Anxi ety d i so rd e rs include disorders that share features of excessive fear and anxiety

and related behavioral disturbances. Fear is the emotional response to real or perceived
imminent threat, whereas anxiety is anticipation of future threat. Obviously, these
two states overlap, but they also differ, with fear more often associated with surges of autonomic
arousal necessary for fight or flight, thoughts of immediate danger, and escape
behaviors, and anxiety more often associated with muscle tension and vigilance in preparation
for future danger and cautious or avoidant behaviors. Sometimes the level of fear
or anxiety is reduced by pervasive avoidance behaviors. Panic attacks feature prominently
within the anxiety disorders as a particular type of fear response. Panic attacks are not limited
to anxiety disorders but rather can be seen in other mental disorders as well.
The anxiety disorders differ from one another in the types of objects or situations that
induce fear, anxiety, or avoidance behavior, and the associated cognitive ideation. Thus,
while the anxiety disorders tend to be highly comorbid with each other, they can be differentiated
by close examination of the types of situations that are feared or avoided and
the content of the associated thoughts or beliefs.
Anxiety disorders differ from developmentally normative fear or anxiety by being excessive
or persisting beyond developmentally appropriate periods. They differ from transient
fear or anxiety, often stress-induced, by being persistent (e.g., typically lasting 6 months
or more), although the criterion for duration is intended as a general guide with allowance
for some degree of flexibility and is sometimes of shorter duration in children (as in separation
anxiety disorder and selective mutism). Since individuals with anxiety disorders
typically overestimate the danger in situations they fear or avoid, the primary determination
of whether the fear or anxiety is excessive or out of proportion is made by the clinician,
taking cultural contextual factors into account. Many of the anxiety disorders develop in
childhood and tend to persist if not treated. Most occur more frequently in females than in
males (approximately 2:1 ratio). Each anxiety disorder is diagnosed only when the symptoms
are not attributable to the physiological effects of a substance/medication or to another
medical condition or are not better explained by another mental disorder.
The chapter is arranged developmentally, with disorders sequenced according to the
typical age at onset. The individual with separation anxiety disorder is fearful or anxious
about separation from attachment figures to a degree that is developmentally inappropriate.
There is persistent fear or anxiety about harm coming to attachment figures and
events that could lead to loss of or separation from attachment figures and reluctance to go
away from attachment figures, as well as nightmares and physical symptoms of distress. Although
the symptoms often develop in childhood, they can be expressed throughout adulthood
as well.
Selective mutism is characterized by a consistent failure to speak in social situations in
which there is an expectation to speak (e.g., school) even though the individual speaks in
other situations. The failure to speak has significant consequences on achievement in academic
or occupational settings or otherwise interferes with normal social communication.
Individuals with specific phobia are fearful or anxious about or avoidant of circumscribed
objects or situations. A specific cognitive ideation is not featured in this disorder,
as it is in other anxiety disorders. The fear, anxiety, or avoidance is almost always imme-
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diately induced by the phobic situation, to a degree that is persistent and out of proportion
to the actual risk posed. There are various types of specific phobias: animal; natural environment;
blood-injection-injury; situational; and other situations.
In social anxiety disorder (social phobia), the individual is fearful or anxious about or
avoidant of social interactions and situations that involve the possibility of being scrutinized.
These include social interactions such as meeting unfamiliar people, situations in
which the individual may be observed eating or drinking, and situations in which the individual
performs in front of others. The cognitive ideation is of being negatively evaluated
by others, by being embarrassed, humiliated, or rejected, or offending others.
In panic disorder, the individual experiences recurrent unexpected panic attacks and is
persistently concerned or worried about having more panic attacks or changes his or her
behavior in maladaptive ways because of the panic attacks (e.g., avoidance of exercise or of
unfamiliar locations) . Panic attacks are abrupt surges of intense fear or intense discomfort
that reach a peak within minutes, accompanied by physical and / or cognitive symptoms.
Limited-symptom panic attacks include fewer than four symptoms. Panic attacks may be
expected, such as in response to a typically feared object or situation, or unexpected, meaning
that the panic attack occurs for no apparent reason. Panic attacks function as a marker and
prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders,
including, but not limited to, the anxiety disorders (e.g., substance use, depressive
and psychotic disorders) . Panic attack may therefore be used as a descriptive specifier for
any anxiety disorder as well as other mental disorders.
Individuals with agoraphobia are fearful and anxious about two or more of the following
situations: using public transportation; being in open spaces; being in enclosed places;
standing in line or being in a crowd; or being outside of the home alone in other situations.
The individual fears these situations because of thoughts that escape might be difficult or
help might not be available in the event of developing panic-like symptoms or other incapacitating
or embarrassing symptoms. These situations almost always induce fear or anxiety
and are often avoided and require the presence of a companion.
The key features of generalized anxiety disorder are persistent and excessive anxiety
and worry about various domains, including work and school performance, that the individual
finds difficult to control. In addition, the individual experiences physical symptoms,
including restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating
or mind going blank; irritability; muscle tension; and sleep disturbance.
Substance /medication-induced anxiety disorder involves anxiety due to substance intoxication
or withdrawal or to a medication treatment. In anxiety disorder due to another
medical condition, anxiety symptoms are the physiological consequence of another medical
condition.
Disorder-specific scales are available to better characterize the severity of each anxiety
disorder and to capture change in severity over time. For ease of use, particularly for individuals
with more than one anxiety disorder, these scales have been developed to have
the same format (but different focus) across the anxiety disorders, with ratings of behavioral
symptoms, cognitive ideation symptoms, and physical symptoms relevant to each
disorder.