ABNORMAL PSYCHOLOGY

ANXIETY DISORDERS

I. ANXIETY DISORDER
include disorders that share features of excessive fear and anxiety and related
behavioral disturbances.

Fear - the emotional response to real or perceived imminent threat

associated with surges of autonomic arousal necessary for fight or flight,
thoughts of immediate danger, and escape behaviors

Anxiety is anticipation of future threat

associated with muscle tension and vigilance in preparation for future danger
and cautious or avoidant behaviors

Most occur more frequently in females than in males (approximately 2:1 ra-
tio).

Disorders sequenced according to the typical age at onset.

Separation anxiety disorder- persistent fear or anxiety about harm coming to

attachment figures and events that could lead to loss of or separation from at-
tachment figures and reluctance to go away from attachment figures, as well
as nightmares and physical symptoms of distress. Although the symptoms of-
ten develop in childhood, they can be expressed throughout adulthood as
well.

Selective mutism is characterized by a consistent failure to speak in social sit-

uations in which there is an expectation to speak (e.g., school) even though
the individual speaks in
other situations.

Individuals with specific phobia are fearful or anxious about or avoidant of cir-
cumscribed objects or situations.

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 possi-
bility of being scrutinized.
The cognitive ideation is of being negatively evaluated by others, by being
embarrassed, humiliated, or rejected, or offending others.(cognitive ideation -
generates alternate scenarios or creates fantasy worlds)

In panic disorder, the individual experiences recurrent unexpected panic at-

tacks 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)

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 function as a marker and prognostic factor for severity of diag-
nosis, course, and comorbidity across an array of disorders, including, but not
limited to, the anxiety disorders (e.g., substance use, depressive and psy-
chotic disorders). Panic attack may therefore be used as a descriptive speci-
fier 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.

I.A SSEPARATION ANXIETY DISORDER

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.about possible harm to them, such as illness, injury, disasters, or death.

3. untoward event (e.g., getting lost, being kidnapped, having an accident, be-
coming 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.about being alone or without major attachment figures at home or in other

settings.

6. 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, stom-

achaches, nausea, vomiting) when separation from major attachment figures
occurs or is anticipated.

B. lasting at least 4 weeks in children and adolescents and typically 6 months

or more in adults.

the most prevalent anxiety disorder in children younger than 12 years.

early as preschool age and may occur at any time during childhood and more
rarely in adolescence.

Separation anxiety disorder often develops after life stress, especially a loss

Children with separation anxiety disorder display particularly enhanced sensi-

tivity to respiratory stimulation using CO2-enriched air.

Separation anxiety disorder in children may be associated with an increased

risk for suicide.

In children, separation anxiety disorder is highly comorbid with generalized

anxiety disorder and specific phobia.

I.B SELECTIVE MUTISM

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 disor-
der.

The disturbance is often marked by high social anxiety.

Associated features of selective mutism may include excessive shyness, fear

of social embarrassment, social isolation and withdrawal, clinging, compulsive
traits, negativism,
temper tantrums, or mild oppositional behavior.

In clinical settings, children with selective mutism are almost always given an
additional diagnosis of another anxiety disorder—most commonly, social anxi-
ety disorder (social phobia)

Selective mutism is a relatively rare disorder

The onset of selective mutism is usually before age 5 years

Negative affectivity (neuroticism) or behavioral inhibition may play a role, as

may
parental history of shyness, social isolation, and social anxiety.

I.C SPECIFIC PHOBIA

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 im-

pairment 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 re-
lated 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 proce-
dures).

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).

75% of individuals with specific phobia fear more than one situation or object.
Average (fears three objects or situations)

Diagnosis: specific phobia, natural environment, and specific phobia, situa-

tional.

Also, the fear or anxiety occurs as soon as the phobic object or situation is en-
countered (i.e., immediately rather than being delayed).

Active avoidance means the individual intentionally behaves in ways that are
designed to prevent or minimize contact with phobic objects or situations

individuals with situational, natural environment, and animal specific phobias

are likely to show sympathetic nervous system arousal (sympathetic nervous
system is the part of your nervous system that carries signals related to your
“fight-or-flight” response.)

individuals with blood-injection-injury specific phobia often demonstrate a

vasovagal fainting or near-fainting response that is marked by initial brief ac-
celeration of heart rate and elevation of blood pressure followed by a deceler-
ation of heart rate and a drop in blood pressure.

amygdala- associated with specific phobias

Females are more frequently affected than males, at a rate of approximately

2:1

animal, natural environment, and situational specific phobias are predomi-

nantly experienced by females, whereas blood-injection-injury phobia is expe-
rienced nearly equally by both genders.

Specific phobia sometimes develops following a traumatic event, observation

of others going through a traumatic event, an unexpected panic attack in the
to be feared situation ,informational transmission

develops in early childhood, with the majority of cases developing prior to age
10
years. 7 and 11 years (median) 10 (mean)

First, older individuals may be more likely to endorse natural environment

specific phobias, as well as phobias of falling.

Second, specific phobia (like all anxiety disorders) tends to co-occur with med-
ical
concerns in older individuals

Third, older individuals may be more likely to attribute the symptoms of anxi-
ety to medical conditions.

Fourth, older individuals may be more likely to manifest anxiety in an atypical

manner

Individuals with specific phobia are up to 60% more likely to make a suicide
attempt

Individuals with specific phobia are at increased risk for the development of
other disorders, including other anxiety disorders, depressive and bipolar dis-
orders, substancerelated disorders, somatic symptom and related disorders,
and personality disorders (particularly dependent personality disorder).

A. Marked fear or anxiety about one or more social situations in which the in-
dividual 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 symp-
toms 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 so-
cial 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 im-

pairment in
social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological ef-

fects 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 dysmorphic disorder, or autism
spectrum
disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigure-

ment from burns 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

The individual is concerned that he or she will be judged as anxious, weak,

crazy, stupid, boring, intimidating, dirty, or unlikable.
paruresis, or “shy bladder syndrome”).

They may show overly rigid body posture or inadequate eye contact, or speak
with an overly soft voice.

slightly higher for males in clinical samples, and it is assumed that gender
roles and social expectations play a significant role in explaining the height-
ened help-seeking behavior in male patients.

onset between 8 and 15 years.

Median age at onset of social anxiety disorder in the United States is 13 years
taijin kyofusho- (Japan and Korea) associated with the fear that the individual
makes other people uncomfortable

Females with social anxiety disorder report a greater number of social fears
and comorbid
depressive, bipolar, and anxiety disorders, whereas males are more likely to
fear dating,
have oppositional defiant disorder or conduct disorder, and use alcohol and il-
licit drugs to
relieve symptoms of the disorder. Paruresis is more common in males.

I.D PANIC DISORDER

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of in-
tense 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.

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 conse-

quences
(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 unfa-
miliar
situations).

nocturnal panic attack (i.e., waking from sleep in a state of panic, which dif-
fers from panicking after fully waking from sleep)

Females are more frequently affected than males, at a rate of approximately

2:1

The median age at onset for panic disorder in the United States is 20–24
years.

Ataque de nervios may involve trembling, uncontrollable screaming or crying,

aggressive or suicidal behavior, and depersonalization or derealization, which
may be experienced longer than the few minutes typical (“attack of nerves”)

(trúng gió; “hit by the wind”) may attribute the panic attack to exposure to
wind as a result of the cultural syndrome that links these two experiences, re-
sulting in classification of the panic attack as expected Vietnamese

khyâl attacks and “soul loss” among Cambodians.

The clinical features of panic disorder do not appear to differ between males
and females

panic attacks are related to hypersensitive medullary carbon dioxide detec-

tors, resulting in hypocapnia and other respiratory irregularities.

Reported lifetime rates of comorbidity between major depressive disorder and

panic
disorder vary widely, ranging from 10% to 65% in individuals with panic disor-
der.

the depression precedes the onset of panic disorder.

Comorbidity with other anxiety disorders and illness anxiety disorder is also
common.

I.PANIC ATTACK SPECIFIER

Symptoms are presented for the purpose of identifying a panic attack; how-
ever,
panic attack is not a mental disorder and cannot be coded.

It should be noted as a specifier (e.g., “posttraumatic stress disorder

with panic attacks”)

The essential feature of a panic attack is an abrupt surge of intense fear or in-
tense discomfort that reaches a peak within minutes and during which time
four or more of 13 physical and cognitive symptoms occur. Eleven of these 13
symptoms are physical (e.g., palpitations, sweating), while two are cognitive
(i.e., fear of losing control or going crazy, fear of dying)

Attacks that meet all other criteria but have fewer than four physical and/or
cognitive symptoms are referred to as limited-symptom attacks

Expected panic attacks are attacks for which there is an obvious cue or trig-
ger, such as situations in which panic attacks have typically occurred

Unexpected panic attacks are those for which there is no obvious cue or trig-
ger at the time of occurrence (e.g., when relaxing or out of sleep [nocturnal
panic attack])

The mean age at onset for panic attacks in the United States is approximately
22–23 years
among adults.

I.E AGORAPHOBIA
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 es-
cape 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).

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder.

If an individual’s presentation meets criteria for panic disorder and agorapho-
bia, both diagnoses
should be assigned.

Agoraphobia may occur in childhood, but incidence peaks in late adolescence

and early adulthood.
In two-thirds of all cases of agoraphobia, initial onset is before age 35 years

The overall mean age at onset for agoraphobia is 17 years, although the age
at onset without preceding panic attacks or panic disorder is 25–29 years.

The majority of individuals with agoraphobia also have other mental disorders.
The most
frequent additional diagnoses are other anxiety disorders (e.g., specific pho-
bias, panic disorder, social anxiety disorder), depressive disorders (major de-
pressive disorder), PTSD,
and alcohol use disorder.

Whereas other anxiety disorders (e.g., separation anxiety disorder, specific

phobias, panic disorder) frequently precede onset of agoraphobia, depressive
disorders and substance use disorders typically occur secondary to agorapho-
bia.

I.F GENERALIZED ANXIETY DISORDER

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, unsatisfy-
ing
sleep).

somatic symptoms (e.g., sweating, nausea, diarrhea)

autonomic hyperarousal (e.g., accelerated heart rate, shortness of breath,
dizziness)
Females are twice as likely as males to experience generalized anxiety disor-
der
The prevalence of the diagnosis peaks in middle age and declines across the
later years of life.
The clinical expression of generalized anxiety disorder is relatively consistent
across
the lifespan
Children with the disorder may be overly conforming, perfectionist, and un-
sure of themselves and tend to redo tasks because of excessive dissatisfac-
tion with less-than-perfect performance.
In females, comorbidity is largely confined to the anxiety disorders and unipo-
lar depression, whereas in males, comorbidity is more likely to extend to the
substance use disorders as well.