DSM5577 - SECTION 13: ADDRESSING THE COMPLEXITIES - ANXIETY DISORDERS
Section XIII: Addressing the Complexities - Anxiety Disorders
Statistic: Social phobia affects between 3-13% of the population (NIMH, 1998).
Anxiety disorders are another common class of disorders listed in the DSM-5. Anxiety can be described as set of somatic changes marked by physiological, emotional and cognitive changes in which there is increased worry, uneasiness, and apprehension, and elevated activity of the sympathetic nervous system.
All anxiety disorders include elements of excessive fear and intense worry. Fear is an emotional response to a person’s real or perceived threat that is imminent. Anxiety or excessive worry is present when the person believes that a threat or some type of harm will happen in the future with no specific details. In a 12-month period, 18.1% of US adults are diagnosed with anxiety (NIMH, 2005). The same report notes that women are 60% more likely to receive an anxiety diagnosis in their lifetimes.
The implementation of the DSM 5 resulted in significant changes. Several diagnoses which were previously grouped with anxiety disorders have been moved to other sections in the transition from the DSM-IV-TR to the DSM-5.
- Obsessive-compulsive disorder (Now grouped with Obsessive-Compulsive and Related disorders)
- Post-traumatic stress disorder (Now grouped with Trauma- and Stressor- Related disorders)
- Acute stress disorder (Now grouped with Trauma- and Stressor- Related disorders)
The anxiety disorders of the DSM 5 are:
Separation Anxiety Disorder F93.0
Selective mutism F94.0
Social Anxiety Disorder F40.10
Panic Disorder F41.0
General Anxiety Disorder F41.1
Substance Medication-Induced Anxiety*
*Specific codes correlate with related drug or substance
(See p.227 in DSM 5 for ICD-10 codes)
Anxiety Disorder due to Another Medical Condition F06.44
Other Specified Anxiety Disorder F41.8
Unspecified Anxiety Disorder F41.9
Panic attacks are not coded because a panic attack is not a mental disorder. Panic attacks can occur along with any mental health disorder and are not limited to anxiety disorders. A panic attack can be listed as a specifier for all DSM 5 diagnoses.
There are many culture-related issues that may appear to be a panic attack. A list of many of the recognized culture related issues that clinicians can refer to (rather than assuming a panic attack) is found on page 216 of the DSM 5 (APA, 2013). Become familiar with this list to insure that accepted cultural behaviors are not labeled incorrectly as panic attacks.
Unexpected panic attacks have no defined precipitant – that is, no situation which triggers the attack. Situationally-bound panic attacks happen immediately each time the individual is exposed to the panic-creating situation. Situationally-predisposed panic attacks often occur after being in a situation, with the attacks not necessarily occurring in the situation. Several of the most common disorders will be described in more detail. Again, it is important to refer to the DSM to study the criteria and to be fully aware of the intricacies and details of the different diagnoses. (APA, 2013)
In diagnosing anxiety disorders, it is important to realize that people often complain of general anxiety first. It is helpful in diagnosing the anxiety further to ask whether the patient has experienced any of the symptoms of panic attacks. Often people are unaware of the panic attack criteria or label, and thus they do not initially state that they have had a panic attack.
Panic Disorder and Agoraphobia are now unlinked. They are two separate disorders (see above). The ‘generalized’ specifier for Social Anxiety Disorder has been replaced with the ‘performance only’ specifier.
Specific Phobias are usually related to a specific object or activity (e.g., flying, spiders or any other animal, getting a shot). Avoiding that object or behavior, excessive worry or anxiety when thinking about the object or activity or excessive fear indicates a phobia. A phobia is not explained by any other medical or mental health concern. There are five subtypes: Animal, Natural Environment, Situational, Blood-Injection-Injury, and Other (APA, 2013). The most common of these is the Situational Type, which includes fear of flying, fear of heights, etc.
Separation Anxiety Disorder must last for a minimum of four weeks in children and adolescence younger than age 18. For adults, the symptoms of fear or separation from attachment figures or the security or home must last longer than six months. The fear and/or anxiety needed for this diagnosis must exceed the normal expectations for the developmental level of the client. Consistent worries or fears about loss of the relationship and/or attachment that are not reasonable given the actual circumstances may lead to this diagnosis.
Social Anxiety Disorder is very different as it relates to the client’s serious and consistent fear of social situations where scrutiny, judgment or rejection is feared by the client. Persons with social anxiety disorder will isolate themselves and avoid the company of others (acquaintances or strangers) because they fear embarrassment, humiliation or rejection by another. The simple avoidance of any of these perceived circumstances creates fear and/or anxiety. The level of intensity of the social anxiety is usually out of proportion to the actual event or interaction. There is no connection to the physiological reaction to any substance. Any possible medical condition should be ruled out before this diagnosis is given.
Panic Disorder diagnosis is used when the person reports repeated, and unexpected, panic attacks that are not related to any medical condition. These recurrent ‘energy’ surges can feel like a sudden heart attack and the client may report any combination of the symptoms listed below on page 208 of the DSM 5 (APA, 2013).
- Palpitation, pounding heart or accelerated heart rate.
- Trembling or shaking.
- Sensation of shortness of breath or smothering.
- Feelings of choking.
- Chest pain or discomfort.
- Nausea or abdominal distress.
- Feeling dizzy, unsteady, light-headed or faint.
- Chills or heat sensations.
- Paresthesias (numbness or tingling sensations).
- Derealization (thoughts of unreality) or depersonalization (being detached from oneself).
- Fear of losing control or “going crazy”.
- Fear of dying.
Education is important as many of the above symptoms occur during a heart attack. Persons will often seek immediate medical attention when having a panic attack for fear of a heart attack. Education that assist clients in learning to self-soothe (such as deep breathing and visualization) will help them to manage panic attacks rather than seeking medical attention that is not needed.
The median age for onset of panic disorder in the US is early twenties (20-24). It is a diagnosis that comes and goes, and can become chronic is untreated. This diagnosis is rare in children and panic disorder in older adults is usually related to specific stressful events, often related to health concerns. Any medical condition must be ruled out before the diagnosis of panic disorder is used.