ANXIETY

DISORDERS
Anxiety disorders are a group of mental disorders characterized by feelings
of anxiety and fear. Anxiety is a worry about future events and fear is a reaction to
current events. These feelings may cause physical symptoms, such as a fast heart
rateand shakiness. There are a number of anxiety disorders: including generalized
anxiety disorder, specific phobia, social anxiety disorder, separation anxiety
disorder, agoraphobia, and panic disorder. The disorder differs by what results in the
symptoms. People often have more than one anxiety disorder.
The cause of anxiety disorders is a combination of genetic and environmental
factors. Risk factors include a history of child abuse, a family history of mental
disorders, and poverty. They often occur with other mental disorders, particularly major
depressive disorder, personality disorder, and substance use disorder. To be diagnosed
symptoms typically need to be present at least six months, be more than would be
expected for the situation, and decrease functioning. Other psychiatric and medical
problems that may result in similar symptoms including hyperthyroidism, heart
disease, caffeine , alcohol or cannabisuse, and withdrawal from certain drugs.

Separation Anxiety Disorder

Separation anxiety disorder (SAD), is a psychological condition in which an individual
experiences excessive anxiety regarding separation from home or from people to whom
the individual has a strong emotional attachment (e.g. a parent, caregiver, significant
other or siblings). It is most common in infants and small children, typically between the
ages of 6–7 months to 3 years. Separation anxiety is a natural part of the
developmental process. Unlike SAD (indicated by excessive anxiety), normal separation
anxiety indicates healthy advancements in a child’s cognitive maturation and should not
be considered a developing behavioral problem.
According to the American Psychology Association, separation anxiety disorder is an
excessive display of fear and distress when faced with situations of separation from the
home or from a specific attachment figure. The anxiety that is expressed is categorized
as being atypical of the expected developmental level and age. The severity of the
symptoms ranges from anticipatory uneasiness to full-blown anxiety about separation.
SAD may cause significant negative effects within areas of social and emotional
functioning, family life, and physical health of the disordered individual.[2] The duration of
this problem must persist for at least four weeks and must present itself before a child is
18 years of age to be diagnosed as SAD in children, but can now be diagnosed in
adults with a duration typically lasting 6 months in adults as specified by the DSM-5.
Symptoms of separation anxiety:
 Excessive distress when separated from the primary caregiver
 Worry about losing or harm coming to the primary caregiver
 Recurrent reluctance to go anywhere because of fear of separation
 Reluctance to go to sleep without the significant adult nearby
 Nightmares
 Repeated physical complaints
 Symptoms last four weeks or longer
 Symptoms begin before 18 years of age
 Impairment of school, social, or personal functioning as a result of anxiety

Diagnostic Criteria
A. 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:
1. Recurrent excessive distress when anticipating or experiencing separation from
home or from major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or about
possible harm to them, such as illness, injury, disasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e.g., getting
lost, being kidnapped, having an accident, becoming ill) that causes separation from
a major attachment figure.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or
elsewhere because of fear of separation.
5. Persistent and excessive fear of or reluctance about being alone or without major
attachment figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without
being near a major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches,
nausea, vomiting) when separation from major attachment figures occurs or is
anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and
adolescents and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social,
academic, occupational, or other important areas of functioning.
D. 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 an illness in illness anxiety disorder.
Selective Mutism
Selective Mutism is a complex childhood anxiety disorder characterized by a child's
inability to speak and communicate effectively in select social settings, such as school.
These children are able to speak and communicate in settings where they are
comfortable, secure, and relaxed.
More than 90% of children with Selective Mutism also have social phobia or social
anxiety.This disorder is quite debilitating and painful to the child. Children and
adolescents with Selective Mutism have an actual FEAR of speaking and of social
interactions where there is an expectation to speak and communicate. Many children
with Selective Mutism have great difficulty responding or initiating communication in a
nonverbal manner; therefore social engagement may be compromised in many children
when confronted by others or in an overwhelming setting where they sense a feeling of
expectation.

Not all children manifest their anxiety in the same way. Some may be completely mute
and unable to speak or communicate to anyone in a social setting, others may be able
to speak to a select few or perhaps whisper. Some children may stand motionless with
fear as they are confronted with specific social settings. They may freeze, be
expressionless, unemotional and may be socially isolated. Less severely affected
children may look relaxed and carefree, and are able to socialize with one or a few
children but are unable to speak and effectively communicate to teachers or most/all
peers.

When compared to the typically shy and timid child, most children with Selective Mutism
are at the extreme end of the spectrum for timidity and shyness.
Signs and Symptoms of Selective Mutism:
Besides lack of speech, other common behaviors and characteristics displayed by
selectively mute people include:

 Shyness, social anxiety, fear of social embarrassment, and/or social isolation

and withdrawal
 Difficulty maintaining eye contact
 Blank expression and reluctance to smile
 Stiff and awkward movements
 Difficulty expressing feelings, even to family members
 Tendency to worry more than most people of the same age
 Desire for routine and dislike of changes
 Sensitivity to noise and crowds
On the positive side, many people with this condition have:

 Above-average intelligence, perception, or inquisitiveness

 Creativity and a love for art or music
 Empathy and sensitivity to others' thoughts and feelings
 A strong sense of right and wrong

Diagnostic Criteria
A. Consistent failure to speak in specific social situations in which there is an
expectation for speaking (e.g., at school) despite speaking in other situations.
B. The disturbance interferes with educational or occupational achievement or with
social communication.
C. The duration of the disturbance is at least 1 month (not limited to the first month of
school).
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the
spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder (e.g.,
childhoodonset fluency disorder) and does not occur exclusively during the course of
autism spectrum disorder, schizophrenia, or another psychotic disorder.
Specific Phobia

A specific phobia, formerly called a simple phobia, is a lasting and unreasonable fear
caused by the presence or thought of a specific object or situation that usually poses
little or no actual danger. Exposure to the object or situation brings about an immediate
reaction, causing the person to endure intense anxiety (nervousness) or to avoid the
object or situation entirely. The distress associated with the phobia and/or the need to
avoid the object or situation can significantly interfere with the person's ability to
function. Adults with a specific phobia recognize that the fear is excessive or
unreasonable, yet are unable to overcome it.

There are different types of specific phobias, based on the object or situation feared,
including:

 Animal phobias- Examples include the fear of dogs, snakes, insects, or mice.
Animal phobias are the most common specific phobias.
 Situational phobias- These involve a fear of specific situations, such as flying, riding
in a car or on public transportation, driving, going over bridges or in tunnels, or of
being in a closed-in place, like an elevator.
 Natural environment phobias- Examples include the fear of storms, heights, or
water.
 Blood-injection-injury phobias- These involve a fear of being injured, of
seeing blood or of invasive medical procedures, such as blood tests or injections
 Other phobias- These include a fear of falling down, a fear of loud sounds, and a
fear of costumed characters, such as clowns.

Symptoms of specific phobias:

 Excessive or irrational fear of a specific object or situation

 Avoiding the object or situation or enduring it with great distress
 Physical symptoms of anxiety or a panic attack, such as a
poundingheart, nausea or diarrhea, sweating, trembling or shaking,
numbness or tingling, problems with breathing (shortness of breath), feeling
dizzy or lightheaded, feeling like you are choking
 Anticipatory anxiety, which involves becoming nervous ahead of time about
being in certain situations or coming into contact with the object of your
phobia; for example, a person with a fear of dogs may become anxious about
going for a walk because he or she may see a dog along the way.
 Children with a specific phobia may express their anxiety by crying, clinging to
a parent, or throwing a tantrum.

Diagnostic Criteria
A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights,
animals, receiving an injection, seeing blood). Note: In children, the fear or anxiety
may be expressed by crying, tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or
anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific
object or situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or
more.
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
G. 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 (as in agoraphobia): objects or
situations related to obsessions (as in obsessive-compulsive disorder); reminders of
traumatic events (as in posttraumatic stress disorder); separation from home or
attachment figures (as in separation anxiety disorder); or social situations (as in
social anxiety disorder).
Specify if:
Code based on the phobic stimulus:
300.29 (F40.218) Animal (e.g., spiders, insects, dogs).
300.29 (F40.228) Natural environment (e.g., heights, storms, water).
300.29 (F40.23X) Blood-injection-injury (e.g., needles, invasive medical procedures).
Coding note: Select specific ICD-10-CM code as follows:
F40.230 fear of blood; F40.231 fear of injections and transfusions; F40.232 fear
of other medical care; or F40.233 fear of injury.
300.29 (F40.248) Situational (e.g., airplanes, elevators, enclosed places).
300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting: in
children, e.g., loud sounds or costumed characters).
Coding note: When more than one phobic stimulus is present, code all ICD-10-CM
codes that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal,
and F40.248 specific phobia, situational).
Social Anxiety Disorder (Social Phobia)

Social anxiety disorder, also called social phobia, is an anxiety disorderin which a
person has an excessive and unreasonable fear of social situations. Anxiety (intense
nervousness) and self-consciousness arise from a fear of being closely watched,
judged, and criticized by others.

A person with social anxiety disorder is afraid that he or she will make mistakes, look
bad, and be embarrassed or humiliated in front of others. The fear may be made worse
by a lack of social skills or experience in social situations. The anxiety can build into
a panic attack. As a result of the fear, the person endures certain social situations in
extreme distress or may avoid them altogether. In addition, people with social anxiety
disorder often suffer "anticipatory" anxiety -- the fear of a situation before it even
happens -- for days or weeks before the event. In many cases, the person is aware that
the fear is unreasonable, yet is unable to overcome it.

People with social anxiety disorder suffer from distorted thinking, including false beliefs
about social situations and the negative opinions of others. Without treatment,
social anxiety disorder can negatively interfere with the person's normal daily routine,
including school, work, social activities, and relationships.

People with social anxiety disorder may be afraid of a specific situation, such as
speaking in public. However, most people with social anxiety disorder fear more than
one social situation. Other situations that commonly provoke anxiety include:

 Eating or drinking in front of others

 Writing or working in front of others
 Being the center of attention
 Interacting with people, including dating or going to parties
 Asking questions or giving reports in groups
 Using public toilets
 Talking on the telephone
Social anxiety disorder may be linked to other mental illnesses, such as panic
disorder, obsessive compulsive disorder, and depression. In fact, many people with
social anxiety disorder initially see the doctor with complaints related to these disorders,
not because of social anxiety symptoms.
Signs and Symptoms of Social Anxiety Disorder:

Many people with social anxiety disorder feel that there is "something wrong," but don't
recognize their feeling as a sign of illness. Symptoms of social anxiety disorder can
include:

 Intense anxiety in social situations

 Avoidance of social situations
 Physical symptoms of anxiety, including confusion, pounding heart,sweating,
shaking, blushing, muscle tension, upset stomach, anddiarrhea
Children with this disorder may express their anxiety by crying, clinging to a parent, or
throwing a tantrum.

Diagnostic Criteria

A. 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 (e.g.,
having a conversation, meeting unfamiliar people), being observed (e.g., eating or
drinking), and performing in front of others (e.g., giving a speech).

Note: In children, the anxiety must occur in peer settings and not just during
interactions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that
will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to
rejection or offend others).
C. 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.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social
situation and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication) or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another
mental disorder, such as panic disorder, body dysmoφhic disorder, or autism spectrum
disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from

bums or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is
excessive.

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

public
Panic Disorder
Panic disorder is an anxiety disorder characterized by recurring panic attacks, causing
a series of intense episodes of extremeanxiety during panic attacks. It may also include
significant behavioral changes, and ongoing worries about having other attacks. The
latter are called anticipatory attacks (DSM-IVR). According to the American Academy of
Child & Adolescent Psychiatry, panic disorder usually begins during adolescence and
can be hereditary. Over 3 million Americans experience panic disorder during their
lifetime.

People with panic disorder have sudden and repeated attacks of fear that last for
several minutes or longer. These are called panic attacks. Panic attacks are
characterized by a fear of disaster or of losing control even when there is no real
danger. A person may also have a strong physical reaction during a panic attack. It may
feel like having a heart attack. Panic attacks can occur at any time, and many people
with panic disorder worry about and dread the possibility of having another attack.
A person with panic disorder may become discouraged and feel ashamed because he
or she cannot carry out normal routines like going to the grocery store or driving. Having
panic disorder can also interfere with school or work.

Panic disorder often begins in the late teens or early adulthood. More women than men
have panic disorder. But not everyone who experiences panic attacks will develop panic
disorder.

Panic disorder sometimes runs in families, but no one knows for sure why some people
have it, while others don't. Researchers have found that several parts of the brain are
involved in fear and anxiety. Some researchers think that people with panic disorder
misinterpret harmless bodily sensations as threats. Researchers are also looking for
ways in which stress and environmental factors may play a role.
Signs and symptoms of Panic Disorder

People with panic disorder may have:

 Sudden and repeated attacks of fear

 A feeling of being out of control during a panic attack
 An intense worry about when the next attack will happen
 A fear or avoidance of places where panic attacks have occurred in the past
 Physical symptoms during an attack, such as a pounding or racing heart, sweating,
breathing problems, weakness or dizziness, feeling hot or a cold chill, tingly or numb
hands, chest pain, or stomach pain.

Diagnostic Criteria
A. Recurrent 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 occur;
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from
oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache,
uncontrollable screaming or crying) may be seen. Such symptoms should not
count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of
the following:
1. Persistent concern or worry about additional panic attacks or their
consequences (e.g., losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g.,
behaviors designed to avoid having panic attacks, such as avoidance of exercise
or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism,
cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic
attacks do not occur only in 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: in response to
reminders of traumatic events, as in posttraumatic stress disorder: or in response to
separation from attachment figures, as in separation anxiety disorder).
Agoraphobia
Agoraphobia is an anxiety disorder characterized by symptoms of anxiety in situations
where the person perceives the environment to be unsafe with no easy way to get
away. These situations can include open spaces, public transit, shopping malls, or
simply being outside the home. Being in these situations may result in a panic
attack. The symptoms occur nearly every time the situation is encountered and lasts for
more than six months. Those affected will go to great lengths to avoid these
situations.[1] In severe cases people may become unable to leave their homes.
People with agoraphobia often have a hard time feeling safe in any public place,
especially where crowds gather. You may feel that you need a companion, such as a
relative or friend, to go with you to public places. The fears can be so overwhelming that
you may feel unable to leave your home.
Agoraphobia treatment can be challenging because it usually means confronting your
fears. But with talk therapy (psychotherapy) and medications, you can escape the trap
of agoraphobia and live a more enjoyable life.

Many people assume agoraphobia is simply a fear of open spaces, but it's actually
a more complex condition. Someone with agoraphobia may be scared of:
 travelling on public transport

 visiting a shopping centre

 leaving home
If someone with agoraphobia finds themselves in a stressful situation, they'll usually
experience the symptoms of a panic attack, such as:
 rapid heartbeat

 rapid breathing (hyperventilating)

 feeling hot and sweaty
 feeling sick
They'll avoid situations that cause anxiety and may only leave the house with a friend or
partner. They'll order groceries online rather than going to the supermarket. This change
in behaviour is known as avoidance.
Agoraphobia usually develops as a complication of panic disorder, an anxiety disorder
involving panic attacks and moments of intense fear. It can arise by associating panic
attacks with the places or situations where they occurred and then avoiding them.
A minority of people with agoraphobia have no history of panic attacks. In these cases,
their fear may be related to issues like a fear of crime, terrorism, illness, or being in an
accident.
Traumatic events, such as bereavement, may contribute towards agoraphobia, as well
as certain genes inherited from your parents.
Diagnostic Criteria
A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.

B. The individual fears or avoids these situations because of thoughts that escape might
be difficult or help might not be available in the event of developing panic-like symp
toms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the
elderly; fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a
companion, or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the
agoraphobic situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease)
is present, the fear, anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another
mental disorder—for example, the symptoms are not confined to specific phobia,
situational type; do not involve only social situations (as in social anxiety disorder): and
are not related exclusively to obsessions (as in obsessive-compulsive disorder),
perceived defects or flaws in physical appearance (as in body dysmoφhic disorder),
reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation
(as in separation anxiety 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. Diagnostic Features The essential feature of
agoraphobia is mark
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is an anxiety disorder characterized by
excessive, uncontrollable and often irrational worry, that is, apprehensive expectation
about events or activities. This excessive worry often interferes with daily functioning, as
individuals with GAD typically anticipate disaster, and are overly concerned about
everyday matters such as health issues, money, death, family problems, friendship
problems, interpersonal relationship problems, or work difficulties. Individuals often
exhibit a variety of physical symptoms, including fatigue, fidgeting,
headaches, nausea, numbness in hands and feet, muscle tension, muscle aches,
difficulty swallowing, excessive stomach acid buildup, stomach pain, vomiting, diarrhea,
bouts of breathing difficulty, difficulty concentrating, trembling, twitching,
irritability, agitation, sweating, restlessness, insomnia, hot flashes,rashes, and inability
to fully control the anxiety (ICD-10). These symptoms must be consistent and ongoing,
persisting at least six months, for a formal diagnosis of GAD.
Generalized anxiety disorder (or GAD) is characterized by excessive,
exaggerated anxiety and worry about everyday life events with no obvious reasons for
worry. People with symptoms of generalized anxiety disorder tend to always expect
disaster and can't stopworrying about health, money, family, work, or school. In people
with GAD, the worry is often unrealistic or out of proportion for the situation. Daily life
becomes a constant state of worry, fear, and dread. Eventually, the anxiety so
dominates the person's thinking that it interferes with daily functioning, including work,
school, social activities, and relationships.
Signs and symptoms of GAD:

Generalized anxiety disorder symptoms include:

 Restlessness or feeling wound-up or on edge

 Being easily fatigued
 Difficulty concentrating or having their minds go blank
 Irritability
 Muscle tension
 Difficulty controlling the worry
 Sleep problems (difficulty falling or staying asleep or restless, unsatisfying sleep)

Diagnostic Criteria
A. Excessive anxiety and worry (apprehensive expectation), occurring more days than
not for at least 6 months, about a number of events or activities (such as work or school
performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms having been present for more days than not
for the past 6 months);
Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless,
unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g., anxiety or
worry about having panic attacks in panic disorder, negative evaluation in social anxiety
disorder [social phobia], contamination or other obsessions in obsessive-compulsive
disorder, separation from attachment figures in separation anxiety disorder, reminders
of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa,
physical complaints in somatic symptom disorder, perceived appearance flaws in body
dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content
of delusional beliefs in schizophrenia or delusional disorder).
Substance-induced Anxiety Disorders
A substance-induced anxiety disorder is subtyped or categorized based on whether the
prominent feature is generalized anxiety, panic attacks, obsessive-compulsive
symptoms, or phobia symptoms. In addition, the disorder is subtyped based on whether
it began during intoxication on a substance or during withdrawal from a substance. A
substance-induced anxiety disorder that begins during substance use can last as long
as the drug is used. A substance-induced anxiety disorder that begins during withdrawal
may first manifest up to four weeks after an individual stops using the substance.

A substance-induced anxiety disorder, by definition, is directly caused by the effects of

drugs—including alcohol, medications, and toxins. Anxiety symptoms can result from
intoxication on alcohol, amphetamines (and related substances), caffeine, cannabis
(marijuana), cocaine, hallucinogens, inhalants, phencyclidine (PCP) and related
substances, and other or unknown substances. Anxiety symptoms can also result from
withdrawal from alcohol, sedatives, hypnotics, and anxiolytics, cocaine, and other or
unknown substances. Some of the medications which may induce anxiety symptoms
include anesthetics and analgesics, sympathomimetics (epinephrine or norepinephrine,
for example) or other bronchodilators, anticholinergic agents, anticonvulsants,
antihistamines, insulin, thyroid preparations, oral contraceptives, antihypertensive and
cardiovascular medications, antiparkinsonian medications, corticosteroids,
antidepressant medications, lithium carbonate , and antipsychotic medications. Heavy
metals and toxins, such as volatile substances like fuel and paint, organophosphate
insecticides, nerve gases, carbon monoxide, and carbon dioxide may also induce
anxiety.

Diagnostic Criteria
A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of
both (1)and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or
withdrawal or atter exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion
A.
C. 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 substance/medication use; the
symptoms persist for a substantial period of time (e.g., about 1 month) atter the
cessation of acute withdrawal or severe intoxication: or there is other evidence
suggesting the existence of an independent non-substance/medication-induced anxiety
disorder (e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Note: This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and they are sufficiently severe to warrant clinical attention.
Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific
substance/medication]-induced anxiety disorders are indicated in the table below. Note
that the ICD-10-CM code depends on whether or not there is a comorbid substance use
disorder present for the same class of substance. If a mild substance use disorder is
comorbid with the substance-induced anxiety disorder, the 4th position character is “1,”
and the clinician should record “mild [substance] use disorder” before the substance-
induced anxiety disorder (e.g., “mild cocaine use disorder with cocaine-induced anxiety
disorder”). If a moderate or severe substance use disorder is comorbid with the
substance-induced anxiety disorder, the 4th position character is “2,” and the clinician
should record “moderate [substance] use disorder or “severe [substance] use disorder,”
depending on the severity of the comorbid substance use disorder. If there is no
comorbid substance use disorder (e.g., after a one time heavy use of the substance),
then the 4th position character is “9,” and the clinician should record only the substance-
induced anxiety disorder.
Anxiety due to Medical Condition
In anxiety due to another medical condition, the most frequently displayed symptom is
anxiety in some form, even though there is another medical condition present
that underlies and leads to the anxiety. General characteristics of anxiety include
muscle tension, heart palpitations, sweating, dizziness, or difficulty catching the breath.
In addition to these physical symptoms, anxiety in general also leads to restlessness,
possibly a fear of something impending that will be catastrophic, or fear of being
embarrassed or humiliated.

Anxiety due to another medical condition may exhibit several symptom pictures. For
example, if the anxiety shows itself as panic disorder, symptoms may include sudden
onset of terror with no specific precipitating event (NIMH, n.d.). Along with the terror, a
pounding heart, sweating, feeling faint, or dizziness may be
experienced. The patient with panic may have physical symptoms that suggest a heart
attack, also. These include feeling chilled, numbness in hands, nausea, chest
pain, and feelings of smothering. A sense of loss of touch with reality, fear of some
impending doom, and fear of losing control add to the impact of panic. Many people
who experience panic attacks are convinced they are having a heart attack and seek
medical attention at emergency rooms.
Diagnostic Criteria

A. Panic attacks or anxiety is predominant in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings that
the disturbance is the direct pathophysiological consequence of another medical
condition.

C. The disturbance is not better explained by another mental disorder.

D. The disturbance does not occur exclusively during the course of a delirium.

E. The disturbance causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

Coding note: Include the name of the other medical condition within the name of the
mental disorder (e.g., 293.84 [F06.4] anxiety disorder due to pheochromocytoma). The
other medical condition should be coded and listed separately immediately before the
anxiety disorder due to the medical condition (e.g., 227.0 [D35.00] pheochromocytoma;
293.84 [F06.4] anxiety disorder due to pheochromocytoma.

Other Specified or Unspecified Anxiety Disorder

Someone may not fully meet the diagnostic criteria for a particular anxiety disorder. For
instance, un-cued (unexpected) panic attacks are a diagnostic criterion for Panic
Disorder. A person might meet all the diagnostic criteria for Panic Disorder except one.
Instead of un-cued (unexpected) panic attacks, they experience limited symptom panic
attacks. Although they do not meet the full criteria, it may still be worthwhile to note
these anxiety symptoms if they cause significant distress or impairment. In this case,
they could receive a diagnosis of Other Specified Anxiety Disorder.

This category applies to presentations in which symptoms characteristic of an anxiety

disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any
of the disorders in the anxiety disorders diagnostic class. The other specified anxiety
disorder category is used in situations in which the clinician chooses to communicate
the specific reason that the presentation does not meet the criteria for any specific
anxiety disorder. This is done by recording “other specified anxiety disorder” followed by
the specific reason (e.g., “generalized anxiety not occurring more days than not”).
Examples of presentations that can be specified using the “other specified” designation
include the following;

1. Limited-symptom attacks.

2. Generalized anxiety not occurring more days than not.

3. Khyâl cap (wind attacks): See “Glossary of Cultural Concepts of Distress” in the
Appendix.

4. Ataque de nervios (attack of nerves): See “Glossary of Cultural Concepts of Distress”

in the Appendix.

Other Unspecified Anxiety Disorder

is used when there are anxiety-like symptoms that cause significant distress or impaired
functioning. However, there is insufficient information to determine what particular type
of Anxiety Disorder may be present. This situation may occur in emergency room
settings, where a complete history and full psychiatric evaluation are not always
feasible.
The signs of unspecified anxiety disorder will usually mirror the symptoms of two or
more of the other anxiety disorders. This means they may include sleep problems, panic
attacks, and selective amnesia. Other emotional symptoms of unspecified anxiety
disorder are irritability and an avoidance of situations or circumstances that may trigger
a memory of past trauma. Many people also suffer extreme detachment, withdrawing
from friends and family.

There are also physical problems associated with this disorder. Crippling panic attacks
are common for those with unspecified anxiety disorder. A person may have some or all
of the above symptoms as well as others that appear with other types of anxiety
disorders. If treatment isn’t sought, there is a good chance that the problem will get
worse before it gets better.