Assessing Anxiety Disorders

Anxiety is subject to misdiagnosis because its symptoms can be confused with symptoms of other mental or physical health conditions and it frequently co-occurs with other disorders (e.g., depression, substance disorders, bipolar disorders).

An accurate diagnosis requires careful evaluation by a trained mental health professional.

Panic Disorder is an anxiety disorder in which the person experiences Panic Attacks — usually many, but always more than one — and worries about having another. Full-blown Panic Disorder affects about 3 percent of the general U.S. adult population (6 million people); about 10 percent of the general population suffers Panic Attacks.

• 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 (feelings of unreality) or depersonalization (being detached from oneself)
• fear of losing control or going crazy
• fear of dying, impending doom
• paresthesias (numbness or tingling sensations)
• chills or hot flushes

Criteria for Panic Disorder

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:
   • persistent concern about having additional attacks
   • worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)
   • a significant change in behavior related to the attacks, such as doing something to avoid or combat the attacks

About half the people who suffer from panic attacks have symptoms of Agoraphobia — the fear of open spaces.

Agoraphobia and Panic Attacks are not codable disorders in themselves; rather, they’re building blocks of several different anxiety disorders. Agoraphobia occurs within the context of Panic Disorder, but may occur in a person with no history of Panic Disorder.

Criteria for Panic Disorder With Agoraphobia:

• A. Anxiety about being in places or situations from which either or both:
  1. Escape might be difficult (or embarrassing)
  2. Help may not be available in the event of having an unexpected Panic Attack or panic-like symptoms. Agoraphobic fears typically involve situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile. Note: Consider the diagnosis of Specific Phobia (e.g., avoidance limited to a single situation like elevators) if the avoidance is limited to one or only a few specific situations, or if the avoidance is limited to social situations.
• B. The person avoids these situations or places (e.g., restricting travel) or endures them with marked distress or with anxiety about having panic-like symptoms, or requires the presence of a companion in these situations or places.
• C. The anxiety or phobic avoidance is not better explained by another mental disorder, such as Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

• The person has Agoraphobia related to fear of experiencing panic-like symptoms (e.g., dizziness or diarrhea).
• The person has never met the criteria for Panic Disorder.
• The symptoms are not being caused by a general medical condition or by the use of substances, including medications.
• If the person does have a general medical condition, the fears clearly exceed those that usually accompany the medical condition.

A diagnosis of OCD does not require both obsessions and compulsions. Some people with OCD only have obsessions, some only compulsions.

Criteria for Obsessive-Compulsive Disorder:

A. The person has obsessions, compulsions or both:

Obsessions — the person must have all these:

1. Recurrent and persistent thoughts, impulses, or images that inappropriately intrude into awareness and cause marked anxiety or distress
2. These thoughts, impulses, or images are not simply excessive worries about real-life problems
3. The person tries to ignore or suppress these ideas, or to neutralize them with some other thought or behavior
4. The person recognizes that the obsessional ideas are a product of his or her own mind

Compulsions — the person must have all these:

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

B. At some point during the course of the disorder, the person realizes that the obsessions or compulsions are excessive or unreasonable.  Note: This does not apply to children. (If, for most of the time during the current episode the person does not recognize that the obsessions and compulsions are excessive or unreasonable, a specifier of poor insight is included.)

C. 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.

D. The obsessions or compulsions are not restricted to another disorder (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 Abuse Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).

E. The symptoms are not being caused by a general medical condition or by the use of substances, including medications.

Annual prevalence of Social Phobia in U.S. adults is around 6.8 percent. Women and men are equally likely to develop the disorder.

Criteria for Social Anxiety Disorder:

• 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 person fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: Children cannot receive this diagnosis unless they have demonstrated the capacity for age-appropriate social relationships with familiar people; 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 be a cued 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 feared social or performance situations are avoided or are 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 (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
• F. Individuals under age 18 must have these symptoms for at least 6 months.
• G. The fear or avoidance is not being caused by a general medical condition or by the use of substances (including medications), and is not better explained 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.
• H. If a general medical condition or another mental disorder is present, the phobia is unrelated to it (e.g., the fear is not of stuttering).

The diagnosis should specify whether the condition is generalized; i.e., the fears include most social situations. If generalized, the person should also be evaluated for Avoidant Personality Disorder.

Annual prevalence in U.S. adults is around 8.7 percent. Around 10 percent of all adults have suffered from a specific phobia at some point in their lives. Specific phobias are twice as common in women as men.

Criteria for Specific Phobia:

• A. 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).
• B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a cued 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 phobic situation(s) 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. Individuals under age 18 must have these symptoms for at least 6 months.
• G. The anxiety, panic attacks, or phobic avoidance associated with the specific object or situation are not better explained by another mental disorder, such as OCD , PTSD, Separation Anxiety Disorder (e.g., avoidance of school), Social Phobia, Panic Disorder with Agoraphobia or Agoraphobia Without History of Panic Disorder.

Specific Phobia Subtypes:

• Animal Type (e.g., spiders, snakes)
• Natural Environment Type (e.g., heights, storms, water)
• Blood-Injection-Injury Type (e.g., fear of blood, injuries, injections or other invasive medical procedures)
• 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)

GAD is diagnosed when a person worries excessively about a variety of everyday problems (practically everything) for at least 6 months. GAD affects about 3 to 5 percent (6.8 million) U.S. adults, and impacts twice as many women as men.

Criteria for Generalized Anxiety Disorder

• A. For more than half the days of at least 6 months, the person experiences excessive anxiety and worry about several events or activities.
• B. The person has trouble controlling the anxiety and worry, regaining control, relaxing, and coping.
• C. For more than half the days of the previous six months, 3 or more (1 for children) of the following symptoms are present:
  1. Feeling wound-up, edgy, tense, or restless
  2. Tiring easily
  3. Trouble concentrating
  4. Irritability
  5. Increased muscle tension
  6. Trouble sleeping (initial insomnia or restless, unrefreshing sleep)

PTSD affects nearly 8 million adults each year in the U.S., but it can occur at any age, including childhood. Women are more likely to develop PTSD than men, and older adults are less likely to develop symptoms than are younger ones.

Criteria for Posttraumatic Stress Disorder

• A. The person has experienced or witnessed a traumatic event which has both of these elements:
  1. The event involved actual or threatened death or serious physical injury to the person or others
  2. The person felt intense fear, helplessness, or horror. In children, this may be expressed by disorganized or agitated behavior.
• B. The person repeatedly relives the event in at least one (or more) of these ways:
  1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
  2. Repeated distressing dreams of the event. In children, these frightening dreams may not have recognizable content.
  3. Acting or feeling as if the traumatic event is recurring (a sense of reliving the experience) through illusions, hallucinations, and dissociative flashback episodes, including experiences that occur upon awakening or when intoxicated).
  4. Marked mental distress in reaction to internal or external cues that symbolize or resemble an aspect of the traumatic event.
  5. Physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event, such as rapid heartbeat, elevated blood pressure).
• C. The person repeatedly avoids the trauma-related stimuli and has numbing of general responsiveness (not present before the trauma), as shown by three (or more) of the following:
  1. Tries to avoid thoughts, feelings, or conversations associated with the trauma
  2. Tries to  avoid activities, places, or people that arouse recollections of the trauma
  3. Cannot recall an important aspect of the trauma
  4. Markedly diminished interest or participation in activities normally important to the person
  5. Feels detached or isolated from others
  6. Experiences restricted range of affect (e.g., unable to have loving feelings or other strong emotions for others)
  7. Sense of a foreshortened future, feels life will be brief or unfulfilled (e.g., does not expect to have a career, marriage, children, or a normal life span)
• D. The person has had at least two of the following symptoms of hyperarousal that were not present before the traumatic event:
  1. Difficulty falling or staying asleep
  2. Irritability or outbursts of anger
  3. Difficulty concentrating
  4. Hypervigilance or excessive vigilance
  5. Increased startle response
• E. The symptoms above have lasted longer than one month.
• F. These symptoms cause clinically significant distress or impairment in social, occupational, or other personal functioning.

Physiologically, many PTSD victims may report initially feeling numb, disoriented, or shocked. Unfortunately, a response that can be easily misinterpreted by others as either an inappropriate lack of feeling (why isn’t he upset about what happened?) or a lack of emotional impact (he’s such a strong person; maybe he just didn’t let it get to him). This physical and emotional numbing is often short-lived, followed by a flood of emotions including terror, rage, grief, and physiological arousal.

PTSD is considered to be acute if the symptoms last less than 3 months and chronic if they’ve lasted longer than 3 months. It’s not uncommon for PTSD to have a delayed onset; that is, the symptoms may not appear until 6 months after the traumatic event.

About half of all PTSD victims recover within a few months; others can experience years of incapacity. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.

Acute Stress Disorder begins during or immediately after a stressful event, and only lasts from two days to one month. The diagnostic criteria for Acute Stress Disorder include all the elements required for PTSD.

Criteria for Acute Stress Disorder:

• A. The person has been exposed to a traumatic event in which both of the following were present:
  1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
  2. The person’s response involved intense fear, helplessness, or horror
• B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
  1. Feelings of numbness, detachment, or absence of emotional responsiveness
  2. A reduction in awareness of his or her surroundings (e.g., “being in a daze”)
  3. Derealization
  4. Depersonalization
  5. Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
• C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
• D. The person strongly avoids stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
• E. The person has marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
• F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task, such as obtaining necessary legal or medical assistance or mobilizing personal resources by telling family members about the traumatic experience.
• G. The disturbance occurs within 4 weeks of the traumatic event and lasts for 2 days to 4 weeks.
• H. The symptoms are not being caused by a general medical condition or by the use of substances, including medications, and is not better explained by Brief Psychotic Disorder or other mental health disorders.