ANXIETY DISORDERS Selective Mutism Social Anxiety Disorder (Social Phobia)

excessive fear and anxiety and related behavioral A. Consistent failure to speak in specific social situations in A. Marked fear or anxiety about one or more social situations
disturbances which there is an expectation for speaking (e.g., at school) in which the individual is exposed to possible scrutiny by
Fear - emotional response to real or perceived imminent despite speaking in other situations. others. Examples include social interactions (e.g., having a
threat B. The disturbance interferes with educational or occupational conversation, meeting unfamiliar people), being observed
Anxiety - anticipation of future threat achievement or with social communication. (e.g., eating or drinking), and performing in front of others
C. The duration of the disturbance is at least 1 month (not (e.g., giving a speech).
limited to the first month of school). a. Note: In children, the anxiety must occur in peer
Separation Anxiety Disorder
D. The failure to speak is not attributable to a lack of settings and not just during interactions with
A. Developmentally inappropriate and excessive fear or
knowledge of, or comfort with, the spoken language adults.
anxiety concerning separation from those to whom
required in the social situation. B. The individual fears that he or she will act in a way or show
the individual is attached, as evidenced by at least three
E. The disturbance is not better explained by a anxiety symptoms that will be negatively evaluated (i.e.,
of the following:
communication disorder (e.g., childhoodonset fluency will be humiliating or embarrassing: will lead to rejection or
1. Recurrent excessive distress when anticipating or
disorder) and does not occur exclusively during the course offend others).
experiencing separation from home or from major
of autism spectrum disorder, schizophrenia, or another C. The social situations almost always provoke fear or anxiety.
attachment figures.
psychotic disorder. a. Note: In children, the fear or anxiety may be
2. Persistent and excessive worry about losing major
Associated Features Supporting Diagnosis expressed by crying, tantrums, freezing,
attachment figures or about possible harm to them, such
excessive shyness, fear of social embarrassment, social clinging, shrinking, or failing to speak in social
as illness, injury, disasters, or death.
isolation and withdrawal, clinging, compulsive traits, situations.
3. Persistent and excessive worry about experiencing an
negativism, temper tantrums, or mild oppositional D. The social situations are avoided or endured with intense
untoward event (e.g., getting lost, being kidnapped,
behavior. fear or anxiety.
having an accident, becoming ill) that causes separation
may occasionally be an associated communication disorder E. The fear or anxiety is out of proportion to the actual threat
from a major attachment figure.
children with selective mutism are almost always given an posed by the social situation and to the sociocultural
4. Persistent reluctance or refusal to go out, away from
additional diagnosis of another anxiety disordermost context.
home, to school, to work, or elsewhere because of fear
commonly, social anxiety disorder (social phobia). F. The fear, anxiety, or avoidance is persistent, typically
of separation.
lasting for 6 months or more.
5. Persistent and excessive fear of or reluctance about
Specific Phobia G. The fear, anxiety, or avoidance causes clinically significant
being alone or without major attachment figures at
A. Marked fear or anxiety about a specific object or situation distress or impairment in social, occupational, or other
home or in other settings.
(e.g., flying, heights, animals, receiving an injection, seeing important areas of functioning.
6. Persistent reluctance or refusal to sleep away from home
blood). H. The fear, anxiety, or avoidance is not attributable to the
or to go to sleep without being near a major attachment
Note: In children, the fear or anxiety may be expressed by physiological effects of a substance (e.g., a drug of abuse,
figure.
crying, tantrums, freezing, or clinging. a medication) or another medical condition.
7. Repeated nightmares involving the theme of separation.
B. The phobic object or situation almost always provokes I. The fear, anxiety, or avoidance is not better explained by
8. Repeated complaints of physical symptoms (e.g.,
immediate fear or anxiety. the symptoms of another mental disorder, such as panic
headaches, stomachaches, nausea, vomiting) when
C. The phobic object or situation is actively avoided or disorder, body dysmohic disorder, or autism spectrum
separation from major attachment figures occurs or is
endured with intense fear or anxiety. disorder.
anticipated.
D. The fear or anxiety is out of proportion to the actual J. If another medical condition (e.g., Parkinsons disease,
B. The fear, anxiety, or avoidance is persistent, lasting at least
danger posed by the specific object or situation and to the obesity, disfigurement from bums or injury) is present, the
4 weeks in children and adolescents and typically 6
sociocultural context. fear, anxiety, or avoidance is clearly unrelated or is
months or more in adults.
E. The fear, anxiety, or avoidance is persistent, typically excessive.
C. The disturbance causes clinically significant distress or
lasting for 6 months or more. Specify if: Performance only: If the fear is restricted to speaking
impairment in social, academic, occupational, or other
F. The fear, anxiety, or avoidance causes clinically significant or performing in public.
important areas of functioning.
distress or impairment in social, occupational, or other Associated Features Supporting Diagnosis
D. The disturbance is not better explained by another mental
important areas of functioning. may be inadequately assertive or excessively submissive or,
disorder, such as refusing to leave home because of excessive
G. The disturbance is not better explained by the symptoms of less commonly, highly controlling of the conversation.
resistance to change in autism spectrum disorder; delusions
another mental disorder, including fear, anxiety, and may show overly rigid body posture or inadequate eye
or hallucinations concerning separation in psychotic disorders;
avoidance of situations associated with panic-like contact, or speak with an overly soft voice
refusal to go outside without a trusted companion in
symptoms or other incapacitating symptoms (as in may be shy or withdrawn, and they may be less open in
agoraphobia; worries about ill health or other harm befalling
agoraphobia): objects or situations related to obsessions conversations and disclose little
significant others in generalized anxiety disorder; or concerns
(as in obsessive-compulsive disorder); reminders of may seek employment in jobs that do not require social
about having an illness in illness anxiety disorder.
traumatic events (as in posttraumatic stress disorder); contact
separation from home or attachment figures (as in may live at home longer
separation anxiety disorder); or social situations (as in Men may be delayed in marrying and having a family,
social anxiety disorder). women who may live a life as homemaker and mother
* Approximately 75% of individuals with specific phobia fear Self-medication with substances is common
more than one situation or object. Blushing is a hallmark physical response of social
anxiety disorder.
 Panic Disorder Panic Attack Specifier G. the fear, anxiety, or avoidance causes clinically significant
A. Recurrent unexpected panic attacks. A panic attack is an Note: Symptoms are presented for the purpose of identifying a distress or impairment in social, occupational, or other
abrupt surge of intense fear or intense discomfort that panic attacl<; however, panic attack is not a mental disorder important areas of functioning.
reaches a peak within minutes, and during which time four and cannot be coded. Panic attacl<s can occur in the context of H. If another medical condition (e.g., inflammatory bowel
(or more) of the following symptoms occur; any anxiety disorder as well as other mental disorders (e.g., disease, Parkinsons disease) is present, the fear, anxiety, or
Note: The abrupt surge can occur from a calm state or an depressive disorders, posttraumatic stress disorder, substance avoidance is clearly excessive.
anxious state. use disorders) and some medical conditions (e.g., cardiac, I. the fear, anxiety, or avoidance is not better explained by the
1. Palpitations, pounding heart, or accelerated heart respiratory, vestibular, gastrointestinal). When the presence of a symptoms of another mental disorderfor example, the
rate. panic attack is identified, it should be noted as a specifier (e.g., symptoms are not confined to specific phobia, situational
2. Sweating. posttraumatic stress disorder with panic attacks). For panic type; do not involve only social situations (as in social anxiety
3. Trembling or shaking. disorder, the presence of panic attack is contained within the disorder): and are not related exclusively to obsessions (as in
4. Sensations of shortness of breath or smothering. criteria for the disorder and panic attack is not used as a obsessive-compulsive disorder), perceived defects or flaws in
5. Feelings of choking. specifier. physical appearance (as in body dysmohic disorder),
6. Chest pain or discomfort. An abrupt surge of intense fear or intense discomfort that reminders of traumatic events (as in posttraumatic stress
7. Nausea or abdominal distress. reaches a peak within minutes, and during which time four (or disorder), or fear of separation (as in separation anxiety
8. Feeling dizzy, unsteady, light-headed, or faint. more) of the following symptoms occur: disorder).
9. Chills or heat sensations. Note: The abrupt surge can occur from a calm state or an
10. Paresthesias (numbness or tingling sensations). anxious state. Note: Agoraphobia is diagnosed irrespective of the presence of
11. Derealization (feelings of unreality) or 1. Palpitations, pounding heart, or accelerated heart rate. panic disorder. If an individuals presentation meets criteria for
depersonalization (being detached from oneself). 2. Sweating. panic disorder and agoraphobia, both diagnoses should be
12. Fear of losing control or going crazy. 3. Trembling or shaking. assigned.
13. Fear of dying. 4. Sensations of shortness of breath or smothering.
B. At least one of the attacks has been followed by 1 month 5. Feelings of choking.
(or more) of one or both of the following: 6. Chest pain or discomfort.
1. Persistent concern or worry about additional panic 7. Nausea or abdominal distress.
attacks or their consequences (e.g., losing control, 8. Feeling dizzy, unsteady, light-headed, or faint. Generalized Anxiety Disorder
having a heart attack, going crazy). 9. Chilis or heat sensations. A. Excessive anxiety and worry (apprehensive
2. A significant maladaptive change in behavior related 10. Paresthesias (numbness or tingling sensations). expectation), occurring more days than
to the attacks (e.g., behaviours designed to avoid 11. Derealization (feelings of unreality) or depersonalization not for at least 6 months, about a number of events or
having panic attacks, such as avoidance of exercise (being detached from oneself). activities (such as work or school
or unfamiliar situations). 12. Fear of losing control or going crazy. performance).
C. The disturbance is not attributable to the physiological 13. Fear of dying. B. The individual finds it difficult to control the worry.
effects of a substance (e.g., a drug of abuse, a medication) C. The anxiety and worry are associated with three (or more)
or another medical condition (e.g., hyperthyroidism, Agoraphobia of the following six symptoms
cardiopulmonary disorders). A. Marked fear or anxiety about two (or more) of the following (with at least some symptoms having been present for
D. The disturbance is not better explained by another mental five situations: more days than not for the past 6 months);
disorder (e.g., the panic attacks do not occur only in 1. Using public transportation (e.g., automobiles, buses, Note: Only one item is required in children.
response to feared social situations, as in social anxiety trains, ships, planes). 1. Restlessness or feeling keyed up or on edge.
disorder: in response to circumscribed phobic objects or 2. Being in open spaces (e.g., parking lots, marketplaces, 2. Being easily fatigued.
situations, as in specific phobia: in response to obsessions, bridges). 3. Difficulty concentrating or mind going blank.
as in obsessive-compulsive disorder: in response to 3. Being in enclosed places (e.g., shops, theaters, 4. Irritability.
reminders of traumatic events, as in posttraumatic stress cinemas). 5. Muscle tension.
disorder: or in response to separation from attachment 4. Standing in line or being in a crowd. 6. Sleep disturbance
figures, as in separation anxiety disorder). 5. Being outside of the home alone. D. The anxiety, worry, or physical symptoms cause clinically
B. The individual fears or avoids these situations because of significant distress or impairment in social, occupational,
Associated Features Supporting Diagnosis thoughts that escape might be difficult or help might not be or other important areas of functioning.
One type of unexpected panic attack is a nocturnal panic available in the event of developing panic-like symptoms or E. The disturbance is not attributable to the physiological
attack other incapacitating or embarrassing symptoms (e.g., fear of effects of a substance.
individuals with panic disorder report constant or falling in the elderly; fear of incontinence). F. The disturbance is not better explained by another mental
intermittent feelings of anxiety that are more broadly C. The agoraphobic situations almost always provoke fear or disorder (e.g., anxiety or worry about having panic attacks
related to health and mental health concerns there may be anxiety. in panic disorder, negative evaluation in social anxiety
pervasive concerns about abilities to D. The agoraphobic situations are actively avoided, require the disorder.
presence of a companion, or are endured with intense fear or
anxiety. Associated Features Supporting Diagnosis
E. The fear or anxiety is out of proportion to the actual danger Associated with muscle tension, there may be
posed by the agoraphobic situations and to the sociocultural trembling, twitching, feeling shaky, and muscle aches
context. or soreness. Many individuals with generalized anxiety
F. The fear, anxiety, or avoidance is persistent, typically lasting disorder also experience somatic symptoms (e.g.,
for 6 months or more. sweating, nausea, diarrhea) and an exaggerated
 startle response. Anxiety Disorder Due to Another Medical
Symptoms of autonomic hyperarousal (e.g.,
accelerated heart rate, shortness of breath, dizziness)
Condition
A. Panic attacks or anxiety is predominant in the clinical picture.
are less prominent in generalized anxiety disorder
B. There is evidence from the history, physical examination, or
than in other anxiety disorders, such as panic
laboratory findings that the disturbance is the direct
disorder.
pathophysiological consequence of another medical condition.
C. he disturbance is not better explained by another mental
Other conditions that may be associated with stress
disorder.
(e.g., irritable bowel syndrome, headaches)
D. The disturbance does not occur exclusively during the course
frequently accompany generalized anxiety disorder.
of a delirium.
E. The disturbance causes clinically significant distress or
Substance/Medication-Induced impairment in social, occupational, or other important areas of
Anxiety Disorder functioning.
A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or Associated Features Supporting Diagnosis
laboratory findings of both (1)and (2): A number of medical conditions are known to include anxiety as
1. The symptoms in Criterion A developed during or soon after a symptomatic manifestation. Examples include endocrine
substance intoxication or withdrawal or after exposure to a disease (e.g., hyperthyroidism, pheochromocytoma,
medication. hypoglycemia, hyperadrenocortisolism), cardiovascular disorders
2. The involved substance/medication is capable of producing (e.g., congestive heart failure, pulmonary embolism, arrhythmia
the symptoms in Criterion A. such as atrial fibrillation), respiratory illness, and neurological
C. The disturbance is not better explained by an anxiety disorder illness (e.g., neoplasms, vestibular dysfunction, encephalitis,
that is not substance/ medication-induced. Such evidence of an seizure disorders). Anxiety due to another medical condition is
independent anxiety disorder could include the following: diagnosed when the medical condition is known to induce
The symptoms precede the onset of the anxiety and when the medical condition preceded the onset of
substance/medication use; the symptoms persist for a the anxiety.
substantial period of time (e.g., about 1 month) after
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.
Associated Features Supporting Diagnosis
Panic or anxiety can occur in association with intoxication with
the following classes of substances: alcohol, caffeine,
cannabis, phencyclidine, other hallucinogens, inhalants,
stimulants (including cocaine), and other (or unknown)
substances. Panic or anxiety can occur in association with
withdrawal from the following classes of substances: alcohol;
opioids; sedatives, hypnotics, and anxiolytics; stimulants
(including cocaine); and other (or unknown) substances.
Some medications that evoke anxiety symptoms include
anesthetics and analgesics, sympathomimetics or other
bronchodilators, anticholinergics, insulin, thyroid preparations,
oral contraceptives, antihistamines, antiparkinsonian
medications, corticosteroids, antihypertensive and
cardiovascular medications, anticonvulsants, lithium
carbonate, antipsychotic medications, and antidepressant
medications. Heavy metals and toxins (e.g., organophosphate
insecticide, nerve gases, carbon monoxide, carbon dioxide,
volatile substances such as gasoline and paint) may also
cause panic or anxiety symptoms.