

A phobia is a

A phobia is a persistent, intensely felt, and irrational fear of a specific object, activity, or situation that results in a compelling desire to avoid the feared stimulus. Describe the symptoms of a client with a phobia. Agoraphobia is the fear that some patients have of being in open shops and markets, although it may be more related to fears of being vulnerable and in a less secure environment. The individual experiences fear of being in places or situations from which escape might be difficult or in which help might not be available in the event that panic symptoms should occur. Impairment can be severe. In extreme cases the individual is unable to leave his or her home without being accompanied by a friend or relative

anxiety cont

A stressor is an external pressure that is brought to bear on the individual. Anxiety is the subjective emotional response to that stressor. Anxiety may be distinguished from fear in that anxiety is an emotional process, whereas fear is a cognitive one.

Epidemiological Statistics

Anxiety disorders are the most common of all psychiatric illnesses and result in considerable functional impairment and distress. More common in women than in men Vulnerability to comorbidities include parental psychiatric history, childhood trauma, and negative life events. A familial predisposition probably exists. more common in women than in men by at least 2 to 1. The prevalence for any anxiety disorder is estimated at 18.1 percent for adults and 25.2 percent for children aged 13 to 18 years of age. Common comorbidities include another anxiety disorder, depression, and substance abuse

Historical Aspects

Anxiety was once identified by its physiological symptoms, focusing largely on the cardiovascular system. Freud was the first to associate anxiety with neurotic behaviors. uFor many years, anxiety disorders were viewed as purely psychological or purely biological in nature.

Generalized anxiety disorder (GAD)

Characterized by chronic, unrealistic, and excessive anxiety and worry This must occur on most days for 6 months or more 3 or more of following must accompany this: Restlessness Fatigue Poor concentration Irritability Muscle tension Trouble sleeping

uPanic disorder

Characterized by recurrent panic attacks, the onset of which are unpredictable and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort At least one of the attacks must be followed by 1 month or more of either worry about having another attack OR making a maladaptive change in behavior related to the attacks (like if exercise tends to be accompanied by panic attacks-avoiding exercise May or may not be accompanied by agoraphobia

Social anxiety disorder (social phobia)

Excessive fear of situations in which the affected person might do something embarrassing or be evaluated negatively by others Social anxiety disorder is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others. The individual has extreme concerns about being exposed to possible scrutiny by others and fears social or performance situations in which embarrassment may occur. In some instances, the fear may be quite defined, such as the fear of speaking or eating in a public place, fear of using a public restroom, or fear of writing in the presence of others. In other cases, the social phobia may involve general social situations, such as saying things or answering questions in a manner that would provoke laughter on the part of others.

Agoraphobia

Fear of being in places or situations from which escape might be difficult or in which help might not be available if panic-like symptoms or other incapacitating symptoms examples traveling in public transportation Being in open spaces being in shops, theaters, or cinemas standing in line or being in a crowd Being outside of the home alone in other situations

Describe the symptoms of generalized anxiety disorder.

Generalized anxiety disorder (GAD) is characterized by persistent, unrealistic, and excessive anxiety and worry, which have occurred more days than not for at least 6 months, and cannot be attributed to specific organic factors, such as caffeine intoxication or hyperthyroidism. The anxiety and worry are associated with muscle tension, restlessness, or feeling keyed up or on edge. The symptoms in generalized anxiety disorder are intense enough to cause clinically significant impairment in social, occupational, or other important areas of functioning. The individual often avoids activities or events that may result in negative outcomes, or spends considerable time and effort preparing for such activities. Anxiety and worry often result in procrastination in behavior or decision-making, and the individual repeatedly seeks reassurance from others. Discuss the various theories on predisposing factors of panic and generalized anxiety disorder. The psychodynamic view of anxiety disorders focuses on the inability of the ego to intervene when conflict occurs between the id and the superego, producing anxiety. For various reasons ego development is delayed. When developmental defects in ego functions compromise the capacity to modulate anxiety, the individual resorts to unconscious mechanisms to resolve the conflict.

differences between anxiety, stress, and fear.

Individuals face anxiety on a daily basis. Stress, or more properly, a stressor, is an external pressure that is brought to bear on the individual. Anxiety is the subjective emotional response to that stressor. Anxiety may be distinguished from fear in that the former is an emotional process, whereas fear is a cognitive one. Fear involves the intellectual appraisal of a threatening stimulus; anxiety involves the emotional response to that appraisal. The neurobiology of anxiety disorders is presented in Figure 27-1.

anxiety

Introduction: Anxiety is an emotional response to anticipation of danger, the source of which is largely unknown or unrecognized. Anxiety is a necessary force for survival. It is not the same as stress. Define anxiety. Anxiety is a feeling of discomfort, apprehension or dread related to anticipation of danger, the source of which is often nonspecific or unknown. Anxiety is considered a disorder (or pathological) when fears and anxieties are excessive (in a cultural context) and there are associated behavioral disturbances such as interference with social and occupational functioning

Describe the symptoms of panic disorder.

Panic disorder is characterized by recurrent panic attacks, the onset of which is unpredictable, and manifested by intense apprehension, fear, or terror, often associated with feelings of impending doom and accompanied by intense physical discomfort. The physical sensations can be so intense that the individual believes they are having a heart attack or other critical illness. The symptoms come on suddenly and unexpectedly. The role of organic factors in the etiology has been ruled out.

panic

Sudden overwhelming feeling of terror or impending doom This most severe form of emotional anxiety is usually accompanied by behavioral, cognitive, and physiological signs and symptoms considered extremely intense and frightening. Having a panic attack is not a disorder (unless accompanied by the other criteria of panic disorder) Can be a specifier of several disorders (e.g. Generalized Anxiety Disorder with panic attacks) Adding this specifier does not change the ICD-10 code If the criteria for panic disorder are met, it is listed as a separate disorder and the panic attack specifier is not used For example: a person can have both GAD and panic disorder

How Much Is Too Much?

When anxiety is out of proportion to the situation that is creating it When anxiety interferes with social, occupational, or other important areas of functioning Discuss criteria for abnormal or pathological anxiety. It is difficult to differentiate between normal and abnormal anxiety as normality is determined by societal standards. However, anxiety can be generally considered abnormal or pathological if it is out of proportion to the situation that is creating it, or it interferes with social, occupational, or other areas of functioning. It is clear that when anxiety becomes excessive and persistent humans respond in a variety of ways that are likely a complex interaction of genetic vulnerability, biochemical influences, and environmental factors.

Agoraphobia · diagnostic criteria cont

because of thoughts that escape might be difficult or might not be available in the event of developing panic like symptoms or other incapacitating or embarrassing symptoms (fear of falling in the elevator, fear of incontinence) o the agoraphobic situation almost always provokes fear or anxiety o the agoraphobic situations are actively avoided, require the presence of a companion, or endured with intense fear or anxiety o the fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the socio-cultural context o the fear, anxiety, or avoidance is persistent, typically lasting for six months or more o the fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning o If another medical condition (inflammatory bowel disease, Parkinson's disease) is present, the fear, anxiety, or avoidance is clearly excessive o the fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder § note: agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual's presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.

Selective Mutism associated features

o 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 opposition behavior. o although children with this disorder generally have normal language skills, there may occasionally be an associated communication disorder, although no association with a specific communication disorder has been identified o in clinical settings, children with selective mutism are almost always given an additional diagnosis of other anxiety disorder, most commonly social anxiety disorder

Panic Disorder · Diagnostic Criteria cont

o At least one of the attacks has been followed by one month or more of one or both of the following: § persistent concern or worry about additional panic attacks or their consequences (losing control, having a heart attack, going crazy) § a significant maladaptive change in behavior related to the attacks (behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations) o the disturbance is not attributable to the physiological effects of a substance (a drug of abuse, medication) or another medical condition, hyperthyroidism, cardiopulmonary disorders o the disturbance is not better explained by another mental disorder (the panic attacks do not occur only response to feared social situations, as in social anxiety disorder, in response to circumscribed phobic objects or situations as in specific phobia, in response to obsessions, as in obsessive-compulsive disorder, and response to reminders of traumatic events, as in PTSD, or in response to separation from attachment figures, as in separation anxiety disorder)

Separation Anxiety Disorder · Diagnostic features

o Central feature of separation anxiety is excessive fear or anxiety concerning separation from home or attachment figures § the anxiety extends what may be expected given the individual's developmental level o Individuals must have three of the following A criteria

Generalized Anxiety Disorder · Diagnostic features cont

o Children with generalized anxiety disorder tend to worry excessively about their confidence or the quality of their performance. o several features distinguish generalized anxiety disorder from non-pathological 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 participants. § Third, everyday worries are much less likely to be accompanied by physical symptoms (restlessness or feeling keyed up or on edge). o Individuals with generalized anxiety disorder report subjective distress because of constant worry and related impairment in social, occupational, or other important areas of functioning.

Selective Mutism · Diagnostic Criteria

o Consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations. o The disturbance interferes with educational or occupational achievement or with social communication o the duration of the disturbances at least one month (not limited to the first month of school) o the failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in social situation o the disturbance is not better explained by a communication disorder (childhood onset fluency disorder) and does not occur exclusively during autism spectrum disorder, schizophrenia, or other psychiatric disorders

Separation Anxiety Disorder · Diagnostic Criteria

o Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: § recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures § persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. § Persistent and excessive worry about experiencing and untoward event (getting last, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure § persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation § persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings § repeated nightmares involving the theme of separation § repeated complaints of physical symptoms (headaches, stomach aches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated

Generalized Anxiety Disorder · Diagnostic Criteria

o Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance) § the individual finds it difficult to control the worry § the anxiety and worry are associated with three or more of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months): · note: only one item is required in children · restlessness or feeling keyed up or on edge · being easily fatigued · difficulty concentrating or mind going blank · irritability · muscle tension · sleep disturbance o the anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning o the disturbance is not attributable to physiological effects of a substance or other medical condition o the disturbance is not better explained by another mental disorder

Separation Anxiety Disorder: · Comorbidity

o In children, separation anxiety disorder is highly comorbid with generalized anxiety disorder and specific phobia o in adults, common comorbidities include specific phobia, PTSD, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia, obsessive compulsive disorder, prolonged grief disorder, and personality disorders.

Functional Consequences of Panic Attack

o 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 symptoms severity, higher rates of comorbidity, and poor treatment response. o Recurrent panic attacks are associated with increased odds of many mental health diagnoses. § Furthermore, more severe panic attacks are associated with a greater likelihood of developing panic disorder and a variety of other mental health conditions, as well as greater persistence of mental illness and impaired functioning.

Specific Phobia associated features

o Individuals with specific phobia typically experience an increase in physiological or arousal in anticipation of or during exposure to phobic object or situation. o However, the physical response to the feared situation or object varies. o 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 an initial brief acceleration of heart rate or elevation of blood pressure followed by a deceleration of heart rate and a drop in blood pressure.

Specific Phobia · Diagnostic Criteria

o Marked fear or anxiety about a specific object or situation (flying, heights, animals, receiving an injection, seeing blood) § note in children, the fear or anxiety may be expressed by crying, tantrums, freezing or clinging o the phobic object or situation almost always provokes immediate fear or anxiety o The phobic object or situation is actively avoided or endured with intense fear or anxiety o the fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context o the fear, anxiety, or avoidance is persistent, typically lasting for six months or more o the fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other areas of functioning o the disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic like symptoms or other incapacitating symptoms; objects or situations related to obsessions, reminders of traumatic events, separation from home or attachment figures, or social situations

Social Anxiety Disorder · Diagnostic Criteria

o Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (having a conversation, meeting unfamiliar people), being observed (eating or drinking), and performing in front of others (giving a speech). § Note in children, the anxiety must occur in peer settings and not just during interactions with adults. o the individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (will be humiliating or embarrassing, will lead to rejection or offend others). o The social situations almost always provoke fear or anxiety. § Note in children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. o The social situations are avoided or endeared with intense fear or anxiety. o The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context o The fear, anxiety, or avoidance is persistent, typically lasting for six months or more.

Scales Used in Anxiety Disorders

uHamilton Anxiety Scale (HAM-A) uGood for assessing treatment response in anxiety disorders uAdministered by a clinician uNeed formal training to administer to achieve high reliability uThe Generalized Anxiety Disorder 7 item scale (GAD-7) uSelf-reported questionnaire for screening and severity measure of generalized anxiety disorder uZung Self-rating Anxiety Scale uSelf-report scale uMeasures anxiety levels

Substance/Medication-Induced Anxiety Disorder · Diagnostic Criteria

o Panic attacks or anxiety is predominant in the clinical picture o there is evidence from history, physical examination, or laboratory findings of both (1) and (2) § The symptoms in criteria developing or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication § they involve substance slash medication can produce the symptoms and criteria A. o the disturbance is not better explained by an anxiety disorder that is not substance/medication induced. Such evidence of an independent anxiety disorder could include the following: § the symptoms precede the onset of the medication or substance use, the symptoms persist for a substantial period (about 1 on) after the cessation of acute withdrawal or severe intoxication, or there is other evidence suggesting existence of an independent nonsubstance or non-medication induced anxiety disorder (a history of recurrent nonsubstance or non-medication related episode). o The disturbance does not occur exclusively during a delirium o the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. § Note: the diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in criteria a predominate in the clinical picture and they are sufficiently severe to warrant clinical attention.

Panic Disorder · Diagnostic features

o Panic disorder is characterized by reoccurring unexpected panic attacks. o A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which four or more of a list of 13 physical and cognitive symptoms occur. o The frequency and severity of panic attacks vary widely. o In terms of frequency, there may be moderately frequent attacks (1 per week) for months at a time, or short bursts of more frequent attacks, daily, separated by weeks or months without any attacks or with less frequent attacks over many years. o Individuals who have infrequent panic attacks resemble those with more frequent panic attacks in terms of panic attacks symptoms, demographic characteristics, core morbidity with other disorders, family history, and biological data.

Panic Disorder · Diagnostic Criteria

o Reoccurring unexpected panic attacks. 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 the following symptoms can occur: § Note: the abrupt surge can occur from a calm state or an anxious state § palpitations, pounding heart, or accelerated heart rate § sweating § trembling or shaking § sensations of shortness of breath or smothering § feelings of choking § chest pain or discomfort § nausea or abdominal distress § feeling dizzy, unsteady, lightheaded, or faint § chills or heat sensations § paresthesia (numbness Or tingling sensations) § derealization or depersonalization § fear of losing control or "going crazy" § fear of dying § note: culture-specific symptoms (tinnitus, next soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Separation Anxiety Disorder · associated features cont

o Some individuals become homesick and extremely uncomfortable when away from home in children this may lead to school refusal, which in turn may lead to academic difficulties and social isolations. § Extremely upset at the prospect of separation, children may show anger or occasionally aggression towards someone who is forcing separation. § When alone, especially in the evening or dark, young children may report unusual perceptual experiences (seeing people peering into the room, frightening creatures reaching for them, feeling eyes staring at them) § children with this disorder maybe described as demanding, intrusive, and in need of constant attention o Adults with this disorder may be described as dependent and overprotective as parents § they are more likely to text or phone their major attachment figures throughout the day and repeatedly check on their whereabouts o the individual's excessive demands often becomes a source of frustration for the family members, leading to resentment and conflict within the family.

Generalized Anxiety Disorder · Diagnostic features

o The essential feature of generalized anxiety disorder is excessive worry and anxiety about a number of events or activities o the intensity, duration, or frequency of the anxiety and worry is out of proportion to the actual likelihood or impact of the anticipated event. o The individual finds it difficult to control the worry and to keep worrisome thoughts from interfering with attention to tasks at hand o 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 (doing household chores or being late for an appointment).

Social Anxiety Disorder · Diagnostic Criteria cont

o The fear, anxiety, or avoidance causes clinically significant distress or impairment and social, occupational, or other important areas of functioning o the fear, anxiety, or voidance is not attributable to the physiological effects of a substance (drug of abuse, a medication) or another medical condition o the fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder. o If another medical condition open Princess Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive. o Specify if § performance only: if the fear is restricted to speaking or performing in public

Separation Anxiety Disorder · Diagnostic Criteria cont

o The fear, anxiety, or avoidance is persistent, lasting at least four weeks in children and adolescents and typically six months for more in adults o the disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning o the disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder, delusions or hallucinations concerning separation in psychotic disorders, refusal to go outside without a trusted companion in agoraphobia, worries about ill health or other harm befalling significant others in generalized anxiety disorder or concerns about having illness in illness anxiety disorder

Agoraphobia · diagnostic features cont

o The individual actively avoids a situation requires the presence of a companion, or, if he or she either is unable or decides not to avoid it, the situation evokes intense fear or anxiety o Often, an individual is better able to confront a feared situation when accompanied by a companion, such as a partner, friend, or health professional. § Also, the individual may employ safety behaviors (sitting near exits when taking public transportation or at the movies) to better endure such situations. o Differentiating disproportionate, clinically significant agoraphobic fears from reasonable fears (not wanting to leave the house during a bad storm) or from situations that are deemed dangerous (walking the parking lot or using public transportation in a high crime area) is important for several reasons. § first, what constitutes avoidance may be difficult to judge across cultures and sociocultural context. § second, older adults are likely to over attribute their fears to age-related constraints and are less likely to judge their fears as being out of proportion to actual risk. § third, individuals with agoraphobia are likely to overestimate danger in relation to panic like or other bodily symptoms

Selective Mutism delveoplment and course

o The onset of selective mutism is usually before age five years, but the disturbance may not come to clinical attention until entry into school, where there is an increase in social interaction and performance tasks. o In most cases selected mutism may fade but symptoms of social anxiety disorder will often remain

Social Anxiety Disorder · Diagnostic features cont

o They 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 § sometimes, the anxiety may not be judged to be excessive, because it is related to an actual danger (being bully 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. o Creation threshold helps distinguish this disorder from transient social fears that are common, particularly among children and in the community. § 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.

Selective Mutism · Diagnostic features

o When encountering other individuals in social interactions, children with selective mutism do not initiate speech or reciprocally respond when spoken to by others o Children with selective mutism will speak in their homes in the presence of immediate family members but often not even in front of close friends or second-degree relatives o the disturbance is most often marked by high social anxiety o children with selective mutism often refused 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 non spoken or nonverbal means to communicate and may be willing or eager to perform or engage in social encounters one speech is not required.

Social Anxiety Disorder · Diagnostic features

o When exposed to 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, week, crazy, stupid, boring, intimidating, dirty, or unlikeable. o 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. o The social situations almost always provoke fear or anxiety. § Thus, an individual who becomes anxious only occasionally in social situations would not be diagnosed with social anxiety disorder. § However, the degree and type of fear and anxiety may vary (anticipatory anxiety, panic attack) across different occasions. · The anticipatory anxiety maker sometimes far in advance of upcoming situations (worrying every day for weeks before attending a social event, repeating his speech for days in advance). · Avoidance can be extensive (not going to parties, refusing school) or subtle (over preparing the text of his speech, diverting attention to others, limiting eye contact).

Separation Anxiety Disorder · associated features

o When separated from major attachment figures, children and adults with separation anxiety disorder may exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work or play. o 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.

Agoraphobia · diagnostic features

o anticipated exposure to wide range of situations. o When experiencing fear and anxiety cued by such situations, individuals typically experience thoughts that something terrible might happen. § Individuals frequently believe that escape from such situations might be difficult or that help might be unavailable when panic like symptoms or other incapacitating or embarrassing symptoms occur. o The amount of fear experience may vary with proximity to the feared situation and may occur in anticipation of or in the actual presence of the agoraphobic situation. § The fear or anxiety may take the form of a full or limited symptom panic attack.

Panic Disorder associated features

o 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 mental health concerns. o There may be persuasive concerns about abilities to complete daily tasks or withstand daily stressors, excessive use of drugs (alcohol, prescribe medications or illicit drugs) to control panic attacks, or extreme behaviors aimed at controlling panic attacks (severe restrictions on food intake or avoidance of specific foods or medications because of concerns about physical symptoms that provoke panic attacks).

Anxiety Disorder Attributable to Another Medical Condition

uMedical conditions that may produce anxiety symptoms uCardiac uEndocrine uRespiratory uNeurological Describe the symptoms of anxiety disorders due to medical conditions and substance/medication use. A number of medical conditions have been associated with the development of anxiety symptoms. Some of these include cardiac conditions, such as myocardial infarction, congestive heart failure, and mitral valve prolapse; endocrine conditions, such as hypoglycemia, hypo- or hyperthyroidism, and pheochromocytoma; respiratory conditions, such as chronic obstructive pulmonary disease and hyperventilation; and neurological conditions, such as complex partial seizures, neoplasms, and encephalitis.

Panic Disorder · Diagnostic features cont

o in terms of severity, individuals with panic disorder may have both full symptom (four or more) and limited symptom (less than 4) attacks, and the number and type of panic attack symptoms frequently differ from one panic attack to the next. o The worries about panic attacks and their consequences usually pertain to physical concerns, such as worry that panic attacks reflect the presence of life-threatening illnesses (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. o Individuals who report fear of dying in their panic attacks tend to have more severe presentations of panic disorders (panic attacks involving more symptoms). o 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 agoraphobic type situations, such as leaving home, using public transportation, or shopping. § If agoraphobia is present, a separate diagnosis of agoraphobia is given.

Agoraphobia · diagnostic criteria

o marked fear or anxiety about two or more of the following five situations: § using public transportation (automobiles, buses, trains, ships, planes) § being in open space (parking lots, marketplaces, bridges) § being in enclosed space (shops, theaters, cinemas) § standing in line or being in a crowd § being outside of the home alone o the individual fears or avoids these situations

Anxiety disorder due to another medical condition · diagnostic criteria

o panic attacks or anxiety is predominant in the clinical picture o there is evidence from the history, physical examination, or laboratory findings that the disturbances the direct pathophysiological consequence of another medical condition o the disturbance is not better explained by another mental disorder o the disturbance is not occur exclusively during a delirium o the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. § Note: include the name of the other medical condition within the name of the mental disorder (anxiety disorder due to pheochromocytoma). The other medical condition should be coded in listed separately immediately before the anxiety disorder due to the medical condition (pheochromocytoma, anxiety disorder due to pheochromocytoma).

Functional consequences of panic disorder

o panic disorder is associated with high levels of social, occupational, and physical disability; considerable economic costs; in the highest number of medical visits among the anxiety disorders, although the effects are strongest with the presence of agoraphobia. o Individuals with panic disorder maybe frequently absent from work or school for doctor and emergency room visits, which can lead to unemployment or dropping out of school. o Full symptom panic attacks typically are associated with greater morbidity (greater health care utilization, more disability, poorer quality of health) than limited symptom attacks.

Substance/Medication-Induced Anxiety Disorder · associated features

o panic or anxiety can occur in association with intoxication with the following classes of substances: § alcohol, caffeine, cannabis, phencyclidine, other hallucinogens, inhalants, stimulant, and other unknown substances. o Panic or anxiety can occur in association with withdrawal from the following classes of substances: § Alcohol, opioids, sedatives, hypnotics, and anxiolytics, stimulant, and other or unknown substances. o Some medications that evoke anxiety symptoms include analgesics, sympathomimetics or other bronchodilators, anticholinergics, insulin, thyroid preparation, oral contraceptives, antihistamines, antiparkinsonian medications, corticosteroids, anti-hypertensive and cardiovascular medications, anticonvulsants, lithium carbonate, antipsychotic medications, and antidepressant medications. · diagnostic markers laboratory assessments (urine toxicology) may be useful to measure substance intoxication as part of an assessment for substance or medication induced anxiety disorder

Substance/Medication-Induced Anxiety Disorder Diagnostic features

o the essential features of substance or medication induced anxiety disorder are prominent symptoms of panic or anxiety that are judged to be because of substance. o The panic or anxiety symptoms must have developed during or soon after substitute toxication or withdrawal or after exposure to or withdrawal from medication, and the substance or medications must be capable of producing the symptoms. o The diagnosis of substance or medication induced anxiety disorder should not be given if the onset of the panic or anxiety symptoms proceeds the substance or medication intoxication or withdrawal, or if the symptoms persist for a substantial period (usually longer than one month) from the time of severe intoxication or withdrawal. § If the panic or anxiety symptoms persist for a substantial period, other causes for the symptoms should be considered.

Specific Phobia · Diagnostic Criteria specify

§ Animal (spiders, insects, dogs, etc.) § Natural Environment (heights, storms, water) § Blood-injection-injury (needles, invasive medical procedures) § Situational (airplanes, elevators, enclosed places) § Others (situations that may lead to choking or vomiting, in children, loud sounds or costumed characters) § Note: when more than one phobic situation is present, code all ICD-10 codes that apply.

Specific Phobia · Diagnostic Criteria cont

§ 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. · Active avoidance means the individual intentionally behaves in ways that are designed to prevent or minimize contact with phobic objects or situations. · Avoidance behaviors are often obvious (an individual who fears blood refusing to go to the doctor) but are sometimes less obvious (an individual who fears snakes refusing to look at pictures that 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. · Therefore, they no longer experience fear or anxiety in their daily life. § in such instances, avoidance behaviors are ongoing refusal to engage in activities that would involve exposure to phobic object or situation (repeated refusal to accept offers in work related travel because of fear of flying) may be helpful in confirming the diagnosis in the absence of overt anxiety or panic. § Although individuals with specific phobia often recognize their reactions as disproportionate, they tend to overestimate the danger in feared situations, and thus the judgment of being out of proportion is made by the clinician. · for example, fears of the dark may be reasonable in context of ongoing violence, and the degree of fear of insects considered to be disproportionate would be higher in settings where insects are consumed in the diet.

Specific Phobia · Diagnostic features

§ of a particular situation or object, which may be termed the phobic stimulus. § Diagnosis of specific phobia, the response must differ from normal, transient fears that a commonly occur in the population · to meet the criteria for a diagnosis, the fear or anxiety must be intense or severe § 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. · the fear or anxiety may take the form of a full or limited symptom panic attack § Another characteristic of specific phobias is that the fear or anxiety is evoked nearly every time the individual encounters the phobic stimulus · thus, an individual who becomes anxious only occasionally upon being confronted with the situation or object would not be diagnosed with specific phobia

Social Anxiety Disorder · Diagnostic specifiers

§ performance only: if the fear is restricted to speaking or performing in public · Specifiers o Individuals with the performance only type of social anxiety disorders have performance fears that are typically most impairing in their professional lives; musician, dancers, performers, athletes, or in roles that require regular public speaking. o Performance fears may also manifest in work, school, or academic settings in which regular public presentations are required.

Separation Anxiety Disorder: Functional Consequences of Separation Anxiety Disorder

· o Individuals with separation anxiety disorder often limit independent activities away from home or attachment figures § in children avoiding school, not going to camp, having difficulty sleeping alone § in adolescence not going away to college § in adults not leaving the parental home, not traveling long distance without their close attachments, not working outside the home o symptoms in adults are often debilitating and affect multiple areas of their lives o Separation anxiety disorder is associated with graded reported impairment in individuals from high- and upper-middle-income countries compared to those from low-and lower-middle-income countries

panic disorder Association with Suicidal Thoughts or Behaviors

· o Panic attacks and diagnosis of panic disorder in the past twelve months are related to a higher rate of suicidal behavior and suicidal thoughts in the past 12 months even with comorbidity in a history of childhood abuse and other suicide risk factors are considered. o Epidemiological survey data of panic attack symptoms show that cognitive symptoms of panic (derealization) may be associated with suicidal thoughts, whereas physical symptoms (dizziness, nausea) may be associated with suicidal behaviors.

Functional Consequences of Selective Mutism

· o Selective mutism may result in social impairment, as children may be too anxious to engage in reciprocal social interaction with other children. o As children with selective mutism, mature they may face increasing social isolation o In school settings, these children may suffer academic impairment, because often they do not communicate with teachers regarding their academic or personal needs (not understanding a class assignment, not asking to use the restroom) § severe impairment in school and social functioning, including the resulting from teasing by peers is common.

functional consequences of agoraphobia

· o agoraphobia is associated with considerable impairment and disability in terms of role functioning, work productivity, and disability days. o 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. o Individuals with agoraphobia can be completely homebound or unable to work.

Social Anxiety Disorder associated features

· Associated Features o Individuals with social anxiety disorder may be inadequately assertive or excessively submissive or, less commonly, highly controlling of the conversation. o They may show overly rigid body posture or inadequate eye contact or speak with you with an overly soft voice. o These individuals may be shy or withdrawn, and they may be less open in conversations and disclose little about themselves. o 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. o Men may be delighted marrying and having a family, whereas women who would want to work outside the home they live a life without ever doing so. o Self-medication with substances is common (drinking before going to a party). o Blushing is a hallmark physical response in social anxiety disorder.

Specific Phobia Association with Suicidal Thoughts or Behavior Functional Consequences of Specific Phobia

· Association with Suicidal Thoughts or Behavior o Specific phobia is associated with both suicidal thoughts and suicide attempts based on national US survey data. o Specific phobia is also associated with a transition from I dictation to attempt. · Functional Consequences of Specific Phobia o Individuals with specific phobias show similar patterns of impairment in psychosocial functioning and decrease quality of life as individuals with other anxiety disorders and alcohol and substance use disorders, including impairments in occupational and interpersonal functioning. o The distress and impairment caused by specific phobias tend to increase with the number of feared objects in situations. § Thus, individual who fears four objects or situations is likely to have more impairment in his or her occupational and social roles in a lower quality of life than an individual who fears only one object or situation.

Functional Consequences of social anxiety disorder

· Functional Consequences of social anxiety disorder o 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. o Social anxiety disorder is also associated with being single, unmarried, or divorced and with not having children, particularly among men, whereas women are more likely to be unemployed. o social anxiety disorder is also negatively associated with friendship quality, such that individuals with social anxiety disorder report having friendships that are less close and less supportive than persons without this disorder. o In older adults, there may be impairment in caregiving duties and volunteer activities. o Not being employed as a strong predictor for the presence of social anxiety disorder.

Panic Attack Specifier

· Symptoms are presented for the purpose of identifying a panic attack, however, panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (depressive disorders, PTSD, substance use disorders close print sis and some medical conditions (cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (post-traumatic stress disorder with panic attacks). For panic disorder the presence of a panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.

associated features and · Association with suicidal thoughts or behaviors

· associated features o in its most severe forms, agoraphobia can cause individuals to become completely homebound, unable to leave their home and depending on others for services or assistance to provide even the basic needs. o Demoralization and depressive symptoms, as well as abuse of alcohol and sedative medications as inappropriate self-medication strategies are common. · Association with suicidal thoughts or behaviors o approximately 15% of individuals with agoraphobia report suicidal thoughts or behavior for individuals with panic disorder, symptoms of agoraphobia may be at risk for suicidal thoughts.

association with suicidal thoughts or behavior and Functional consequences of generalized anxiety disorder

· association with suicidal thoughts or behavior o Anxiety disorder is associated with increased suicidal thoughts and behavior, even after adjustment or comorbid disorders and stressful life events. · Functional consequences of generalized anxiety disorder o 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 distorted 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 o generalized anxiety disorder is associated with significant disability and distress that is independent of comorbid disorders, and most noninstitutionalized adults with the disorder are moderately to seriously disabled generalized anxiety disorder is also linked to decreased work performance, increase medical resource use, and increase risk for coronary morbidity

Separation Anxiety Disorder Association with Suicidal Thoughts or Behavior

·o Separation anxiety disorder in children and adolescents may be associated with an increased risk for suicide, although this association is not specific to separation anxiety disorder and is found in other anxiety disorders where there is significant comorbidity

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) states that at least four of the following symptoms must be present to identify the presence of a panic attack.

•Palpitations, pounding heart, or accelerated heart rate •Sweating •Trembling or shaking •Sensations of shortness of breath or smothering •Feelings of choking •Chest pain or discomfort •Nausea or abdominal distress •Feeling dizzy, unsteady, lightheaded, or faint •Chills or heat sensations •Paresthesias (numbness or tingling sensations) •Derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself) •Fear of losing control or going crazy •Fear of dying The attacks usually last minutes, or more rarely, hours. The individual often experiences varying degrees of nervousness and apprehension between attacks. Symptoms of depression are common. Note: a panic attack is not a diagnosis within itself. Panic disorder occurs when a patient is afraid to have another panic attack and many disorders can have a panic attack specifier.