Chapter 5
Anxiety Disorders

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).

Major Changes From DSM-IV-TR to DSM-5

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.

Differential Diagnosis

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).

Etiology and Treatment

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).

Implications for Counselors

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.

309.21 Separation Anxiety Disorder (F93.0)

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).

Essential Features

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.

Special Considerations

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).

Cultural Considerations

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.

Differential Diagnosis

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).

Coding, Recording, and Specifiers

There is only one diagnostic code for separation anxiety disorder: 309.21(F93.0). There are no specifiers for this diagnosis.

313.23 Selective Mutism (F94.0)

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).

Essential Features

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).

Special Considerations

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 Considerations

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.

Differential Diagnosis

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).

Coding, Recording, and Specifiers

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.

300.29 Specific Phobia (F40._ _ _)

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).

Essential Features

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).

Special Considerations

Physiological arousal responses resulting from specific phobia may include feeling faint, accelerated heart rate and blood pressure, and hyperarousal. Quality of life is negatively affected, and impairment in overall functioning is common. Early intervention is key because the recovery rate for specific phobia in children has been shown to be as high as 60% after CBT (Mohr & Schneider, 2013).

Cultural Considerations

It is important to take sociocultural context into account when assessing specific phobia because in some contexts fear of a stimulus is real and proportionate (e.g., being bitten by a poisonous snake in certain geographic locations). African Americans have the highest lifetime prevalence of specific phobia, with Caucasians ranking second among ethnic groups within the United States (Marques et al., 2011). Generally, Asians and Latinos possess overall lower rates of specific phobia than other groups (Marques et al., 2011).

Differential Diagnosis

When considering whether to diagnose a specific phobia, counselors are wise to consider the degree to which the fear and response to the fear are consistent with one's developmental level and cultural context. This diagnosis should not be made if the fear is seen as culturally appropriate. Similarly, counselors must consider the degree of distress and impairment associated with the phobia. Common differential diagnoses for specific phobia include agoraphobia, social anxiety disorder, separation anxiety disorder, panic disorder, OCD, trauma and stressor-related disorders, eating disorders, and schizophrenia spectrum and other psychotic disorders. Agoraphobia has many fears that overlap with specific phobias. The counselor should diagnose agoraphobia when more than one condition/situation is feared. Social anxiety disorder should be diagnosed instead of specific phobia when social situations are the cause of the fear. Panic attacks can occur in conjunction with specific phobia; however, the diagnosis of panic disorder would supersede the diagnosis of specific phobia if the attacks are unexpected. A diagnosis of specific phobia would not be given if the fear results from delusional thought processes such as those disorders in the schizophrenia spectrum and other psychotic disorders (APA, 2013a).

Coding, Recording, and Specifiers

There is one ICD-9-CM diagnostic code for specific phobia: 300.29. Counselors using the ICD-10-CM will assign the appropriate diagnostic code based on the phobia specifier. These specifiers for specific phobia include animal, natural environment, blood-injection injury, situational, and other. Blood-injection injury includes four subtypes: fear of blood, fear of injections and transfusions, fear of other medical care, and fear of injury. If more than one specific phobia is present, the counselor codes all of those present using the ICD-10-CM diagnostic codes. Approximately 75% of individuals diagnosed with specific phobia fear more than one object. When this occurs, more than one diagnosis is given. The following is a complete list of codes and specifiers for specific phobia.

300.29 (F40.218)	Animal
300.29 (F40.228)	Natural environment
300.29 (F40.23x)	Blood-injection injury
F40.230	Fear of blood
F40.231	Fear of injections and transfusions
F40.232	Fear of other medical care
F40.233	Fear of injury
300.29 (F40.248)	Situational (e.g., airplanes, elevators, enclosed places)
300.29 (F40.298)	Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or costumed characters)

In cases in which individuals experience panic attacks in response to their phobia, counselors should add with panic attacks to the diagnosis.

300.23 Social Anxiety Disorder (Social Phobia) (F40.10)

I was so relieved when I was told I could work from home. Even though my job is working on computer programs, the anxiety around interacting with the people in the other cubes was overwhelming. I don't think they liked me anyway because I always said the wrong things. I thought my boss was going to fire me because I had such a hard time going into work, but I am good at my job so she made this arrangement. My family members seem concerned though because I almost never leave my house. —Ryan

Social phobia was originally classified as a mental disorder in the DSM-III and has been renamed social anxiety disorder in the DSM-5. It is one of the most common mental disorders with a lifetime prevalence rate of slightly greater than 10%; the majority of diagnoses are made during childhood or early adolescence (Kerns, Comer, Pincus, & Hofmann, 2013; Marques et al., 2011). Social anxiety disorder is often seen in conjunction with MDD, other anxiety disorder, and substance use disorder (APA, 2013a).

Essential Features

The main feature of social anxiety disorder is ongoing fear and worry surrounding myriad social situations (Kerns et al., 2013). Individuals with social anxiety disorder often fear negative evaluation (e.g., being humiliated, embarrassed, or rejected) by others (either unfamiliar or familiar) in performance, interaction, or observation situations. A performance only specifier has been added for social anxiety disorder in the DSM-5 and includes a minimum duration of 6 months. Children, adolescents, and adults now share the same criteria for duration, and the criterion for adult insight has been dropped (Mohr & Schneider, 2013).

Special Considerations

Women tend to be diagnosed with social anxiety disorder more often than men, but both genders experience lifelong consequences from the symptoms. Individuals with social anxiety disorder tend to never marry or have children. They often drop out of school, have difficulties maintaining continuous employment, and experience low socioeconomic status. Although individuals with this disorder tend to seek mental health care after suffering for 15 to 20 years, being unemployed is frequently a trigger for initiating treatment (APA, 2013a).

Cultural Considerations

Across cultural demographics, social anxiety disorder is highest among Caucasian and Native American adults; however, studies have shown it to also be high among Latino and Caucasian youth (Marques et al., 2011; Martinez, Polo, & Carter, 2012). In an article examining Asian cultural constructs, Hsu et al. (2012) posited that reticence and social restraint may appear as social anxiety when, in fact, they are normalized behaviors in Asian culture. As such, it is important for counselors to carefully assess social constructs in diagnosing social anxiety disorder.

Differential Diagnosis

Common differential diagnoses of social anxiety disorder are normative shyness, agoraphobia, panic disorder, GAD, separation anxiety disorder, specific phobias, selective mutism, MDD, body dysmorphic disorder (BDD), delusional disorder, autism spectrum disorder (ASD), personality disorder, and ODD. It is important to note that shyness is viewed as a personality trait and is not pathological in nature; a diagnosis of social anxiety disorder is unwarranted unless there is impairment in functioning. Individuals with social anxiety disorder are fearful of negative evaluation from others; they are not fearful of nor do they worry about separation from loved ones as seen in separation anxiety disorder. Conversely, individuals with specific phobias do not typically worry about being judged in social situations.

Selective mutism is differentiated from social anxiety disorder in that individuals diagnosed with selective mutism are not fearful in social situations where they are not required to speak. For individuals with BDD, fear and avoidance are specifically caused by thoughts about their own appearance. In contrast to individuals diagnosed with ASD, individuals with social anxiety disorder display capacity for age-appropriate interactions and social relationships; however, they avoid them or endure them with intense distress.

Finally, individuals with MDD, personality disorder, and ODD typically are not worried about negative social evaluations. A key differentiating feature of individuals with social anxiety disorder from those with delusional disorder is that individuals diagnosed with social anxiety disorder typically display insight into the disproportionate fear or worry they have in social situations (APA, 2013a).

Coding, Recording, and Specifiers

There is only one diagnostic code for social anxiety disorder: 300.23 (F40.10). Social anxiety disorder has a performance only specifier, which is given if anxiety is specific to speaking or performing in public. Individuals diagnosed with the performance only specifier are mainly impaired in their occupational environments or in school situations where public speaking is a requirement. These individuals are not afraid of and do not avoid other social situations. If individuals experience panic attacks in conjunction with social anxiety disorder, the specifier with panic attacks should be added to the diagnosis.

Case Example

Adam is an 11-year-old fifth grader who is the fourth out of seven children born into an Orthodox Jewish family. Adam is one of five boys in his family. His father is loving and attentive but also works a lot; Adam's mother does most of the hands-on parenting. At home, Adam is quiet and serious but takes time to read to his younger siblings and occasionally plays outside with his brothers. At school, Adam stays by himself and rarely interacts with his classmates. Adam will make excuses to stay in the classroom during recess (such as wanting extra time to study) and prefers to study after school in lieu of extracurricular activities.

Adam is a quiet, serious child who obeys the rules and rarely displays upset emotions or anger. Adam's mom is busy raising seven children and is grateful that Adam has no disciplinary issues and performs well academically. She does not see a problem with his behaviors. His teacher has referred Adam to the school counselor because of his reluctance to work on any group projects or engage with peers. Adam tells his counselor that he has no friends other than his siblings and that he doesn't want any. Adam says that he enjoys studying and playing games with his brothers but “doesn't have time for friends.” Upon questioning, Adam discloses that he has never had any peer friendships and gets nervous in most all situations outside of his home. Unlike his siblings, he does not look forward to religious services although he enjoys his religious studies. Adam generally avoids social interactions and is afraid to travel outside of his hometown. He reports feeling sick to his stomach when his routine changes. At home, although quieter than his brothers, Adam laughs, jokes, and interacts with all of his siblings. He tells his counselor that he would like to have one or two close friends to hang out with but also is “fine” the way things are.

Adam's presenting symptoms include worry that he will embarrass himself, freezing in unfamiliar situations, avoidance of social situations, and emotional distress outside of his home environment. These feelings and behaviors have been extant since he began elementary school and have increased in severity over the course of the past year.

Diagnostic Questions

1. Do Adam's presenting symptoms meet the criteria for an anxiety disorder? If so, which one?
2. Based on the disorder identified in Question 1, which symptom(s) led you to select the diagnosis?
3. What would be the reason(s) a counselor may not diagnose Adam with GAD?
4. Would Adam be more accurately diagnosed with ASD? Why or why not?
5. What rule-outs would you consider for Adam's case?
6. What other information may be needed to make an accurate clinical diagnosis?

300.01 Panic Disorder (F41.0)

I never knew when it was going to hit me, and that made it even worse. My heart would start pounding, my hands shook, and I would start sweating. I couldn't breathe. I felt like the world was going to end and I was going to die at any moment. I felt like I was going crazy. —Mabel

Panic disorder is defined as recurrent, unexpected panic attacks and was initially classified in the DSM-III. There is a median age of onset ranging from 20 to 24 years, with a small percentage of individuals first diagnosed in childhood. Panic disorder is not usually first seen in individuals over the age of 45. There is an annual U.S. prevalence rate of 2.1% to 2.8%; this is one of the highest prevalence rates worldwide (Marques et al., 2011).

Essential Features

The essential features of panic disorder are persistent fear or concern of inappropriate fear responses, with recurrent and unexpected panic attacks including physiological changes, such as accelerated heart rate, sweating, dizziness, trembling, and chest pain. Worry and behavioral changes may also accompany the diagnosis. Panic disorder has physical and cognitive symptoms and involves numerous, unexpected panic attacks (although it is important to note that individuals with panic disorder can have expected panic attacks too). Worry typically focuses on physical symptoms or concern regarding mental functioning such as losing control (APA, 2013a).

Special Considerations

Up to 50% of individuals diagnosed with panic disorder will have nocturnal panic attacks or waking up in a “state of panic” (APA, 2013a, p. 210). Childhood abuse (sexual and physical) is a risk factor, and there is scientific evidence of genetic predisposition, with women being more likely to receive the diagnosis of panic disorder than men.

Cultural Considerations

Individuals with panic disorder display specific variations in physical symptoms based on cultural contexts (Marques et al., 2011). Cultural expectations can lead to the experience of panic attack such as ataque de nervios (“attack of nerves”; see Glossary of Cultural Concepts of Distress Appendix in the DSM-5, p. 833) in Latin Americans that involves trembling, screaming, crying, aggression, depersonalization, and possible suicidal behavior. African American and Afro-Caribbean groups generally have lower rates of panic disorder. Fears related to the symptoms of panic disorder vary across cultures. Although Caucasians have a higher prevalence rate of panic disorder, they typically have less functional impairment than African Americans; this highlights the need for counselors to carefully assess severity with African American clients (APA, 2013a).

Differential Diagnosis

By themselves, panic attacks are not a diagnosable condition; a diagnosis of panic disorder is only made if one's response to unexpected panic attacks includes persistent worry or behavioral changes associated with the attacks. Common differential diagnoses for panic disorder are other specified or unspecified anxiety disorder, anxiety disorder due to another medical condition, substance/medication-induced anxiety disorder, and other mental disorders with panic attacks as an associated feature. Illness anxiety disorder, formerly known as hypochondriasis, often shares features with or is comorbid with panic disorder (Starcevic, 2013). It is the unexpected nature of the panic attacks that makes panic disorder distinct from panic attacks occurring within the context of another anxiety disorder. If an unexpected panic attack has not occurred, the diagnosis of panic disorder is not appropriate and is also not diagnosed if the panic attack results from a medical condition or utilization of a substance (APA, 2013a).

Coding, Recording, and Specifiers

There is only one diagnostic code for panic disorder: 300.01(F41.0). However, there is extensive information about the one specifier, panic attack. See the next section regarding the panic attack specifier. Note that the panic attack specifier is not a mental disorder and is not assigned a diagnostic code.

Panic Attack Specifier

Panic attacks are not classified as a mental disorder and do not have a diagnostic code. Panic attacks are abrupt surges of intense fear; they can occur with mental disorders such as depressive and anxiety disorders and also be extant with physical disorders. Panic attack is a specifier for both mental and physical disorders; however, the elements of panic attack are contained within the criteria for panic disorder so it is not a specifier for that diagnosis. An example of panic attack used as a specifier is social anxiety disorder, with panic attacks (APA, 2013a).

Essential Features

Panic attacks represent intense fear or discomfort that occurs abruptly and peaks rapidly. Physical symptoms predominate and must include a minimum of four out of the 13 identified symptoms. These mostly physical symptoms occur and reach their zenith within minutes. Panic attacks have an 11.2% annual prevalence rate in the general U.S. population (APA, 2013a). See page 214 of the DSM-5 for a list of physical symptoms.

Special Considerations

The rapid time to reach peak intensity distinguishes panic attacks from general or ongoing anxiety. Panic attacks are associated with higher rates of suicidal ideation and attempts. As such, individuals presenting with panic attacks should be carefully screened for suicide risk. Panic attacks are rare in young children and occur more frequently in women than men (APA, 2013a).

Cultural Considerations

There are culturally distinct symptoms that do not count toward four of the 13 symptoms needed for use of the panic attack specifier. Cultural context can also lend to the difference between expected and unexpected panic attacks and may also cause fear of specific situations. The DSM-5 includes an Appendix titled the “Glossary of Cultural Concepts of Distress” that provides specific information about the cultural syndromes (APA, 2013a).

Differential Diagnosis

Common differential diagnoses for the panic attack specifier include other paroxysmal episodes, anxiety disorder due to another medical condition, and substance/medication-induced anxiety disorder. For appropriate application of the panic attack specifier, abrupt surges of intense fear or discomfort must occur in the individual. This distinguishes panic attack from emotional reactions such as grief or anger. Multiple medical conditions, as well as myriad substance intoxication and withdrawal, can cause panic attacks. If the age of onset for panic attacks is older than 45 years or if there are unusual symptoms occurring during the panic attack, it is important to carefully consider the possibility of the panic attack being caused by a medical condition or substance use (APA, 2013a).

300.22 Agoraphobia (F40.00)

I didn't leave my condo for 2 weeks. I even arranged to have my groceries delivered. The fear has been bad for years, but that was the worst. Obviously, I lost my job. But I was certain that if I went out, something awful would happen. —Devin

Agoraphobia is a newly codable disorder in the DSM-5 and represents an intense fear that results from real or imagined exposure to a wide range of situations. There is a 1.7% prevalence rate for the diagnosis of agoraphobia for adolescents and middle-age adults; it is less prevalent in young children and older adults (0.4%; APA, 2013a). Agoraphobia leads to moderate to severe impairment in functioning, with more than 33% of individuals diagnosed with agoraphobia restricted to home environments (APA, 2013a).

Essential Features

Agoraphobia represents fear of situations in which escape from bad things is difficult. The fear may fluctuate depending on exposure to the event; it may also result from anticipation of an event. This response happens almost every time an individual is exposed to the situation or event (it is not agoraphobia if the response occurs only some of the time). Avoidance of the event or situation must also be present and can include cognitive or behavioral aspects (APA, 2013a).

Special Considerations

A diagnosis of agoraphobia is given regardless of whether the individual meets the criteria for panic disorder. If criteria for both conditions are met, both diagnoses are given. It is important to note that agoraphobia can impair functioning to the level that an individual becomes homebound. The mean age of onset of agoraphobia is 17 years, and onset during childhood is rare. Females are twice as likely to be diagnosed with agoraphobia than males. Most people who are given the diagnosis of agoraphobia have comorbid mental disorders, including a higher likelihood of other anxiety disorders (APA, 2013a).

Cultural Considerations

There is a need for research focusing on the cultural considerations of agoraphobia. The DSM-5 does not include cultural information specific to the diagnosis.

Differential Diagnosis

Common differential diagnoses for agoraphobia include the following: specific phobia, situational type, separation anxiety disorder, social anxiety disorder, panic disorder, acute stress disorder, PTSD, MDD, and other medical conditions. A diagnosis of agoraphobia can be given in conjunction with that of another disorder if the criteria for both are met unless the fears result from the sequelae of another disorder. MDD can leave an individual homebound, but this is predominantly from apathy or anhedonia. One of the main challenges is differentiating agoraphobia from specific phobia. Acute stress disorder and PTSD can be distinguished from agoraphobia in that the avoidance occurs only from situations that trigger a memory of the traumatic event, such as a driving or riding in a car after a motor vehicle accident (APA, 2013a).

Coding, Recording, and Specifiers

There is only one diagnostic code for agoraphobia: 300.22 (F40.00). The specifier with panic attacks may be added if individuals experience panic attacks associated with agoraphobia.

Case Example

Daryl is a 40-year-old Native American woman of Navajo descent and a married mother of two teenage sons. During the course of her 19-year marriage, she has rarely worked outside of the home. During the past 5 years, Daryl has gradually given up engaging in most of the leisure and social activities she previously enjoyed, such as painting, making pottery, and attending concerts. She has developed feelings of worry about many bad things happening to her if she leaves her home, including car accidents, robbery, becoming lost, and falling ill. These feelings have increased in intensity and frequency over the course of the past 13 months. Daryl has relied on her husband and children to purchase groceries and household necessities. She no longer paints and has not used her outdoor pottery kiln, a lifelong hobby and a source of income, in over a year. Although she regularly engages in yard work, she no longer receives the enjoyment from it she previously did.

Daryl's husband is worried about her, and her relationships with her sons have suffered because she no longer attends their extracurricular events. Despite repeated attempts at various relaxation and calming techniques, Daryl cannot force herself to reengage in any of these activities.

Daryl reports that she fears situations that include being outside of her home or yard, being in a crowd, standing in a line, crossing a bridge, and driving or riding in a car. Daryl has no prior history of panic attacks or previous trauma.

Diagnostic Questions

1. Do Daryl's presenting symptoms meet the criteria for an anxiety disorder? If so, which one?
2. Based on the disorder identified in Question 1, which symptom(s) led you to select the diagnosis?
3. What would be the reason(s) a counselor may not diagnose Daryl with GAD?
4. Would Daryl be more accurately diagnosed with a depressive disorder? Why or why not?
5. What rule-outs would you consider for Daryl's case?
6. What other information may be needed to make an accurate clinical diagnosis?

300.02 Generalized Anxiety Disorder (F41.1)

I constantly felt tense and jumpy. For months I lived with excessive worry and fears that something was wrong or something bad was going to happen. My friends described me as high-strung. I just wished I could sleep through the night. —Trey

Generalized anxiety disorder (GAD), in existence since the DSM-III, is one of the most common of all mental disorders with an annual prevalence rate of 2.9% among adults in the United States (APA, 2013a; J. S. Comer, Pincus, & Hoffman, 2012). Excessive worry or anxiety about a number of events is the key feature of GAD, with the experience of the anxiety or worry in discord with the actual or expected event.

Essential Features

Although the DSM-5 Task Force proposed changes to GAD that would have resulted in a lowered diagnostic threshold, this disorder remains largely unchanged from the DSM-IV-TR. Essential features include anxiety or worry that takes place across a number of settings and more days than not for at least 6 months. The individual finds it difficult to control the worry and experiences at least three characteristic symptoms, including restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, muscle tension, irritability, and sleep disturbance (APA, 2013a).

Special Considerations

The predominant symptom of GAD is pathological worry. What distinguishes GAD from nonclinical levels of anxiety are the intensity of the worry and its resultant impairment in functioning. These worries can be consuming, marked, and cause considerable concern to the individual suffering from them. Physical and somatic symptoms often accompany GAD; these include muscle tension, sweating, nausea, diarrhea, accelerated heart rate, and dizziness. As with other disorders enumerated in this chapter, women are more likely than men to receive the diagnosis (Friborg et al., 2013).

Cultural Considerations

Cultural considerations include previous exposure to traumatic events occurring environmentally or geographically. In the United States, GAD is highest among Caucasian and Native American populations; it is most notable in younger individuals. Asian, Latino/a, African, and Caribbean Black populations have lower rates of GAD (Marques et al., 2011). Although it may manifest differently, the overall worry and anxiousness associated with GAD is extant across all cultures.

Differential Diagnosis

Common differential diagnoses for GAD are anxiety disorder due to another medical condition, substance/medication-induced anxiety disorder, social anxiety disorder, OCD, PTSD, adjustment disorders, and depressive, bipolar, and psychotic disorders. The clear distinction between GAD and anxiety disorder due to another medical condition is that the substance must be etiologically related to the anxiety. Those with GAD have diffuse worry that focuses on events that have yet to happen; this separates individuals with GAD from individuals living with social anxiety disorder, PTSD, OCD, and adjustment disorders. Adjustment disorders also do not persist for 6 months or more beyond the termination of the stressor or its consequences. If inordinate worry occurs only during the course of depressive, bipolar, and psychotic disorders, GAD should not be diagnosed (APA, 2013a).

Owing to lack of specificity in the criteria, differential diagnosis can be a challenge. Many of the anxiety disorders outlined in this chapter, along with OCD, PTSD, adjustment disorders, depressive disorders, and psychotic disorders possess, similar features to GAD. It is likely that individuals with GAD have, have had, or will develop other anxiety or depressive disorders (APA, 2013a).

Coding, Recording, and Specifiers

There is only one diagnostic code for GAD: 300.02 (F41.1). There are no specifiers for this diagnosis, although counselors may choose to use the with panic attacks specifier if appropriate.

Case Example

Jean is a 65-year-old African American divorced mother and grandmother. She has a successful career in real estate and enjoys good physical health. Throughout her childhood and adulthood, Jean has been characterized as a nervous and high-strung person. She typically worries excessively about all aspects of her life and often lets her fear of the worst keep her from enjoying activities. Jean is very good at putting on a “game face” and masking her anxiety with humor and good cheer. However, Jean's fear and worry keep her from traveling to family reunions and impede her ability to relax.

Over the past year, Jean's worries have increased in intensity and frequency. She has been canceling appointments on occasion in order to “not have to deal with the stress.” Never one to drink much alcohol, Jean will have a glass of wine before bed several times a week to “take the edge off.” She has also experienced some physical symptoms, such as difficulty falling asleep, needing to urinate frequently, and muscle tension.

Jean's emotional symptoms include worrying about many things, having difficulty concentrating, and being irritable, and these symptoms occur multiple times daily. She tires easily and sometimes feels so overwhelmed she does not want to get out of bed. Jean states she has trouble stopping her worrisome thoughts and reports that her family is concerned about her and has encouraged her to see a counselor. Although Jean would like to feel better, she expressed doubt that counseling could be helpful and believes this is just the “way she is.” Jean has been treated for depression in the past and reports that she doesn't feel “depressed” now.

Diagnostic Questions

1. Do Jean's presenting symptoms meet the criteria for an anxiety disorder? If so, which one?
2. Based on the disorder identified in Question 1, which symptom(s) led you to select the diagnosis?
3. What would be the reason(s) a counselor may not diagnose Jean with agoraphobia?
4. Would Jean be more accurately diagnosed with a depressive disorder? Why or why not?
5. What rule-outs would you consider for Jean's case?
6. What other information may be needed to make an accurate clinical diagnosis?

Substance/Medication-Induced Anxiety Disorder

Anxiety caused by substance use is the primary criterion for the diagnosis of substance/medication-induced anxiety disorder. Panic or anxiety must have developed during or soon after substance/medication usage and be in excess of what would be expected to be associated with intoxication or withdrawal from that specific substance. Prevalence rates for this disorder are reportedly low (0.002%), although it is difficult to assess accurate rates because of diagnostic challenges in differentiating it from other anxiety or substance disorders. It is important for counselors to tease out substances used to self-medicate anxious symptoms with anxiety resulting from substance use or withdrawal (APA, 2013a).

Essential Features

Essential features of substance/medication-induced anxiety disorder are that the symptoms occur during intoxication, during withdrawal, or after medication use. The anxiety must be severe enough to cause a need for clinical intervention.

Special Considerations

Laboratory tests can be helpful in assessing substance/medication-induced anxiety disorder (e.g., urinalysis). There are a number of medications that can cause symptoms of anxiety. These include, but are not limited to, antidepressant medications, antihypertensive and cardiovascular medications, corticosteroids, anticonvulsants, antihistamines, oral contraceptives, insulin, and bronchodilators. Counselors are responsible for consulting with physicians to determine whether an anxiety disorder may be physiologically caused by use of a substance or medication.

Differential Diagnosis

Common differential diagnoses for substance/medication-induced anxiety disorder include substance intoxication and substance withdrawal, anxiety disorder not induced by a substance/medication, delirium, and anxiety disorder due to another general medical condition. A diagnosis of substance/medication-induced anxiety disorder is only used when anxiety symptoms are predominant. If panic or anxiety symptoms occur exclusively during the course of delirium, they are not separately addressed.

Coding, Recording, and Specifiers

The extensive coding chart for substance/medication-induced anxiety disorder can be found on page 227 of the DSM-5. When using this chart, counselors will notice specifiers for substance/medication-induced anxiety disorder, including with onset during intoxication, with onset during withdrawal, and with onset after medication use, with severity indicators of accompanying substance use disorder. Again, counselors may use the with panic attacks specifier at their discretion. The specifier follows the name of the disorder. The ICD-9-CM uses a separate diagnostic code for substance use disorder and substance/medication-induced anxiety disorder when a substance use disorder is comorbid. An example of ICD-9-CM coding is 292.89 opioid-induced anxiety disorder, with onset during intoxication. The same example with ICD-10-CM coding is F11.188 mild opioid use disorder with opioid-induced anxiety disorder with onset during intoxication. A second diagnosis of F11.10 opioid use disorder, mild, is also given.

293.84 Anxiety Disorder Due to Another Medical Condition (F06.4)

Medical conditions can cause the development of an anxiety disorder, but they must cause clinically significant distress. APA (2013a, p. 231) reports “unclear” prevalence rates of anxiety disorder due to another medical condition because of the extreme difficulty with differential diagnosis for this category. It is especially important for counselors to carefully rule out differential diagnoses and consult with a physician before using the diagnosis of anxiety disorder due to another medical condition.

Essential Features

Marked anxiety attacks occur and can be directly attributed to an existing medical condition. The development of the anxiety can parallel the course of the illness. Examples of medical conditions that cause anxiety disorder due to another medical condition include endocrine disease, cardiovascular disorders, respiratory illness, metabolic disturbance, and neurological illness (APA, 2013a).

Special Considerations

Because prevalence rates are not clear for this disorder, it is important to track the course of the illness to be able to chart the concomitant course of the anxiety. This is a key consideration within the older adult community because older adults often experience chronic illnesses. Counselors also need to be aware of the possibility of the development of anxiety disorder not related to physical illness.

Differential Diagnosis

Common differential diagnoses are substance intoxication, substance withdrawal, delirium, anxiety disorder due to another medical condition, and adjustment disorders. Anxiety symptoms, such as panic, must be predominant and demand separate clinical assessment. It is important for counselors to rule out the existence of anxiety disorders that have developed during the course of a medical condition but are not resultant from direct effects of the medical condition. Anxiety that occurs during the course of a delirium does not qualify the individual for the diagnosis of anxiety disorder due to another medical condition. The key to discerning anxiety disorder due to another medical condition is that the anxiety symptoms must be attributed to the physiological effects of the medical condition (APA, 2013a).

Coding, Recording, and Specifiers

There is only one diagnostic code for anxiety disorder due to another medical condition: 293.84 (F06.4). Although counselors may specify with panic attacks, there are no other specifiers for this diagnosis.

Other Specified and Unspecified Anxiety Disorders

The other specified anxiety disorder and the unspecified anxiety disorder categories in the DSM-5 replace the NOS category of the DSM-IV-TR. The other specified anxiety disorder, 300.09 (F41.8),

applies to presentations in which symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the anxiety disorder diagnostic class. The other specified anxiety disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific anxiety disorder (e.g., “generalized anxiety not occurring more days than not”). (APA, 2013a, p. 233)

The unspecified anxiety disorder code, 300.00 (F41.9),

is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific anxiety disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings). (APA, 2013a, p. 233)