Anxiety Disorders - Diagnostic Criteria: DSM-IV

1. PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA

A. Both (1) and (2):

(1) recurrent, unexpected panic attacks (see below) 

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

(a) persistent concern about having additional attacks 

(b) worry about the implications of the attack or its consequences (eg, losing control, having a heart attack,"going crazy") 

(c) A significant change in behavior related to the attacks

B. The presence or absence of agoraphobia (see below).

C. The panic attacks are not due to the direct physiological effects of a substance or a general medical condition.

D. The panic attacks are not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety disorder.

Criteria for Panic Attack (not a separate diagnostic category)

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:

• palpitations, pounding heart, or accelerated heart rate 

• sweating 

• trembling or shaking 

• sensations of shortness of breath or smothering feeling of choking chest pain or discomfort 

• nausea or abdominal distress 

• feeling dizzy, unsteady, lightheaded, or faint 

• derealization or depersonalization 

• fear of losing control or going crazy 

• fear of dying 

• paresthesias (numbness or tingling) 

• chills or hot flashes

Criteria for Agoraphobia (not a separate diagnostic category)

A. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling on a bus, train, or automobile.

B. The situations are avoided or endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.

C. The anxiety of phobic avoidance is not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, or separation anxiety disorder.

2. PHOBIC DISORDERS: SPECIFIC PHOBIA & SOCIAL PHOBIA

Specific Phobia:

A. A marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.

B. 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.

C. The person recognizes that the fear is excessive or unreasonable.

• Note: In children, this feature may be absent.

D. The object or situation is avoided or else is endured with intense anxiety or distress.

E. 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.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The anxiety, panic attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as obsessive-compulsive disorder, posttraumatic stress disorder, separation anxiety disorder, social phobia, panic disorder with agoraphobia, or agoraphobia without history of panic disorder.

Specify type:

Animal type: if the fear is cued by animals or insects. This subtype generally has a childhood onset. 

Natural environment type: if the fear is cued by objects in the natural environment, such as storms, heights, or water. This subtype generally has a childhood onset. 

Blood-injection-injury type: if the fear is cued by seeing blood or an injury or by receiving an injection or other invasive medical procedure. This subtype is highly familial and is often characterized by a strong vasovagal response. 

Situational type: if the fear is cued by a specific situation such as public transportation, tunnels, bridges, elevators, flying, driving, or enclosed places. This subtype has a bimodal age-at-onset distribution, with one peak in childhood and another peak in the mid-20s. This subtype appears to be similar to panic disorder with agoraphobia in its characteristic sex ratios, familial aggregation pattern, and age at onset. 

Other type: if the fear is cued by other stimuli. These stimuli might include the fear or avoidance of situations that might lead to choking, vomiting, or contracting an illness;"space" phobia (ie, the individual is afraid of falling down if away from walls or other means of physical support); and children's fears of loud sounds or costumed characters.

Social Phobia:

A. 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.

B. 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.

C. The person recognizes that the fear is excessive or unreasonable.

• Note: In children, this feature may be absent.

D. The social or performance situation is avoided or else is endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance 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.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition and is not better accounted for by another mental disorder.

H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, eg, 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. 

• Note: Also consider the additional diagnosis of avoidant personality disorder.

3. 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 person 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 present for more days than not for the past 6 months).

(1) restlessness or feeling keyed up - on edge 

(2) easily fatigued 

(3) difficulty concentrating or mind going blank 

(4) irritability 

(5) muscle tension 

(6) sleep disturbance

• Note: Only one item is required in children.

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, eg, the anxiety or worry is not about having a panic attack (as in panic disorder), 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.

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

F. The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or medical condition (eg, hypothyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.