Chapter 5 Anxiety is defined as “a state of intense apprehension, uncertainty, and fear resulting from the anticipation of a threatening event or situation, often to a degree that normal physical and psychological functioning is disrupted” (American Heritage Medical Dictionary, 2007, p. 38). The APA (2013a) purports that each of the anxiety disorders shares features of fear and anxiety, which it defines as follows: “Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (p. 189). People who experience anxiety often have physiological symptoms such as muscle tension, heart palpitations, sweating, dizziness, or shortness of breath. Emotional symptoms include restlessness, a sense of impending doom, fear of dying, fear of embarrassment or humiliation, or fear of something terrible happening. People with anxiety disorder worry more than others and display excessive or persistent fear and anxiety (Kessler, Berglund, et al., 2005). Prevalence of anxiety among the general population is high. Each year, anxiety disorders affect approximately 18%, or 40 million, adults in the United States (NIMH, 2013b, 2013d). Anxiety disorders have a lifetime prevalence of approximately 30% (Kessler, Berglund, et al., 2005). Close to 50% of individuals diagnosed with an anxiety disorder also meet the criteria for a depressive disorder. Anxiety and depression are highly comorbid and share genetic predispositions (Batelaan et al., 2010). It is important for counselors to accurately diagnose anxiety disorder as they respond to clinical interventions (ADAA, 2013). Anxiety manifests in multiple ways, including fear for the future on a cognitive level, muscle tension on a somatovisceral level, and situational avoidance on a behavioral level. This symptomatology holds pervasive impact for the functioning of the individual, including varying degrees of difficulty in establishing and maintaining interpersonal relationships (Hickey et al., 2005). Anxiety disorders often persist over time, thus representing ongoing challenges for the many people living with them (Beard, Moitra, Weisber, & Keller, 2010; Rubio & Lopez-Ibor, 2007; Wittchen, 2002). Because the prevalence of anxiety in the general population is so high, these diagnoses are frequently the focus of clinical attention for counselors and are often diagnosed within counseling settings (ADAA, 2013). The DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group separated what had been traditionally known as anxiety disorder into three distinct chapters: anxiety disorders, obsessive-compulsive and related disorders, and trauma- and stressor-related disorders. This represents an overall shift in the organization of the manual that includes clustering comorbid symptoms together. Specific changes to the Anxiety Disorders chapter include removing panic attack as a specifier for agoraphobia, including selective mutism and separation anxiety disorder, and changing the name of social phobia to social anxiety disorder (APA, 2013a). Panic attack criteria are also provided, along with the provision that the specifier may be applied to a wide array of DSM-5 diagnoses. APA’s (2013a) decision to cluster anxiety disorders within one chapter, separate from obsessive-compulsive disorder (OCD) and other stressor-related disorders, affects clinicians’ differential diagnosis. Stein, Craske, Friedman, and Phillips (2011) posited that clinical attention should focus on the discernment of disorders enumerated within this chapter. Perhaps the best way for counselors to accurately diagnose anxiety disorders is to have a clear framework for the specifics of each diagnosis as well as common differential and comorbid diagnoses. Differential diagnosis of anxiety disorders can be challenging, especially considering the comorbidity of anxiety disorders with depressive disorders. One way to differentiate the two is for counselors to keep in mind that depressive disorders are sometimes viewed as “anxious-misery” with high incidences of sadness and anhedonia; this distinguishes them from anxiety disorders, which often include anxious anticipation, uncertainty, and fear (Craske et al., 2009). Anhedonia and lowered affect are more commonly symptoms of depression than anxiety, whereas sleep disturbance, overall fatigue, and difficulty with concentration can be symptoms of both (APA, 2013a). The high comorbidity rates between depression and anxiety often make discernment a difficult task for counselors and researchers alike; clear understanding of the distinctions in sequelae of both disorders can assist with accurate differential diagnosis. Counselors can also consider the propensity of individuals diagnosed with anxiety disorders to worry more about future events and individuals with depressive disorders to be generally sad or morose. Across the spectrum of anxiety disorders, there are heightened responses to threats (real or perceived), increased responses to stress, and reactivity of the amygdala. Common overarching features of anxiety and depressive disorders include inability to focus, appetite or sleep disturbance, and negative impact on self-efficacy (APA, 2013a; Craske et al., 2009). Close to 50% of individuals diagnosed with an anxiety disorder also meet criteria for a depressive disorder (ADAA, 2013). Because of their high prevalence rate, these diagnoses are frequently the focus of clinical attention for counselors. Over the course of a lifetime, an individual’s diagnosis can migrate from anxiety to depression and vice versa. Therefore, it is important for counselors to view the treatment of these disorders from a longitudinal perspective (Batelaan et al., 2010). Anxiety disorders contain myriad psychobiological factors that include genetic predisposition, social and cultural contexts, and life events. Kessler, Petukhova, Sampson, Zaslasvky, and Wittchen (2012) discussed the lifetime morbid risk (LMR) for anxiety disorders; LMR represents the portion of people who will eventually develop the disorder at some time in their life, regardless of risk factors such as comorbid diagnoses. In the United States, specific phobia (18.4%) and social phobia (13.0%) have the highest LMR and agoraphobia has the lowest (3.7%). Women are more likely than men to have coexisting anxiety and depression (Friborg, Martinussen, Kaiser, Overgard, & Rosenvinge, 2013). Although tending toward chronicity, anxiety disorders are responsive to psychotherapeutic treatment modalities. It is important for counselors to note that severe anxiety is a risk factor for suicide (Fawcett, 2013); therefore, assessment of suicide risk should be incorporated into treatment for all clients. Additionally, anxiety disorders are the most common disorders among youth (Sood, Mendez, & Kendall, 2012) and have a median age of onset of 11 years. Additional research is needed for the treatment of anxiety disorders in young people because, at the current time, only CBT has evidenced-based treatment efficacy (Mohr & Schneider, 2013). Because of the prevalence of anxiety disorders in the general population, their diagnoses are frequently the focus of clinical attention for counselors and are common within counseling settings (ADAA, 2013). Individuals with anxiety disorders generally respond well to clinical intervention with effective treatments, including CBT, behavior therapy, and relaxation training (ADAA, 2013). Numerous research studies reveal that positive treatment outcomes for anxiety disorders are maintained longer for individuals, including children and adolescents, who have participated in CBT and behavior therapy (Hausmann et al., 2007; Hofmann & Smits, 2008; Silverman, Pina, & Viswesvaran, 2008). Because anxiety disorders are often diagnosed in counseling settings, it is important for counselors to focus on ongoing assessment and monitoring. To help readers better understand changes from the DSM-IV-TR to the DSM-5, the rest of this chapter outlines each disorder within the Anxiety Disorders chapter of the DSM-5. Readers should note that we have focused on major changes from the DSM-IV-TR to the DSM-5; however, this is not a stand-alone resource for diagnosis. Although a summary and special considerations for counselors are provided for each disorder, when diagnosing clients, counselors need to reference the DSM-5. It is essential that the diagnostic criteria and features, subtypes and specifiers (if applicable), prevalence, course, and risk and prognostic factors for each disorder are clearly understood prior to diagnosis. I know it is irrational but every time my partner begins to get ready for work, I start to feel horrible. I am certain that something bad will happen as soon as he leaves. It may be a car wreck or a heart attack, but I just know something bad will happen. I get physically ill. Sometimes I throw up. Often, I go to work with him. It’s causing problem for him, and he has become very frustrated with me because this has gone on for so long.—Benjamin Separation anxiety disorder has been listed as a mental disorder since the publication of the DSM-III in 1980. In the DSM-5, separation anxiety disorder was moved from the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter of the DSM-IV-TR to the Anxiety Disorders chapter, and the age-of-onset requirement (“before age 18 years”) was dropped, thus allowing for diagnosis of separation anxiety disorder in adults (Mohr & Schneider, 2013). The essential feature for separation anxiety disorder includes developmentally inappropriate nervousness and fear related to separation from the primary caregiver. In addition to fear and anxiety, physical symptoms can include headaches, stomachaches, and cardiovascular symptoms in adolescents and adults. These emotional and somatic symptoms can develop in childhood and persist into adult life. The fear and worry is focused on potential harm to attachment figures. This leads to reluctance on the part of these individuals to be alone or away from loved ones. Typical behaviors are “clinging” or “shadowing” (APA, 2013a, p. 191), with sleep disturbances commonly affecting both children and adults. Separation anxiety disorder can be extant through the life course, although it must last 6 months or longer for diagnosis in adults. For children, there is a minimum duration of 1 month. Prevalence rates are 4% for children, 1.6% for adolescents, and 0.9% to 1.9% for adults. Separation anxiety disorder is the most prevalent anxiety disorder in children, with girls more susceptible than boys. Functionality in school, work, or social settings is often impaired (APA, 2013a). Although considered a diagnosis primarily seen in childhood, separation anxiety disorder also affects adults, with the key features similar across the age spectrum: fear of separation from or harm befalling loved ones (Manicavasagar, Silove, Curtis, & Wagner, 2000). Adults with separation anxiety disorder typically display more covert behaviors, such as staying home or in close proximity to loved ones as well as engaging in frequent check-ins (Marnane & Silove, 2013). In contrast to APA prevalence reports, the National Comorbidity Survey Replication found a lifetime prevalence of separation anxiety disorder in adulthood of 6.6%, indicating that it is one of the most commonly occurring anxiety disorders (Shear, Jin, & Ruscio, 2006). Expectations for physical and emotional closeness in relationships are culturally linked, and counselors must be careful not to pathologize behaviors of individuals from more collectivist cultures, especially cultures in which parents and children are rarely separated. Sood et al. (2012) studied help seeking among Indian American, Puerto Rican, and European American mothers who had children diagnosed with separation anxiety disorder. Puerto Rican mothers were more likely to view the symptoms as resulting from a physical health condition and were thus less likely to seek psychological treatment. Acculturation was directly correlated with help-seeking behaviors, and those with strongly held religious beliefs were more likely to seek assistance from a religious leader. Sood et al.’s study highlights the need to examine cultural variables in addressing perception and treatment. When considering separation anxiety disorder, counselors must distinguish between developmentally and culturally appropriate reactions to separation and abnormal reactions to separation. Common differential diagnoses for separation anxiety disorder include GAD, panic disorder, agoraphobia, conduct disorder, PTSD, illness anxiety disorder, bereavement, depressive and bipolar disorder, ODD, psychotic disorder, and personality disorder. With separation anxiety disorder, the thrust of the anxiety is focused on separation from attachment figures (APA, 2013a). It differentiates from GAD and social anxiety disorder in this regard. GAD’s predominant features are diffuse anxiety, whereas social anxiety disorder is specific to social situations. Panic disorder, with its unexpected panic attacks, is distinguishable from separation anxiety disorder in that the unexpected and incapacitating panic attacks are not extant. PTSD centers around intrusive thoughts about and avoidance of memories related to the traumatic event; the worries central to separation anxiety disorder are related to harm to loved ones. With illness anxiety disorder, depressive disorder, bipolar disorder, and ODD, there is no predominant concern in being separated from attachment figures. Psychotic disorders contain hallucinations; this is not an evident feature of separation anxiety disorder (APA, 2013a). There is only one diagnostic code for separation anxiety disorder: 309.21(F93.0). There are no specifiers for this diagnosis. Camilla didn’t speak to anyone but me for 2 months after the accident. No one knew what to do. Clearly, she had the ability to talk, but she just refused to do so. I didn’t want to constantly punish her, and it didn’t seem to be helping anyway. I promised her rewards, but she didn’t respond to that either. The students in her kindergarten class really teased her.—Jules (Camilla’s mom) Selective mutism represents the voluntary refusal to speak (typically occurring outside of the home or immediate family). Elective mutism, first identified as a mental disorder in the DSM-III, was relabeled to selective mutism in the DSM-IV-TR. This is a new diagnosis in the Anxiety Disorders chapter of the DSM-5, because of the restructuring of the chapters and the removal of the chapter on disorders usually first diagnosed in infancy, childhood, or adolescence (APA, 2013a). The essential feature of selective mutism is a refusal to verbally communicate outside of the home or with people other than immediate family members or caregivers not due to speech/language difficulties. Children with selective mutism may speak only to immediate family members and will sometimes communicate with nonverbals such as nodding or grunting; these children do not usually possess language deficits. Selective mutism typically has an age of onset of under 5 years and is often first noticed in school settings (APA, 2013a). Selective mutism can manifest in adolescents and adults but is much less frequent (APA, 2013a). Excessive shyness is a personality trait often seen with selective mutism. Children diagnosed with selective mutism have high diagnostic comorbidity with other anxiety disorders, most frequently social anxiety disorder (APA, 2013a). Children with selective mutism frequently suffer significant impairment in social and school situations. Social isolation and academic impairment both occur. Cultural formulations play a critical role in the diagnosis of selective mutism. Hollifield, Gepper, Johnson, and Fryer (2003) discussed the ease of misdiagnosis when culture is not integrally considered in diagnosing selective mutism. It is important to assess language acquisition (especially if a child is living in a country whose native language is not his or her own). Further research on cultural contexts and the diagnosis of selective mutism is needed. Counselors who are considering a diagnosis of selective mutism must consider the child’s developmental and contextual functioning so they do not pathologize normal developmental transitions and adjustments. Common differential diagnoses for selective mutism include communication disorders, neurodevelopmental disorders, schizophrenia and other psychotic disorders, and social anxiety disorder. It is important to note that with selective mutism, the communication disorders are not specific to social situations and are more pervasive. Selective mutism should be diagnosed only when a child has readily demonstrated speaking ability in certain situations, such as the home environment. This is distinct from neurodevelopmental disorders, schizophrenia, and other psychotic disorders for which there may be impairment in communication regardless of the setting. Finally, it is not uncommon for social anxiety disorder to occur concomitantly with selective mutism; when this occurs, both disorders should be given (APA, 2013a). There is only one diagnostic code for selective mutism: 313.23 (F94.0). There are no specifiers for this diagnosis. Counselors should note that the original DSM-5 mistakenly published the code 312.23 (F94.0) for selective mutism. This is incorrect, and the code of 313.23 (F94.0) should be used. Ever since I was a child, I’ve been terrified of needles. My friends got their ears pierced but I refused to go near the salon. I avoid the doctor for the same reason, even when I know I should go. Last time I got sick, I waited until the last minute to go in. When the nurse started talking about taking my blood, my stomach started hurting, my heart started pounding in my ears, and I got light-headed. I refused to let her draw blood. It’s been so long since I had blood work, I can’t even remember my blood type. —Marin Specific phobias represent the existence of fear or anxiety in the presence of a specific situation or object. This is called the “phobic stimulus” (APA, 2013a, p. 198). This fear or anxiety must be markedly stronger than the actual threat of the object or situation (e.g., likelihood of being stuck on a well-maintained elevator). Specific phobias were first identified as such in the DSM-III-R (APA, 1987) and carry a lifetime prevalence rate of 9.4% to 12.5% (Marques, Robinaugh, LeBlanc, & Hinton, 2011). The main feature of specific phobia is an inappropriate fear response to a specific object or situation that is incongruent with the danger or threat and out of proportion to the danger posed. Specific phobias can develop after a traumatic event or from witnessing traumatic events. Individuals with specific phobia will avoid situations of exposure to the stimulus. The fear or anxiety happens every time the person is exposed to the stimulus and may include symptoms of a panic attack. The median age of onset for a diagnosis of specific phobia is 13 years (APA, 2013a).
Anxiety Disorders
Major Changes From DSM-IV-TR to DSM-5
Differential Diagnosis
Etiology and Treatment
Implications for Counselors
309.21 Separation Anxiety Disorder (F93.0)
Essential Features
Special Considerations
Cultural Considerations
Differential Diagnosis
Coding, Recording, and Specifiers
313.23 Selective Mutism (F94.0)
Essential Features
Special Considerations
Cultural Considerations
Differential Diagnosis
Coding, Recording, and Specifiers
300.29 Specific Phobia (F40._ _ _)
Essential Features
Special Considerations
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
