Anxiety Disorders



Anxiety Disorders





I. Definition

Anxiety is a state that has many effects: It influences cognition and tends to produce distortions of perception. It is differentiated from fear, which is an appropriate response to a known threat; anxiety is a response to a threat that is unknown, vague, or conflictual. Table 15-1 lists the signs and symptoms of anxiety disorders. Most of the effects of anxiety are dread accompanied by somatic complaints that indicate a hyperactive autonomic nervous system such as palpitations and sweating.


II. Classification

There are 11 diagnostic types of anxiety disorders in Diagnostic Statistical Manual of Mental Disorders, Text Revision, fourth edition, (DSM-IV-TR), ranging from panic disorder with and without agoraphobia to generalized anxiety disorder of unknown or known etiology (e.g., due to a medical condition or to substance abuse). They are among the most common groups of psychiatric disorders. Each disorder is discussed separately below.


A. Panic disorder with and without agoraphobia.

Panic disorder is characterized by spontaneous panic attacks (Table 15-2). It may occur alone or be associated with agoraphobia (fear of being in open spaces, outside the home alone, or in a crowd). Panic may evolve in stages: subclinical attacks, full panic attacks, anticipatory anxiety, phobic avoidance of specific situations, and agoraphobia. It can lead to alcohol or drug abuse, depression, and occupational and social restrictions. Agoraphobia can occur alone, although patients usually have associated panic attacks. Anticipatory anxiety is characterized by the fear that panic, with helplessness or humiliation, will occur. Patients with panic disorder often have multiple somatic complaints related to autonomic nervous system dysfunction, with a higher risk in females. See Table 15-3.


B. Agoraphobia without history of panic disorder.

Anxiety about being in places or situations such as in a crowd or in open spaces, outside the home, from which escape or egress is feared to be impossible. The situation is avoided or endured with marked distress, sometimes including the fear of having a panic attack. Agoraphobic patients may become housebound and never leave the home or go outside only with a companion.


C. Generalized anxiety disorder.

Involves excessive worry about everyday life circumstances, events, or conflicts. The symptoms may fluctuate and overlap with other medical and psychiatric disorders (depressive and other anxiety disorders). The anxiety is difficult to control, is subjectively distressing, and produces impairments in important areas of a person’s life. Occurs in children and adults with a lifetime prevalence of 45%. Ratio of women to men is 2:1. See Table 15-4.









Table 15-1 Signs and Symptoms of Anxiety Disorders





















































Physical Signs Psychological Symptoms
Trembling, twitching, feeling shaky Feeling of dread
Backache, headache Difficulty concentrating
Muscle tension Hypervigilance
Shortness of breath, hyperventilation Insomnia
Fatigability Decreased libido
Startle response “Lump in the throat”
Autonomic hyperactivity Upset stomach (“butterflies”)
   Flushing and pallor  
   Tachycardia, palpitations  
   Sweating  
   Cold hands  
   Diarrhea  
   Dry mouth (xerostomia)  
   Urinary frequency  
Paresthesia  
Difficulty swallowing  


D. Specific phobia.

A phobia is an irrational fear of an object (e.g., horses, heights, needles). The person experiences massive anxiety when exposed to the feared object and tries to avoid it at all costs. Up to 25% of the population have specific phobias. More common in females. See Table 15-5.


E. Social phobia.

Social phobia is an irrational fear of public situations (e.g., speaking in public, eating in public, using public bathrooms [shy bladder]). May be associated with panic attacks. It usually occurs during early teens but can develop during childhood. Affects up to 13% of persons. Equally common in men and women. See Table 15-6.








Table 15-2 DSM-IV-TR Diagnostic Criteria for Panic Attack








Note: A panic attack is not a codable disorder. Code the specific diagnosis in which the panic attack occurs (e.g., panic disorder with agoraphobia).
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:


  1. palpitations, pounding heart, or accelerated heart rate
  2. sweating
  3. trembling or shaking
  4. sensations of shortness of breath or smothering
  5. feeling of choking
  6. chest pain or discomfort
  7. nausea or abdominal distress
  8. feeling dizzy, unsteady, lightheaded, or faint
  9. derealization (feelings of unreality) or depersonalization (being detached from oneself)
  10. fear of losing control or going crazy
  11. fear of dying
  12. paresthesias (numbness or tingling sensations)
  13. chills or hot flushes
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.









Table 15-3 DSM-IV-TR Diagnostic Criteria for Panic Disorder without Agoraphobia








  1. Both 1 and 2:


    1. recurrent unexpected panic attacks
    2. at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:


      1. persistent concern about having additional attacks
      2. worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)
      3. a significant change in behavior related to the attacks

  2. Absence of agoraphobia
  3. The panic attacks are not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).
  4. The panic attacks are not better accounted for by another mental disorder, such as social phobia (e.g., occurring on exposure to feared social situations), specific phobia (e.g., on exposure to a specific phobic situation), obsessive-compulsive disorder (e.g., on exposure to dirt in someone with an obsession about contamination), posttraumatic stress disorder (e.g., in response to stimuli associated with a severe stressor), or separation anxiety disorder (e.g., in response to being away from home or close relatives).
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.








Table 15-4 DSM-IV-TR Diagnostic Criteria for Generalized Anxiety Disorder








  1. 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).
  2. The person finds it difficult to control the worry.
  3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms 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, unsatisfying sleep)

  4. The focus of the anxiety and worry is not confined to features of an Axis I disorder, for example, the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder.
  5. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  6. The disturbance is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive development disorder.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.









Table 15-5 DSM-IV-TR Diagnostic Criteria for Specific Phobia




















  1. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
  2. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack. Note: in children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.
  3. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
  4. The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
  5. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
  6. In individuals under age 18 years, the duration is at least 6 months.
  7. The anxiety, panic attacks, or phobic avoidance associated with the specific object or situation is not better accounted for by another mental disorder, such as obsessive-compulsive disorder (e.g., fear of dirt in someone with an obsession about contamination), posttraumatic stress disorder (e.g., avoidance of stimuli associated with a severe stressor), separation anxiety disorder (e.g., avoidance of school), social phobia (e.g., avoidance of social situations because of fear of embarrassment), panic disorder with agoraphobia, or agoraphobia without history of panic disorder.
Specify type:
   Animal type
   Natural environment type (e.g., heights, storms, water)
   Blood-injection-injury type
   Situational type (e.g., airplanes, elevators, enclosed places)
   Other type (e.g., phobic avoidance of situations that may lead to choking, vomiting, or contracting an illness; in children, avoidance of loud sounds or costumed characters)
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.








Table 15-6 DSM-IV-TR Diagnostic Criteria for Social Phobia












  1. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
  2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
  3. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
  4. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
  5. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
  6. In individuals under age 18 years, the duration is at least 6 months.
  7. The fear or avoidance is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder).
  8. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it (e.g., the fear is not of stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa).
Specify if:
   Generalized: if the fears include most social situations (also consider the additional diagnosis of avoidant personality disorder).
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.









Table 15-7 DSM-IV-TR Diagnostic Criteria for Obsessive–Compulsive Disorder












  1. Other obsessions or compulsions:
    Obsessions as defined by 1, 2, 3, and 4:


    1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
    2. the thoughts, impulses, or images are not simply excessive worries about real-life problems
    3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
    4. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without, as in thought insertion)
    Compulsions as defined by 1 and 2:


    1. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
    2. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

  2. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
  3. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
  4. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an eating disorder, hair pulling in the presence of trichotillomania, concern with appearance in the presence of body dysmorphic disorder, preoccupation with drugs in the presence of a substance use disorder, preoccupation with having a serious illness in the presence of hypochondriasis, preoccupations with sexual urges or fantasies in the presence of a paraphilia, or guilty ruminations in the presence of major depressive disorder).
  5. The disturbance is not caused by the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Specify if:
   With poor insight: If, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.


F. Obsessive–compulsive disorder.

Obsessive–compulsive disorder involves recurrent intrusive ideas, images, ruminations, impulses, thoughts (obsessions), or repetitive patterns of behavior or actions (compulsions). Both obsessions and compulsions are ego-alien and produce anxiety if resisted. Lifetime prevalence is 2% to 3%. Men and women are equally affected. Mean age of onset is 22 years. See Table 15-7.

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Jun 8, 2016 | Posted by in PSYCHIATRY | Comments Off on Anxiety Disorders

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