overview

Anxiety disorders are among the most common mental health conditions, characterized by excessive fear, anxiety, and related behavioral disturbances. Fear is the emotional reaction to real or perceived imminent danger, often associated with immediate physical responses such as increased heart rate, sweating, and a fight-or-flight instinct. Although fear and anxiety often overlap, their distinction is essential for understanding anxiety disorders.

These disorders are marked by heightened and persistent levels of fear or anxiety that go beyond developmentally appropriate responses or temporary stress-induced reactions. Typically, symptoms last six months or more, although shorter durations may be applicable in children, as seen in separation anxiety disorder and selective mutism.

Panic attacks, involving sudden and intense fear accompanied by physical symptoms like dizziness and palpitations, can occur within anxiety disorders but are not exclusive to them.

Anxiety disorders vary based on the specific situations, objects, or thoughts that trigger fear or avoidance. For example, while one individual may fear social scrutiny (as in social anxiety disorder), another may fear open spaces (as in agoraphobia). Despite this variability, anxiety disorders are highly comorbid, meaning individuals often experience multiple anxiety-related conditions.

DSM Chapter Sections:

• Separation Anxiety Disorder
• Selective Mutism
• Specific Phobia
• Social Anxiety Disorder
• Panic Disorder
• Panic Attack Specifier
• Agoraphobia
• Generalized Anxiety Disorder
• Substance/Medication-Induced Anxiety Disorder
• Anxiety Disorder Due to Another Medical Condition
• Other Specified Anxiety Disorder
• Unspecified Anxiety Disorder

separation anxiety disorder

Separation anxiety disorder is characterized by excessive fear or anxiety about separation from home or attachment figures that is developmentally inappropriate. The fear exceeds what is typical for the individual’s age and developmental level.

Key Diagnostic Criteria:
The diagnosis requires at least three of the following symptoms:

1. Recurrent excessive distress when anticipating or experiencing separation.
2. Persistent  and excessive worry about losing attachment figures or harm occurring to them.
3. Persistent and excessive worry about experiencing events (e.g., getting lost, kidnapped) that lead to separation.
4. Persistent reluctance or refusal to go out (e.g., school, work) due to fear of separation.
5. Persistent and excessive fear of or reluctance to be alone without attachment figures.
6. Persistent reluctance or refusal to sleep away from home or without being near attachment figures.
7. Repeated nightmares about separation.
8. Repeated complaints of physical symptoms (e.g., headaches, nausea) during or in anticipation of separation.

Additional Requirements:

• Symptoms persist for at least four weeks in children/adolescents and six months or more in adults.
• Symptoms cause clinically significant distress or impair social, academic, or occupational functioning.
• The condition is not better explained by another mental disorder (e.g., agoraphobia, generalized anxiety disorder).

selective mutism

Selective mutism is a condition where individuals consistently fail to speak in specific social situations where speaking is expected (e.g., at school or public events), despite speaking normally in other settings, such as at home with immediate family members.

Diagnostic Criteria:

A. Consistent failure to speak in specific social situations where 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 one month (not limited to the first month of school).

D. The failure to speak is not due to a lack of knowledge of, or comfort with, the language required in the social situation.

E. The disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

specific phobia

Specific phobia is characterized by intense fear or anxiety about a specific object or situation (e.g., flying, animals, heights) that is persistent, excessive, and leads to significant avoidance behaviors or distress. The fear must be out of proportion to the actual threat and inconsistent with sociocultural norms. Specific phobias can significantly impair daily functioning. While avoidance can temporarily reduce distress, it reinforces the fear over time. Many individuals with specific phobias may go to great lengths to restructure their lives to avoid the phobic stimulus.

Diagnostic Criteria:

A. Marked fear or anxiety triggered by a specific object or situation.

B. The phobic object or situation almost always provokes immediate fear or anxiety.

C. The individual actively avoids the object or situation or endures it with intense fear or anxiety.

D. The fear or anxiety is out of proportion to the actual danger.

E. The symptoms are persistent, lasting at least six months or more.

F. The fear or avoidance causes significant distress or impairs social, occupational, or other areas of functioning.

G. The disturbance cannot be better explained by another mental disorder (e.g., social anxiety, OCD, PTSD).

Specifiers:

• Specific Phobia is categorized based on the feared stimulus:
  • Animal (e.g., spiders, dogs).
  • Natural environment (e.g., heights, storms, water).
  • Blood-injection-injury (e.g., needles, blood).
  • Situational (e.g., airplanes, elevators, enclosed spaces).
  • Other (e.g., choking, vomiting, loud sounds in children).

It is common for individuals to have multiple phobias. Each phobia is diagnosed separately with its own code.

Children vs. Adults:

• Children: May express fear through crying, tantrums, freezing, or clinging.
• Adults: May show more strategic avoidance or subtle modifications to their routines (e.g., relocating to avoid exposure to certain animals).

social anxiety disorder

Social anxiety disorder is characterized by a marked fear or anxiety about social situations in which the individual is exposed to possible scrutiny by others. This fear often involves concern about being negatively evaluated, humiliated, or rejected and leads to avoidance or intense distress in social settings.

Diagnostic Criteria:
A. Marked fear or anxiety about one or more social situations where scrutiny by others is possible (e.g., conversations, being observed, public speaking).

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

B. Fear of acting in a way or showing anxiety symptoms that will be negatively evaluated.

C. The social situations almost always provoke fear or anxiety.

• In children, this may manifest as crying, tantrums, freezing, clinging, shrinking, or failure to speak.

D. Social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat or sociocultural context.

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

G. The symptoms cause significant distress or impairment in social, academic, occupational, or other areas of functioning.

H. The symptoms are not attributable to substance use or a medical condition.

I. The symptoms are not better explained by another mental disorder (e.g., panic disorder, autism spectrum disorder).

J. If a medical condition (e.g., disfigurement) is present, the fear, anxiety, or avoidance is clearly unrelated or excessive.

Specifiers:

• Performance Only: Fear is restricted to public speaking or performing in front of others, typically impacting professional or academic settings.

panic disorder

Panic disorder is characterized by recurrent unexpected panic attacks, which are sudden surges of intense fear or discomfort that peak within minutes and include at least four physical and cognitive symptoms. The disorder involves persistent worry about future attacks or maladaptive changes in behavior aimed at avoiding them.

Diagnostic Criteria:

A. Recurrent unexpected panic attacks. A panic attack involves an abrupt surge of intense fear or discomfort, with 4 or more of the following symptoms:

1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or a smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Dizziness, light-headedness, or fainting.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling).
11. Derealization (feelings of unreality) or depersonalization (detachment from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.

B. At least one attack is 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., fear of losing control, having a heart attack).
2. Significant maladaptive changes in behavior to avoid attacks (e.g., avoiding exercise, unfamiliar situations).

C. The disturbance is not due to the physiological effects of a substance or another medical condition (e.g., hyperthyroidism).

D. The symptoms are not better explained by another mental disorder (e.g., social anxiety, specific phobia, PTSD).

agoraphobia

Agoraphobia is marked by significant fear or anxiety about being in situations where escape might be difficult or help unavailable in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms. These situations are either actively avoided, endured with intense distress, or require the presence of a companion.

Diagnostic Criteria:
A. Marked fear or anxiety about two or more of the following situations:

1. Using public transportation (e.g., buses, trains, planes).
2. Being in open spaces (e.g., parking lots, bridges).
3. Being in enclosed spaces (e.g., theaters, shops).
4. Standing in line or being in a crowd.
5. Being outside the home alone.

B. Fear is driven by thoughts that escape might be difficult or help unavailable during panic-like or incapacitating symptoms.

C. The situations almost always provoke fear or anxiety.

D. The situations are actively avoided, require a companion, or are endured with intense fear or anxiety.

E. Fear or anxiety is out of proportion to the actual danger or sociocultural context.

F. Symptoms are persistent, lasting six months or more.

G. The symptoms cause significant distress or impairment in social, occupational, or other areas of functioning.

H. If another medical condition is present (e.g., inflammatory bowel disease), the fear or anxiety is excessive.

I. The symptoms are not better explained by another mental disorder (e.g., specific phobia, PTSD).

generalized anxiety disorder

Generalized anxiety disorder (GAD) is characterized by excessive and persistent worry or anxiety about various events or activities, occurring more days than not for at least 6 months. This worry is difficult to control and is often disproportionate to the actual likelihood or impact of the anticipated events.

Diagnostic Criteria:
A. Excessive anxiety and worry about multiple events or activities, present most days for at least 6 months.

B. Difficulty controlling the worry.

C. The anxiety and worry are associated with three or more of the following symptoms (only one is required for 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 (e.g., trouble falling or staying asleep, restless sleep).

D. The symptoms cause significant distress or impairment in social, occupational, or other areas of functioning.

E. The disturbance is not due to the physiological effects of a substance or another medical condition.

F. The symptoms are not better explained by another mental disorder (e.g., panic disorder, OCD, PTSD).

substance/medication-Induced anxiety disorder

Substance/medication-induced anxiety disorder is characterized by prominent anxiety or panic symptoms directly attributable to the effects of a substance (e.g., drugs, medications, or toxins). These symptoms arise during or shortly after intoxication, withdrawal, or exposure to a medication. This diagnosis is made only when anxiety symptoms dominate the clinical picture and are severe enough to require independent clinical attention, separate from substance intoxication or withdrawal.

Diagnostic Criteria:
A. Panic attacks or anxiety are predominant in the clinical presentation.

B. Evidence from history, physical examination, or lab findings confirms:

1. Symptoms developed during or shortly after substance intoxication, withdrawal, or medication exposure.
2. The substance/medication is capable of producing the symptoms.

C. The disturbance is not better explained by an independent anxiety disorder (e.g., symptoms that precede substance use, persist significantly after withdrawal/intoxication, or have a history unrelated to substance use).

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

E. The symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

Specifiers “With”:

•  onset during intoxication: Symptoms arise during substance intoxication.
• onset during withdrawal: Symptoms occur during or shortly after withdrawal.
• onset after medication use: Symptoms develop at medication initiation, with a change in dosage, or during withdrawal.

Anxiety Disorder Due to Another Medical Condition

Anxiety disorder due to another medical condition is characterized by clinically significant anxiety or panic attacks that are judged to result directly from the physiological effects of another medical condition.

Diagnostic Criteria: 
A. Panic attacks or anxiety are predominant in the clinical picture.

B. Evidence from history, physical examination, or laboratory findings confirms the symptoms are the direct physiological consequence of another medical condition.

C. The symptoms are not better explained by another mental disorder (e.g., adjustment disorder with anxiety).

D. The symptoms do not occur exclusively during the course of a delirium.

E. The symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

Common Medical Conditions Associated with Anxiety:

• Endocrine Disorders: Hyperthyroidism, pheochromocytoma, hypoglycemia.
• Cardiovascular Disorders: Congestive heart failure, arrhythmias (e.g., atrial fibrillation).
• Respiratory Disorders: Chronic obstructive pulmonary disease (COPD), asthma, pulmonary embolism.
• Metabolic Disturbances: Vitamin B12 deficiency, porphyria.
• Neurological Disorders: Neoplasms, vestibular dysfunction, seizure disorders, encephalitis.

other specified anxiety disorder

This diagnosis applies to anxiety-related presentations that cause significant distress or impairment but do not meet the full criteria for any specific anxiety disorder. It is used when the clinician specifies why the criteria are not fully met for a particular diagnosis.

Examples:

1. Limited-symptom attacks: Panic-like episodes with fewer than four symptoms.
2. Generalized anxiety occurring less often than “more days than not.”
3. Culturally specific syndromes:
   • Khyâl cap (“wind attacks”).
   • Ataque de nervios (“attack of nerves”).

unspecified anxiety disorder

This diagnosis applies to anxiety-related presentations that cause significant distress or impairment but do not meet the criteria for any specific anxiety disorder. The clinician does not specify the reason the criteria are not met, often due to insufficient information (e.g., in emergency settings). Unlike the “other specified” category, this diagnosis does not provide additional detail about why the criteria for a specific anxiety disorder are unmet. It is typically used when further evaluation is not feasible.

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