Anxiety disorder due to another medical condition. Panic disorder is not diagnosed if the panic attacks are judged to be a direct physiological consequence of another medical condition. Examples of medical conditions that can cause panic attacks include hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders, and cardiopulmonary conditions (e.g., arrhythmias, supraventricular tachycardia, asthma, chronic obstructive pulmonary disease [COPD])5. Appropriate laboratory tests (e.g., serum calcium levels for hyperparathyroidism; Holter monitor for arrhythmias) or physical examinations (e.g., for cardiac conditions) may be helpful in determining the etiological role of another medical condition.
Substance/medication-induced anxiety disorder. Panic disorder is not diagnosed if the panic attacks are judged to be a direct physiological consequence of a substance. Intoxication with central nervous system stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis and withdrawal from central nervous system depressants (e.g., alcohol, barbiturates) can precipitate a panic attack. However, if panic attacks continue to occur outside of the context of substance use (e.g., long after the effects of intoxication or withdrawal have ended), a diagnosis of panic disorder should be considered. In addition, because panic disorder may precede substance use in some individuals and may be associated with increased substance use, especially for purposes of self-medication, a detailed history should be taken to determine if the individual had panic attacks prior to excessive substance use. If this is the case, a diagnosis of panic disorder should be considered in addition to a diagnosis of substance use disorder. Features such as onset after age 45 years or the presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness, loss of bladder or bowel control, slurred speech, amnesia) suggest the possibility that another medical condition or a substance may be causing the panic attack symptoms.
Other mental disorders with panic attacks as an associated feature (e.g., other anxiety disorders and psychotic disorders). Panic attacks that occur as a symptom of other anxiety disorders are expected (e.g., triggered by social situations in social anxiety disorder, by phobic objects or situations in specific phobia or agoraphobia, by worry in generalized anxiety disorder, by separation from home or attachment figures in separation anxiety disorder) and thus would not meet criteria for panic disorder. (Note: Sometimes an unexpected panic attack is associated with the onset of another anxiety disorder, but then the attacks become expected, whereas panic disorder is characterized by recurrent unexpected panic attacks.) If the panic attacks occur only in response to specific triggers, then only the relevant anxiety disorder is assigned. However, if the individual experiences unexpected panic attacks as well and shows persistent concern and worry or behavioral change because of the attacks, then an additional diagnosis of panic disorder should be considered.
Panic disorder infrequently occurs in clinical settings in the absence of other psychopathology. The prevalence of panic disorder is elevated in individuals with other disorders, particularly other anxiety disorders (and especially agoraphobia), major depression, bipolar disorder, and possibly mild alcohol use disorder11. While panic disorder often has an earlier age at onset than the comorbid disorder(s), onset sometimes occurs after the comorbid disorder and may be seen as a severity marker of the comorbid illness.
Reported lifetime rates of comorbidity between major depressive disorder and panic disorder vary widely, ranging from 10% to 65% in individuals with panic disorder. In approximately one-third of individuals with both disorders, the depression precedes the onset of panic disorder. In the remaining two-thirds, depression occurs coincident with or following the onset of panic disorder. A subset of individuals with panic disorder develop a substance-related disorder, which for some represents an attempt to treat their anxiety with alcohol or medications23. Comorbidity with other anxiety disorders and illness anxiety disorder is also common.
Panic disorder is significantly comorbid with numerous general medical symptoms and conditions, including, but not limited to, dizziness, cardiac arrhythmias, hyperthyroidism, asthma, COPD, and irritable bowel syndrome. However, the nature of the association (e.g., cause and effect) between panic disorder and these conditions remains unclear. Although mitral valve prolapse and thyroid disease are more common among individuals with panic disorder than in the general population, the differences in prevalence are not consistent.
1. Craske MG, Rowe M: Nocturnal panic. Clin Psychol Sci Pract 4:153–174, 1997
2. Craske MG, Kircanski K, Epstein A, et al: Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V. Depress Anxiety 27(2):93–112, 2010 20099270
3. Domschke K, Deckert J, O’Donovan MC, Glatt SJ: Meta-analysis of COMT val158met in panic disorder: ethnic heterogeneity and gender specificity. Am J Med Genet B Neuropsychiatr Genet 144B(5):667–673, 2007 17357147
4. Eaton WW, Anthony JC, Romanoski A, et al: Onset and recovery from panic disorder in the Baltimore Epidemiologic Catchment Area follow-up. Br J Psychiatry 173:501–507, 1998 9926079
5. Fava GA, Porcelli P, Rafanelli C, et al: The spectrum of anxiety disorders in the medically ill. J Clin Psychiatry 71(7):910–914, 2010 20584526
6. Goodwin RD, Faravelli C, Rosi S, et al: The epidemiology of panic disorder and agoraphobia in Europe. Eur Neuropsychopharmacol 15(4):435–443, 2005 15925492
7. Gratacòs M, Sahùn I, Gallego X, et al: Candidate genes for panic disorder: insight from human and mouse genetic studies. Genes Brain Behav 6(6, suppl 1):2–23, 2007 17543035
8. Hettema JM, Neale MC, Kendler KS: A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry 158(10):1568–1578, 2001 11578982
9. Isensee B, Wittchen HU, Stein MB, et al: Smoking increases the risk of panic: findings from a prospective community study. Arch Gen Psychiatry 60(7):692–700, 2003 12860773
10. Kessler RC, Berglund P, Demler O, et al: Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):593–602, 2005a 15939837
11. Kessler RC, Chiu WT, Demler O, et al: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):617–627, 2005b 15939839
12. Kessler R, Petukhova M, Samson NA, et al: Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States.. Int J Methods Psychiatr Res 21(3):169–184, 2012 22865617 10.1002/mpr.1359
13. Kircanski K, Craske MG, Epstein AM, Wittchen HU: Subtypes of panic attacks: a critical review of the empirical literature. Depress Anxiety 26(10):878–887, 2009 19750553
14. Lewis-Fernãndez R, Hinton DE, Laria AJ, et al: Culture and the anxiety disorders: recommendations for DSM-V. Depress Anxiety 27(2):212–229, 2010 20037918
15. McNally RJ: Anxiety sensitivity and panic disorder. Biol Psychiatry 52(10):938–946, 2002 12437935
16. Meuret AE, Ritz T: Hyperventilation in panic disorder and asthma: empirical evidence and clinical strategies. Int J Psychophysiol 78(1):68–79, 2010 20685222
17. Mohlman J, Bryant C, Lenze EJ, et al: Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group. Int J Geriatr Psychiatry 27(6):549–556, 2012 21773996 10.1002/gps 2752
18. Pine DS, Klein RG: Anxiety disorders, in Rutter’s Child and Adolescent Psychiatry, 5th Edition. Edited by Rutter M, Bishop D, Pine DS, et al. New York, Wiley-Blackwell, 2008, pp 628–647
19. Roy-Byrne PP, Cowley DS: Course and outcome in panic disorder: a review of recent follow-up studies. Anxiety 1(4):151–160, 1994–1995 9160567
20. Roy-Byrne PP, Craske MG, Stein MB: Panic disorder. Lancet 368(9540):1023–1032, 2006 16980119
21. Wittchen HU, Gloster AT, Beesdo-Baum K, et al: Agoraphobia: a review of the diagnostic classificatory position and criteria. Depress Anxiety 27(2):113–133, 2010 20143426
22. Wolitzky-Taylor KB, Castriotta N, Lenze EJ, et al: Anxiety disorders in older adults: a comprehensive review. Depress Anxiety 27(2):190–211, 2010 20099273
23. Zimmermann P, Wittchen HU, Höfler M, et al: Primary anxiety disorders and the development of subsequent alcohol use disorders: a 4-year community study of adolescents and young adults. Psychol Med 33(7):1211–1222, 2003 14580076
Note: Symptoms are presented for the purpose of identifying a panic attack; however, panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g., “posttraumatic stress disorder with panic attacks”). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.
An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
The essential feature of a panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four or more of 13 physical and cognitive symptoms occur. Eleven of these 13 symptoms are physical (e.g., palpitations, sweating), while two are cognitive (i.e., fear of losing control or going crazy, fear of dying). “Fear of going crazy” is a colloquialism often used by individuals with panic attacks and is not intended as a pejorative or diagnostic term. The term within minutes means that the time to peak intensity is literally only a few minutes. A panic attack can arise from either a calm state or an anxious state, and time to peak intensity should be assessed independently of any preceding anxiety. That is, the start of the panic attack is the point at which there is an abrupt increase in discomfort rather than the point at which anxiety first developed. Likewise, a panic attack can return to either an anxious state or a calm state and possibly peak again. A panic attack is distinguished from ongoing anxiety by its time to peak intensity, which occurs within minutes; its discrete nature; and its typically greater severity. Attacks that meet all other criteria but have fewer than four physical and/or cognitive symptoms are referred to as limited-symptom attacks.
There are two characteristic types of panic attacks: expected and unexpected. Expected panic attacks are attacks for which there is an obvious cue or trigger, such as situations in which panic attacks have typically occurred. Unexpected panic attacks are those for which there is no obvious cue or trigger at the time of occurrence (e.g., when relaxing or out of sleep [nocturnal panic attack]). The determination of whether panic attacks are expected or unexpected is made by the clinician, who makes this judgment based on a combination of careful questioning as to the sequence of events preceding or leading up to the attack and the individual’s own judgment of whether or not the attack seemed to occur for no apparent reason. Cultural interpretations may influence their determination as expected or unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen; however, such symptoms should not count as one of the four required symptoms. Panic attacks can occur in the context of any mental disorder (e.g., anxiety disorders, depressive disorders, bipolar disorders, eating disorders, obsessive-compulsive and related disorders, personality disorders, psychotic disorders, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal), with the majority never meeting criteria for panic disorder4. Recurrent unexpected panic attacks are required for a diagnosis of panic disorder.
One type of unexpected panic attack is a nocturnal panic attack (i.e., waking from sleep in a state of panic), which differs from panicking after fully waking from sleep. Panic attacks are related to a higher rate of suicide attempts and suicidal ideation even when comorbidity and other suicide risk factors are taken into account1.
In the general population, 12-month prevalence estimates for panic attacks in the United States is 11.2% in adults4. Twelve-month prevalence estimates do not appear to differ significantly among African Americans, Asian Americans, and Latinos5. Lower 12-month prevalence estimates for European countries appear to range from 2.7% to 3.3%2, 5. Females are more frequently affected than males, although this gender difference is more pronounced for panic disorder4. Panic attacks can occur in children but are relatively rare until the age of puberty, when the prevalence rates increase1. The prevalence rates decline in older individuals, possibly reflecting diminishing severity to subclinical levels4, 8.
The mean age at onset for panic attacks in the United States is approximately 22–23 years among adults4. However, the course of panic attacks is likely influenced by the course of any co-occurring mental disorder(s) and stressful life events. Panic attacks are uncommon, and unexpected panic attacks are rare, in preadolescent children1. Adolescents might be less willing than adults to openly discuss panic attacks, even though they present with episodes of intense fear or discomfort. Lower prevalence of panic attacks in older individuals may be related to a weaker autonomic response to emotional states relative to younger individuals7. Older individuals may be less inclined to use the word “fear” and more inclined to use the word “discomfort” to describe panic attacks8. Older individuals with “panicky feelings” may have a hybrid of limited-symptom attacks and generalized anxiety. In addition, older individuals tend to attribute panic attacks to certain situations that are stressful (e.g., medical procedures, social settings) and may retrospectively endorse explanations for the panic attack even if it was unexpected in the moment. This may result in under-endorsement of unexpected panic attacks in older individuals.
Temperamental. Negative affectivity (neuroticism) (i.e., proneness to experiencing negative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of anxiety are harmful) are risk factors for the onset of panic attacks1. History of “fearful spells” (i.e., limited-symptom attacks that do not meet full criteria for a panic attack) may be a risk factor for later panic attacks1.
Environmental. Smoking is a risk factor for panic attacks3. Most individuals report identifiable stressors in the months before their first panic attack (e.g., interpersonal stressors and stressors related to physical well-being, such as negative experiences with illicit or prescription drugs, disease, or death in the family).
Cultural interpretations may influence the determination of panic attacks as expected or unexpected. Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen; however, such symptoms should not count as one of the four required symptoms. Frequency of each of the 13 symptoms varies cross-culturally (e.g., higher rates of paresthesias in African Americans and of dizziness in several Asian groups)5. Cultural syndromes also influence the cross-cultural presentation of panic attacks, resulting in different symptom profiles across different cultural groups. Examples include khyâl (wind) attacks, a Cambodian cultural syndrome involving dizziness, tinnitus, and neck soreness; and trùng gió (wind-related) attacks, a Vietnamese cultural syndrome associated with headaches. Ataque de nervios (attack of nerves) is a cultural syndrome among Latin Americans that may involve trembling, uncontrollable screaming or crying, aggressive or suicidal behavior, and depersonalization or derealization, and which may be experienced for longer than only a few minutes5. Some clinical presentations of ataque de nervios fulfill criteria for conditions other than panic attack (e.g., other specified dissociative disorder). Also, cultural expectations may influence the classification of panic attacks as expected or unexpected, as cultural syndromes may create fear of certain situations, ranging from interpersonal arguments (associated with ataque de nervios), to types of exertion (associated with khyâl attacks), to atmospheric wind (associated with trùng gió attacks). Clarification of the details of cultural attributions may aid in distinguishing expected and unexpected panic attacks1. For more information about cultural syndromes, see “Glossary of Cultural Concepts of Distress” in the Appendix to this manual.
Panic attacks are more common in females than in males, but clinical features or symptoms of panic attacks do not differ between males and females.
Physiological recordings of naturally occurring panic attacks in individuals with panic disorder indicate abrupt surges of arousal, usually of heart rate, that reach a peak within minutes and subside within minutes1, and for a proportion of these individuals the panic attack may be preceded by cardiorespiratory instabilities6.
In the context of co-occurring mental disorders, including anxiety disorders, depressive disorders, bipolar disorder, substance use disorders, psychotic disorders, and personality disorders, panic attacks are associated with increased symptom severity, higher rates of comorbidity and suicidality, and poorer treatment response. Also, full-symptom panic attacks typically are associated with greater morbidity (e.g., greater health care utilization, more disability, poorer quality of life) than limited-symptom attacks1.
Other paroxysmal episodes (e.g., “anger attacks”). Panic attacks should not be diagnosed if the episodes do not involve the essential feature of an abrupt surge of intense fear or intense discomfort, but rather other emotional states (e.g., anger, grief).
Anxiety disorder due to another medical condition. Medical conditions that can cause or be misdiagnosed as panic attacks include hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders, and cardiopulmonary conditions (e.g., arrhythmias, supraventricular tachycardia, asthma, chronic obstructive pulmonary disease). Appropriate laboratory tests (e.g., serum calcium levels for hyperparathyroidism; Holter monitor for arrhythmias) or physical examinations (e.g., for cardiac conditions) may be helpful in determining the etiological role of another medical condition.
Substance/medication-induced anxiety disorder. Intoxication with central nervous system stimulants (e.g., cocaine, amphetamines, caffeine) or cannabis and withdrawal from central nervous system depressants (e.g., alcohol, barbiturates) can precipitate a panic attack. A detailed history should be taken to determine if the individual had panic attacks prior to excessive substance use. Features such as onset after age 45 years or the presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness, loss of bladder or bowel control, slurred speech, or amnesia) suggest the possibility that a medical condition or a substance may be causing the panic attack symptoms.
Panic disorder. Repeated unexpected panic attacks are required but are not sufficient for the diagnosis of panic disorder (i.e., full diagnostic criteria for panic disorder must be met).
Panic attacks are associated with increased likelihood of various comorbid mental disorders, including anxiety disorders, depressive disorders, bipolar disorders, impulse-control disorders, and substance use disorders4. Panic attacks are associated with increased likelihood of later developing anxiety disorders, depressive disorders, bipolar disorders, and possibly other disorders1.
1. Craske MG, Kircanski K, Epstein A, et al: Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V. Depress Anxiety 27(2):93–112, 2010 20099270
2. Fullana MA, Vilagut G, Ortega N, et al: Prevalence and correlates of respiratory and non-respiratory panic attacks in the general population. J Affect Disord 131(1–3):330–338, 2011 21183222
3. Isensee B, Wittchen HU, Stein MB, et al: Smoking increases the risk of panic: findings from a prospective community study. Arch Gen Psychiatry 60(7):692–700, 2003 12860773
4. Kessler RC, Chiu WT, Demler O, et al: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):617–627, 2005 15939839
5. Lewis-Fernãndez R, Hinton DE, Laria AJ, et al: Culture and the anxiety disorders: recommendations for DSM-V. Depress Anxiety 27(2):212–229, 2010 20037918
6. Meuret AE, Ritz T: Hyperventilation in panic disorder and asthma: empirical evidence and clinical strategies. Int J Psychophysiol 78(1):68–79, 2010 20685222
7. Mohlman J, Bryant C, Lenze EJ, et al: Improving recognition of late life anxiety disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: observations and recommendations of the Advisory Committee to the Lifespan Disorders Work Group. Int J Geriatr Psychiatry 27(6):549–556, 2012 21773996 10.1002/gps 2752
8. Wolitzky-Taylor KB, Castriotta N, Lenze EJ, et al: Anxiety disorders in older adults: a comprehensive review. Depress Anxiety 27(2):190–211, 2010 20099273
|
Diagnostic Criteria |
300.22 (F40.00) |
Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.
The essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the real or anticipated exposure to a wide range of situations (Criterion A). The diagnosis requires endorsement of symptoms occurring in at least two of the following five situations: 1) using public transporation, such as automobiles, buses, trains, ships, or planes; 2) being in open spaces, such as parking lots, marketplaces, or bridges; 3) being in enclosed spaces, such as shops, theaters, or cinemas; 4) standing in line or being in a crowd; or 5) being outside of the home alone. The examples for each situation are not exhaustive; other situations may be feared22. When experiencing fear and anxiety cued by such situations, individuals typically experience thoughts that something terrible might happen (Criterion B). Individuals frequently believe that escape from such situations might be difficult (e.g., “can’t get out of here”) or that help might be unavailable (e.g., “there is nobody to help me”) when panic-like symptoms or other incapacitating or embarrassing symptoms occur. “Panic-like symptoms” refer to any of the 13 symptoms included in the criteria for panic attack, such as dizziness, faintness, and fear of dying. “Other incapacitating or embarrassing symptoms” include symptoms such as vomiting and inflammatory bowel symptoms, as well as, in older adults, a fear of falling or, in children, a sense of disorientation and getting lost.
The amount of fear experienced may vary with proximity to the feared situation and may occur in anticipation of or in the actual presence of the agoraphobic situation. Also, the fear or anxiety may take the form of a full- or limited-symptom panic attack (i.e., an expected panic attack). Fear or anxiety is evoked nearly every time the individual comes into contact with the feared situation (Criterion C). Thus, an individual who becomes anxious only occasionally in an agoraphobic situation (e.g., becomes anxious when standing in line on only one out of every five occasions) would not be diagnosed with agoraphobia5, 22. The individual actively avoids the situation or, if he or she either is unable or decides not to avoid it, the situation evokes intense fear or anxiety (Criterion D). Active avoidance means the individual is currently behaving in ways that are intentionally designed to prevent or minimize contact with agoraphobic situations. Avoidance can be behavioral (e.g., changing daily routines, choosing a job nearby to avoid using public transportation, arranging for food delivery to avoid entering shops and supermarkets) as well as cognitive (e.g., using distraction to get through agoraphobic situations) in nature. The avoidance can become so severe that the person is completely homebound. Often, an individual is better able to confront a feared situation when accompanied by a companion, such as a partner, friend, or health professional.
The fear, anxiety, or avoidance must be out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context (Criterion E). Differentiating clinically significant agoraphobic fears from reasonable fears (e.g., leaving the house during a bad storm) or from situations that are deemed dangerous (e.g., walking in a parking lot or using public transportation in a high-crime area) is important for a number of reasons. First, what constitutes avoidance may be difficult to judge across cultures and sociocultural contexts (e.g., it is socioculturally appropriate for orthodox Muslim women in certain parts of the world to avoid leaving the house alone, and thus such avoidance would not be considered indicative of agoraphobia). Second, older adults are likely to overattribute their fears to age-related constraints and are less likely to judge their fears as being out of proportion to the actual risk24. Third, individuals with agoraphobia are likely to overestimate danger in relation to panic-like or other bodily symptoms4, 18. Agoraphobia should be diagnosed only if the fear, anxiety, or avoidance persists (Criterion F) and if it causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion G). The duration of “typically lasting for 6 months or more” is meant to exclude individuals with short-lived, transient problems. However, the duration criterion should be used as a general guide, with allowance for some degree of flexibility.
In its most severe forms, agoraphobia can cause individuals to become completely homebound, unable to leave their home and dependent on others for services or assistance to provide even for basic needs. Demoralization and depressive symptoms, as well as abuse of alcohol and sedative medication as inappropriate self-medication strategies, are common.
Every year approximately 1.7% of adolescents and adults have a diagnosis of agoraphobia15, 23. Females are twice as likely as males to experience agoraphobia22. Agoraphobia may occur in childhood, but incidence peaks in late adolescence and early adulthood1, 3. Twelve-month prevalence in individuals older than 65 years is 0.4%14. Prevalence rates do not appear to vary systematically across cultural/racial groups9, 16.
The percentage of individuals with agoraphobia reporting panic attacks or panic disorder preceding the onset of agoraphobia ranges from 30% in community samples to more than 50% in clinic samples. The majority of individuals with panic disorder show signs of anxiety and agoraphobia before the onset of panic disorder7, 8.
In two-thirds of all cases of agoraphobia, initial onset is before age 35 years. There is a substantial incidence risk in late adolescence and early adulthood, with indications for a second high incidence risk phase after age 40 years. First onset in childhood is rare. The overall mean age at onset for agoraphobia is 17 years, although the age at onset without preceding panic attacks or panic disorder is 25–29 years19, 22.
The course of agoraphobia is typically persistent and chronic. Complete remission is rare (10%), unless the agoraphobia is treated6. With more severe agoraphobia, rates of full remission decrease, whereas rates of relapse and chronicity increase. A range of other disorders, in particular other anxiety disorders, depressive disorders, substance use disorders, and personality disorders, may complicate the course of agoraphobia. The long-term course and outcome of agoraphobia are associated with substantially elevated risk of secondary major depressive disorder, persistent depressive disorder (dysthymia), and substance use disorders.
The clinical features of agoraphobia are relatively consistent across the lifespan, although the type of agoraphobic situations triggering fear, anxiety, or avoidance, as well as the type of cognitions, may vary. For example, in children, being outside of the home alone is the most frequent situation feared, whereas in older adults, being in shops, standing in line, and being in open spaces are most often feared22. Also, cognitions often pertain to becoming lost (in children), to experiencing panic-like symptoms (in adults), to falling (in older adults).
The low prevalence of agoraphobia in children could reflect difficulties in symptom reporting, and thus assessments in young children may require solicitation of information from multiple sources, including parents or teachers1. Adolescents, particularly males, may be less willing than adults to openly discuss agoraphobic fears and avoidance; however, agoraphobia can occur prior to adulthood and should be assessed in children and adolescents. In older adults, comorbid somatic symptom disorders, as well as motor disturbances (e.g., sense of falling or having medical complications), are frequently mentioned by individuals as the reason for their fear and avoidance17. In these instances, care is to be taken in evaluating whether the fear and avoidance are out of proportion to the real danger involved.
Temperamental. Behavioral inhibition and neurotic disposition (i.e., negative affectivity [neuroticism] and anxiety sensitivity) are closely associated with agoraphobia but are relevant to most anxiety disorders (phobic disorders, panic disorder, generalized anxiety disorder)21, 22. Anxiety sensitivity (the disposition to believe that symptoms of anxiety are harmful) is also characteristic of individuals with agoraphobia10.
Environmental. Negative events in childhood (e.g., separation, death of parent) and other stressful events, such as being attacked or mugged, are associated with the onset of agoraphobia. Furthermore, individuals with agoraphobia describe the family climate and child-rearing behavior as being characterized by reduced warmth and increased overprotection22.
Genetic and physiological. Heritability for agoraphobia is 61%13. Of the various phobias, agoraphobia has the strongest and most specific association with the genetic factor that represents proneness to phobias11, 12.
Females have different patterns of comorbid disorders than males. Consistent with gender differences in the prevalence of mental disorders, males have higher rates of comorbid substance use disorders.
Agoraphobia is associated with considerable impairment and disability in terms of role functioning, work productivity, and disability days. Agoraphobia severity is a strong determinant of the degree of disability, irrespective of the presence of comorbid panic disorder, panic attacks, and other comorbid conditions14, 22. More than one-third of individuals with agoraphobia are completely homebound and unable to work.
When diagnostic criteria for agoraphobia and another disorder are fully met, both diagnoses should be assigned, unless the fear, anxiety, or avoidance of agoraphobia is attributable to the other disorder. Weighting of criteria and clinical judgment may be helpful in some cases.
Specific phobia, situational type. Differentiating agoraphobia from situational specific phobia can be challenging in some cases, because these conditions share several symptom characteristics and criteria. Specific phobia, situational type, should be diagnosed versus agoraphobia if the fear, anxiety, or avoidance is limited to one of the agoraphobic situations. Requiring fears from two or more of the agoraphobic situations is a robust means for differentiating agoraphobia from specific phobias, particularly the situational subtype. Additional differentiating features include the cognitive ideation. Thus, if the situation is feared for reasons other than panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fears of being directly harmed by the situation itself, such as fear of the plane crashing for individuals who fear flying), then a diagnosis of specific phobia may be more appropriate.
Separation anxiety disorder. Separation anxiety disorder can be best differentiated from agoraphobia by examining cognitive ideation. In separation anxiety disorder, the thoughts are about detachment from significant others and the home environment (i.e., parents or other attachment figures), whereas in agoraphobia the focus is on panic-like symptoms or other incapacitating or embarrassing symptoms in the feared situations.
Social anxiety disorder (social phobia). Agoraphobia should be differentiated from social anxiety disorder based primarily on the situational clusters that trigger fear, anxiety, or avoidance and the cognitive ideation. In social anxiety disorder, the focus is on fear of being negatively evaluated.
Panic disorder. When criteria for panic disorder are met, agoraphobia should not be diagnosed if the avoidance behaviors associated with the panic attacks do not extend to avoidance of two or more agoraphobic situations.
Acute stress disorder and posttraumatic stress disorder. Acute stress disorder and posttraumatic stress disorder (PTSD) can be differentiated from agoraphobia by examining whether the fear, anxiety, or avoidance is related only to situations that remind the individual of a traumatic event. If the fear, anxiety, or avoidance is restricted to trauma reminders, and if the avoidance behavior does not extend to two or more agoraphobic situations, then a diagnosis of agoraphobia is not warranted.
Major depressive disorder. In major depressive disorder, the individual may avoid leaving home because of apathy, loss of energy, low self-esteem, and anhedonia. If the avoidance is unrelated to fears of panic-like or other incapacitating or embarrassing symptoms, then agoraphobia should not be diagnosed.
Other medical conditions. Agoraphobia is not diagnosed if the avoidance of situations is judged to be a physiological consequence of a medical condition. This determination is based on history, laboratory findings, and a physical examination. Other relevant medical conditions may include neurodegenerative disorders with associated motor disturbances (e.g., Parkinson’s disease, multiple sclerosis), as well as cardiovascular disorders. Individuals with certain medical conditions may avoid situations because of realistic concerns about being incapacitated (e.g., fainting in an individual with transient ischemic attacks) or being embarrassed (e.g., diarrhea in an individual with Crohn’s disease). The diagnosis of agoraphobia should be given only when the fear or avoidance is clearly in excess of that usually associated with these medical conditions.
The majority of individuals with agoraphobia also have other mental disorders. The most frequent additional diagnoses are other anxiety disorders (e.g., specific phobias, panic disorder, social anxiety disorder), depressive disorders (major depressive disorder), PTSD, and alcohol use disorder. Whereas other anxiety disorders (e.g., separation anxiety disorder, specific phobias, panic disorder) frequently precede onset of agoraphobia, depressive disorders and substance use disorders typically occur secondary to agoraphobia2, 20.
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2. Bittner A, Goodwin RD, Wittchen HU, et al: What characteristics of primary anxiety disorders predict subsequent major depressive disorder? J Clin Psychiatry 65(5):618–626, 2004 15163247
3. Bittner A, Egger HL, Erkanli A, et al: What do childhood anxiety disorders predict? J Child Psychol Psychiatry 48(12):1174–1183, 2007 18093022
4. Chambless DL, Caputo GC, Bright P, Gallagher R: Assessment of fear of fear in agoraphobics: the body sensation questionnaire and the agoraphobic cognitions questionnaire. J Consult Clin Psychol 52(6):1090–1097, 1984 6520279
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9. Gustavsson A, Svensson M, Jacobi F, et al: Cost of disorders of the brain. Eur Neuropsychopharmacol 21(10):718–779, 2011 21924589
10. Hayward C, Wilson KA: Anxiety sensitivity: a missing piece to the agoraphobia-without-panic puzzle. Behav Modif 31(2):162–173, 2007 17307933
11. Kendler KS, Neale MC, Kessler RC, et al: Childhood parental loss and adult psychpathology in women: a twin study perspective. Arch Gen Psychiatry 49(2):109–116, 1992a 1550463
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15. Kessler RC, Petukhova M, Sampson NA, et al: Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res 21(3):169–184, 2012 22865617 10.1002/mpr.1359
16. Lewis-Fernãndez R, Hinton DE, Laria AJ, et al: Culture and the anxiety disorders: recommendations for DSM-V. Depress Anxiety 27(2):212–229, 2010 20037918
17. McCabe L, Cairney J, Veldhuizen S, et al: Prevalence and correlates of agoraphobia in older adults. Am J Geriatr Psychiatry 14(6):515–522, 2006 16731720
18. McNally RJ, Lorenz M: Anxiety sensitivity in agoraphobics. J Behav Ther Exp Psychiatry 18(1):3–11, 1987 3558849
19. Nocon A, Wittchen HU, Beesdo K, et al: Differential familial liability of panic disorder and agoraphobia. Depress Anxiety 25(5):422–434, 2008 18023003
20. Reed V, Wittchen HU: DSM-IV panic attacks and panic disorder in a community sample of adolescents and young adults: how specific are panic attacks? J Psychiatr Res 32(6):335–345, 1998 9844949
21. Rohrbacher H, Hoyer J, Beesdo K, et al: Psychometric properties of the Retrospective Self Report of Inhibition (RSRI) in a representative German sample. Int J Methods Psychiatr Res 17(2):80–88, 2008 18409182
22. Wittchen HU, Gloster AT, Beesdo-Baum K, et al: Agoraphobia: a review of the diagnostic classificatory position and criteria. Depress Anxiety 27(2):113–133, 2010 20143426
23. Wittchen HU, Jacobi F, Rehm J, et al: The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 21(9):655–679, 2011 21896369
24. Wolitzky-Taylor KB, Castriotta N, Lenze EJ, et al: Anxiety disorders in older adults: a comprehensive review. Depress Anxiety 27(2):190–211, 2010 20099273
|
Diagnostic Criteria |
300.02 (F41.1) |
Note: Only one item is required in children.
The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive expectation) about a number of events or activities. The intensity, duration, or frequency of the anxiety and worry is out of proportion to the actual likelihood or impact of the anticipated event. The individual finds it difficult to control the worry and to keep worrisome thoughts from interfering with attention to tasks at hand. Adults with generalized anxiety disorder often worry about everyday, routine life circumstances, such as possible job responsibilities, health and finances, the health of family members, misfortune to their children, or minor matters (e.g., doing household chores or being late for appointments). Children with generalized anxiety disorder tend to worry excessively about their competence or the quality of their performance. During the course of the disorder, the focus of worry may shift from one concern to another.
Several features distinguish generalized anxiety disorder from nonpathological anxiety. First, the worries associated with generalized anxiety disorder are excessive and typically interfere significantly with psychosocial functioning, whereas the worries of everyday life are not excessive and are perceived as more manageable and may be put off when more pressing matters arise. Second, the worries associated with generalized anxiety disorder are more pervasive, pronounced, and distressing; have longer duration; and frequently occur without precipitants. The greater the range of life circumstances about which a person worries (e.g., finances, children’s safety, job performance), the more likely his or her symptoms are to meet criteria for generalized anxiety disorder. Third, everyday worries are much less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up or on edge). Individuals with generalized anxiety disorder report subjective distress due to constant worry and related impairment in social, occupational, or other important areas of functioning.
The anxiety and worry are accompanied by at least three of the following additional symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and disturbed sleep, although only one additional symptom is required in children.
Associated with muscle tension, there may be trembling, twitching, feeling shaky, and muscle aches or soreness. Many individuals with generalized anxiety disorder also experience somatic symptoms (e.g., sweating, nausea, diarrhea) and an exaggerated startle response. Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of breath, dizziness) are less prominent in generalized anxiety disorder than in other anxiety disorders, such as panic disorder. Other conditions that may be associated with stress (e.g., irritable bowel syndrome, headaches) frequently accompany generalized anxiety disorder.
The 12-month prevalence of generalized anxiety disorder is 0.9% among adolescents and 2.9% among adults in the general community of the United States19. The 12-month prevalence for the disorder in other countries ranges from 0.4% to 3.6%23. The lifetime morbid risk is 9.0%19. Females are twice as likely as males to experience generalized anxiety disorder28, 29. The prevalence of the diagnosis peaks in middle age and declines across the later years of life11, 19.
Individuals of European descent tend to experience generalized anxiety disorder more frequently than do individuals of non-European descent (i.e., Asian, African, Native American and Pacific Islander)23. Furthermore, individuals from developed countries are more likely than individuals from nondeveloped countries to report that they have experienced symptoms that meet criteria for generalized anxiety disorder in their lifetime21.
Many individuals with generalized anxiety disorder report that they have felt anxious and nervous all of their lives. The median age at onset for generalized anxiety disorder is 30 years; however, age at onset is spread over a very broad range19. The median age at onset is later than that for the other anxiety disorders. The symptoms of excessive worry and anxiety may occur early in life but are then manifested as an anxious temperament1, 14. Onset of the disorder rarely occurs prior to adolescence4. The symptoms of generalized anxiety disorder tend to be chronic and wax and wane across the lifespan, fluctuating between syndromal and subsyndromal forms of the disorder2, 3. Rates of full remission are very low6, 31.
The clinical expression of generalized anxiety disorder is relatively consistent across the lifespan. The primary difference across age groups is in the content of the individual’s worry. Children and adolescents tend to worry more about school and sporting performance, whereas older adults report greater concern about the well-being of family or their own physical heath. Thus, the content of an individual’s worry tends to be age appropriate. Younger adults experience greater severity of symptoms than do older adults30.
The earlier in life individuals have symptoms that meet criteria for generalized anxiety disorder, the more comorbidity they tend to have and the more impaired they are likely to be7, 22. The advent of chronic physical disease can be a potent issue for excessive worry in the elderly. In the frail elderly, worries about safety—and especially about falling—may limit activities. In those with early cognitive impairment, what appears to be excessive worry about, for example, the whereabouts of things is probably better regarded as realistic given the cognitive impairment.
In children and adolescents with generalized anxiety disorder, the anxieties and worries often concern the quality of their performance or competence at school or in sporting events, even when their performance is not being evaluated by others. There may be excessive concerns about punctuality. They may also worry about catastrophic events, such as earthquakes or nuclear war. Children with the disorder may be overly conforming, perfectionist, and unsure of themselves and tend to redo tasks because of excessive dissatisfaction with less-than-perfect performance. They are typically overzealous in seeking reassurance and approval and require excessive reassurance about their performance and other things they are worried about.
Generalized anxiety disorder may be overdiagnosed in children. When this diagnosis is being considered in children, a thorough evaluation for the presence of other childhood anxiety disorders and other mental disorders should be done to determine whether the worries may be better explained by one of these disorders. Separation anxiety disorder, social anxiety disorder (social phobia), and obsessive-compulsive disorder are often accompanied by worries that may mimic those described in generalized anxiety disorder. For example, a child with social anxiety disorder may be concerned about school performance because of fear of humiliation. Worries about illness may also be better explained by separation anxiety disorder or obsessive-compulsive disorder.
Temperamental. Behavioral inhibition, negative affectivity (neuroticism), and harm avoidance have been associated with generalized anxiety disorder4, 10, 24, 27.
Environmental. Although childhood adversities and parental overprotection have been associated with generalized anxiety disorder4, 10, 24, 27, no environmental factors have been identified as specific to generalized anxiety disorder or necessary or sufficient for making the diagnosis.
Genetic and physiological. One-third of the risk of experiencing generalized anxiety disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are shared with other anxiety and mood disorders, particularly major depressive disorder8, 12.
There is considerable cultural variation in the expression of generalized anxiety disorder. For example, in some cultures, somatic symptoms predominate in the expression of the disorder, whereas in other cultures cognitive symptoms tend to predominate. This difference may be more evident on initial presentation than subsequently, as more symptoms are reported over time. There is no information as to whether the propensity for excessive worrying is related to culture, although the topic being worried about can be culture specific. It is important to consider the social and cultural context when evaluating whether worries about certain situations are excessive23.
In clinical settings, generalized anxiety disorder is diagnosed somewhat more frequently in females than in males (about 55%–60% of those presenting with the disorder are female). In epidemiological studies, approximately two-thirds are female. Females and males who experience generalized anxiety disorder appear to have similar symptoms but demonstrate different patterns of comorbidity consistent with gender differences in the prevalence of disorders. In females, comorbidity is largely confined to the anxiety disorders and unipolar depression, whereas in males, comorbidity is more likely to extend to the substance use disorders as well20, 29.
Excessive worrying impairs the individual’s capacity to do things quickly and efficiently, whether at home or at work. The worrying takes time and energy; the associated symptoms of muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrating, and disturbed sleep contribute to the impairment. Importantly the excessive worrying may impair the ability of individuals with generalized anxiety disorder to encourage confidence in their children.
Generalized anxiety disorder is associated with significant disability and distress that is independent of comorbid disorders15, 16, and most non-institutionalized adults with the disorder are moderately to seriously disabled. Generalized anxiety disorder accounts for 110 million disability days per annum in the U.S. population17, 26.
Anxiety disorder due to another medical condition. The diagnosis of anxiety disorder associated with another medical condition should be assigned if the individual’s anxiety and worry are judged, based on history, laboratory findings, or physical examination, to be a physiological effect of another specific medical condition (e.g., pheochromocytoma, hyperthyroidism).
Substance/medication-induced anxiety disorder. A substance/medication-induced anxiety disorder is distinguished from generalized anxiety disorder by the fact that a substance or medication (e.g., a drug of abuse, exposure to a toxin) is judged to be etiologically related to the anxiety. For example, severe anxiety that occurs only in the context of heavy coffee consumption would be diagnosed as caffeine-induced anxiety disorder.
Social anxiety disorder. Individuals with social anxiety disorder often have anticipatory anxiety that is focused on upcoming social situations in which they must perform or be evaluated by others, whereas individuals with generalized anxiety disorder worry, whether or not they are being evaluated.
Obsessive-compulsive disorder. Several features distinguish the excessive worry of generalized anxiety disorder from the obsessional thoughts of obsessive-compulsive disorder. In generalized anxiety disorder the focus of the worry is about forthcoming problems, and it is the excessiveness of the worry about future events that is abnormal. In obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of intrusive and unwanted thoughts, urges, or images.
Posttraumatic stress disorder and adjustment disorders. Anxiety is invariably present in posttraumatic stress disorder. Generalized anxiety disorder is not diagnosed if the anxiety and worry are better explained by symptoms of posttraumatic stress disorder. Anxiety may also be present in adjustment disorder, but this residual category should be used only when the criteria are not met for any other disorder (including generalized anxiety disorder). Moreover, in adjustment disorders, the anxiety occurs in response to an identifiable stressor within 3 months of the onset of the stressor and does not persist for more than 6 months after the termination of the stressor or its consequences.
Depressive, bipolar, and psychotic disorders. Although generalized anxiety/worry is a common associated feature of depressive, bipolar, and psychotic disorders, generalized anxiety disorder may be diagnosed comorbidly if the anxiety/worry is sufficiently severe to warrant clinical attention.
Individuals whose presentation meets criteria for generalized anxiety disorder are likely to have met, or currently meet, criteria for other anxiety and unipolar depressive disorders5, 9, 13. The neuroticism or emotional liability that underpins this pattern of comorbidity is associated with temperamental antecedents and genetic and environmental risk factors shared between these disorders8, 18, although independent pathways are also possible4, 25, 27. Comorbidity with substance use, conduct, psychotic, neurodevelopmental, and neurocognitive disorders is less common.
1. Akiskal HS: Toward a definition of generalized anxiety disorder as an anxious temperament type. Acta Psychiatr Scand Suppl 393:66–73, 1998 9777050
2. Angst J, Gamma A, Baldwin DS, et al: The generalized anxiety spectrum.: prevalence, onset, course and outcome. Eur Arch Psychiatry Clin Neurosci 259(1):37–45, 2009 18575915
3. Ballenger JC, Davidson JRT, Lecrubier Y, et al: Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry 62(suppl 1):153–158, 2001 11414552
4. Beesdo K, Pine DS, Lieb R, Wittchen HU: Incidence and risk patterns of anxiety and depressive disorders and categorization of generalized anxiety disorder. Arch Gen Psychiatry 67(1):47–57, 2010 20048222
5. Brown TA, Campbell LA, Lehman CL, et al: Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. J Abnorm Psychol 110(4):585–599, 2001 11727948
6. Bruce SE, Yonkers KA, Otto MW, et al: Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study. Am J Psychiatry 162(6):1179–1187, 2005 15930067
7. Campbell LA, Brown TA, Grisham JR: The relevance of age of onset to the psychopathology of generalized anxiety disorder. Behav Ther 34:31–48, 2003
8. Goldberg DP, Krueger RF, Andrews G, Hobbs MJ: Emotional disorders: cluster 4 of the proposed meta-structure for DSM-V and ICD-11. Psychol Med 39(12):2043–2059, 2009 19796429
9. Grant BF, Hasin DS, Stinson FS, et al: Co-occurrence of 12-month mood and anxiety disorders and personality disorders in the US: results from the national epidemiologic survey on alcohol and related conditions. J Psychiatr Res 39(1):1–9, 2005 15504418
10. Green JG, McLaughlin KA, Berglund PA, et al: Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders. Arch Gen Psychiatry 67(2):113–123, 2010 20124111
11. Gum AM, King-Kallimanis B, Kohn R: Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the national comorbidity survey-replication. Am J Geriatr Psychiatry 17(9):769–781, 2009 19700949
12. Hettema JM, Neale MC, Myers JM, et al: A population-based twin study of the relationship between neuroticism and internalizing disorders. Am J Psychiatry 163(5):857–864, 2006 16648327
13. Hunt C, Issakidis C, Andrews G: DSM-IV generalized anxiety disorder in the Australian National Survey of Mental Health and Well-Being. Psychol Med 32(4):649–659, 2002 12102379
14. Kagan J, Snidman N: Early childhood predictors of adult anxiety disorders. Biol Psychiatry 46(11):1536–1541, 1999 10599481
15. Kessler RC, Andrade LH, Bijl R, et al: The effects of co-morbidity on the onset and persistence of generalized anxiety disorder in the ICPE surveys: International Consortium in Psychiatric Epidemiology. Psychol Med 32(7):1213–1225, 2002a 12420891
16. Kessler RC, Berglund PA, Dewit DJ, et al: Distinguishing generalized anxiety disorder from major depression: prevalence and impairment from current pure and comorbid disorders in the US and Ontario. Int J Methods Psychiatr Res 11(3):99–111, 2002b 12459823
17. Kessler RC, Chiu WT, Demler O, et al: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):617–627, 2005 15939839
18. Kessler RC, Cox BJ, Green JG, et al: The effects of latent variables in the development of comorbidity among common mental disorders. Depress Anxiety 28(1):29–39, 2011 21225850
19. Kessler RC, Petukhova M, Sampson NA, et al: Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the US. Int J Methods Psychiatr Res 21(3):169–184, 2012 22865617
20. Kramer MD, Krueger RF, Hicks BM: The role of internalizing and externalizing liability factors in accounting for gender differences in the prevalence of common psychopathological syndromes. Psychol Med 38(1):51–61, 2008 17892625
21. Lee S, Tsang A, Ruscio AM, et al: Implications of modifying the duration requirement of generalized anxiety disorder in developed and developing countries. Psychol Med 39(7):1163–1176, 2009 19091158
22. Le Roux H, Gatz M, Wetherell JL: Age of onset of generalized anxiety disorder in older adults. Am J Geriatr Psychiatry 13(1):23–30, 2005 15653937
23. Lewis-Fernãndez R, Hinton DE, Laria AJ, et al: Culture and the anxiety disorders: recommendations for DSM-V. Depress Anxiety 27(2):212–229, 2010 20037918
24. McLaughlin KA, Green JG, Gruber MJ, et al: Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication II. associations with persistence of DSM-IV disorders. Arch Gen Psychiatry 67(2):124–132, 2010 20124112
25. Mennin DS, Heimberg RG, Fresco DM, Ritter MR: Is generalized anxiety disorder an anxiety or mood disorder?: Considering multiple factors as we ponder the fate of GAD. Depress Anxiety 25(4):289–299, 2008 18412056
26. Merikangas KR, Ames M, Cui L, et al: The impact of comorbidity of mental and physical conditions on role disability in the US adult household population. Arch Gen Psychiatry 64(10):1180–1188, 2007 17909130
27. Moffitt TE, Caspi A, Harrington H, et al: Generalized anxiety disorder and depression: childhood risk factors in a birth cohort followed to age 32. Psychol Med 37(3):441–452, 2007 17201999
28. Seedat S, Scott KM, Angermeyer MC, et al: Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Arch Gen Psychiatry 66(7):785–795, 2009 19581570
29. Vesga-López O, Schneier FR, Wang S, et al: Gender differences in generalized anxiety disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). J Clin Psychiatry 69(10):1606–1616, 2008 19192444
30. Wolitzky-Taylor KB, Castriotta N, Lenze EJ, et al: Anxiety disorders in older adults: a comprehensive review. Depress Anxiety 27(2):190–211, 2010 20099273
31. Yonkers KA, Bruce SE, Dyck IR, Keller MB: Chronicity, relapse and illness—course of panic disorder, social phobia and generalized anxiety disorder: findings in men and women from 8 years of follow-up. Depress Anxiety 17(3):173–179, 2003 12768651
|
Diagnostic Criteria |
The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non-substance/medication-induced anxiety disorder (e.g., a history of recurrent non-substance/medication-related episodes).
Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and they are sufficiently severe to warrant clinical attention.
Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medication]-induced anxiety disorders are indicated in the table below. Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. If a mild substance use disorder is comorbid with the substance-induced anxiety disorder, the 4th position character is “1,” and the clinician should record “mild [substance] use disorder” before the substance-induced anxiety disorder (e.g., “mild cocaine use disorder with cocaine-induced anxiety disorder”). If a moderate or severe substance use disorder is comorbid with the substance-induced anxiety disorder, the 4th position character is “2,” and the clinician should record “moderate [substance] use disorder” or “severe [substance] use disorder,” depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy use of the substance), then the 4th position character is “9,” and the clinician should record only the substance-induced anxiety disorder.
|
|
|
|
ICD-10-CM |
|
|---|---|---|---|---|
|
|
ICD-9-CM |
With use disorder, mild |
With use disorder, moderate or severe |
Without use disorder |
|
Alcohol |
291.89 |
F10.180 |
F10.280 |
F10.980 |
|
Caffeine |
292.89 |
F15.180 |
F15.280 |
F15.980 |
|
Cannabis |
292.89 |
F12.180 |
F12.280 |
F12.980 |
|
Phencyclidine |
292.89 |
F16.180 |
F16.280 |
F16.980 |
|
Other hallucinogen |
292.89 |
F16.180 |
F16.280 |
F16.980 |
|
Inhalant |
292.89 |
F18.180 |
F18.280 |
F18.980 |
|
Opioid |
292.89 |
F11.188 |
F11.288 |
F11.988 |
|
Sedative, hypnotic, or anxiolytic |
292.89 |
F13.180 |
F13.280 |
F13.980 |
|
Amphetamine (or other stimulant) |
292.89 |
F15.180 |
F15.280 |
F15.980 |
|
Cocaine |
292.89 |
F14.180 |
F14.280 |
F14.980 |
|
Other (or unknown) substance |
292.89 |
F19.180 |
F19.280 |
F19.980 |
Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for diagnoses associated with substance class):
With onset during intoxication: This specifier applies if criteria are met for intoxication with the substance and the symptoms develop during intoxication.
With onset during withdrawal: This specifier applies if criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.
With onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use.
ICD-9-CM. The name of the substance/medication-induced anxiety disorder begins with the specific substance (e.g., cocaine, salbutamol) that is presumed to be causing the anxiety symptoms. The diagnostic code is selected from the table included in the criteria set, which is based on the drug class. For substances that do not fit into any of the classes (e.g., salbutamol), the code for “other substance” should be used; and in cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category “unknown substance” should be used.
The name of the disorder is followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal, with onset during medication use). Unlike the recording procedures for ICD-10-CM, which combine the substance-induced disorder and substance use disorder into a single code, for ICD-9-CM a separate diagnostic code is given for the substance use disorder. For example, in the case of anxiety symptoms occurring during withdrawal in a man with a severe lorazepam use disorder, the diagnosis is 292.89 lorazepam-induced anxiety disorder, with onset during withdrawal. An additional diagnosis of 304.10 severe lorazepam use disorder is also given. When more than one substance is judged to play a significant role in the development of anxiety symptoms, each should be listed separately (e.g., 292.89 methylphenidate-induced anxiety disorder, with onset during intoxication; 292.89 salbutamol-induced anxiety disorder, with onset after medication use).
ICD-10-CM. The name of the substance/medication-induced anxiety disorder begins with the specific substance (e.g., cocaine, salbutamol) that is presumed to be causing the anxiety symptoms. The diagnostic code is selected from the table included in the criteria set, which is based on the drug class and presence or absence of a comorbid substance use disorder. For substances that do not fit into any of the classes (e.g., salbutamol), the code for “other substance” should be used; and in cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category “unknown substance” should be used.
When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word “with,” followed by the name of the substance-induced anxiety disorder, followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal, with onset during medication use). For example, in the case of anxiety symptoms occurring during withdrawal in a man with a severe lorazepam use disorder, the diagnosis is F13.280 severe lorazepam use disorder with lorazepam-induced anxiety disorder, with onset during withdrawal. A separate diagnosis of the comorbid severe lorazepam use disorder is not given. If the substance-induced anxiety disorder occurs without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g., F16.980 psilocybin-induced anxiety disorder, with onset during intoxication). When more than one substance is judged to play a significant role in the development of anxiety symptoms, each should be listed separately (e.g., F15.280 severe methylphenidate use disorder with methylphenidate-induced anxiety disorder, with onset during intoxication; F19.980 salbutamol-induced anxiety disorder, with onset after medication use).
The essential features of substance/medication-induced anxiety disorder are prominent symptoms of panic or anxiety (Criterion A) that are judged to be due to the effects of a substance (e.g., a drug of abuse, a medication, or a toxin exposure). The panic or anxiety symptoms must have developed during or soon after substance intoxication or withdrawal or after exposure to a medication, and the substances or medications must be capable of producing the symptoms (Criterion B2). Substance/medication-induced anxiety disorder due to a prescribed treatment for a mental disorder or another medical condition must have its onset while the individual is receiving the medication (or during withdrawal, if a withdrawal is associated with the medication). Once the treatment is discontinued, the panic or anxiety symptoms will usually improve or remit within days to several weeks to a month (depending on the half-life of the substance/medication and the presence of withdrawal). The diagnosis of substance/medication-induced anxiety disorder should not be given if the onset of the panic or anxiety symptoms precedes the substance/medication intoxication or withdrawal, or if the symptoms persist for a substantial period of time (i.e., usually longer than 1 month) from the time of severe intoxication or withdrawal. If the panic or anxiety symptoms persist for substantial periods of time, other causes for the symptoms should be considered.
The substance/medication-induced anxiety disorder diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A are predominant in the clinical picture and are sufficiently severe to warrant independent clinical attention.
Panic or anxiety can occur in association with intoxication with the following classes of substances: alcohol, caffeine, cannabis, phencyclidine, other hallucinogens, inhalants, stimulants (including cocaine), and other (or unknown) substances. Panic or anxiety can occur in association with withdrawal from the following classes of substances: alcohol; opioids; sedatives, hypnotics, and anxiolytics; stimulants (including cocaine); and other (or unknown) substances. Some medications that evoke anxiety symptoms include anesthetics and analgesics, sympathomimetics or other bronchodilators, anticholinergics, insulin, thyroid preparations, oral contraceptives, antihistamines, antiparkinsonian medications, corticosteroids, antihypertensive and cardiovascular medications, anticonvulsants, lithium carbonate, antipsychotic medications, and antidepressant medications. Heavy metals and toxins (e.g., organophosphate insecticide, nerve gases, carbon monoxide, carbon dioxide, volatile substances such as gasoline and paint) may also cause panic or anxiety symptoms.
The prevalence of substance/medication-induced anxiety disorder is not clear. General population data suggest that it may be rare, with a 12-month prevalence of approximately 0.002%1. However, in clinical populations, the prevalence is likely to be higher.
Laboratory assessments (e.g., urine toxicology) may be useful to measure substance intoxication as part of an assessment for substance/medication-induced anxiety disorder.
Substance intoxication and substance withdrawal. Anxiety symptoms commonly occur in substance intoxication and substance withdrawal. The diagnosis of the substance-specific intoxication or substance-specific withdrawal will usually suffice to categorize the symptom presentation. A diagnosis of substance/medication-induced anxiety disorder should be made in addition to substance intoxication or substance withdrawal when the panic or anxiety symptoms are predominant in the clinical picture and are sufficiently severe to warrant independent clinical attention. For example, panic or anxiety symptoms are characteristic of alcohol withdrawal.
Anxiety disorder (i.e., not induced by a substance/medication). Substance/medication-induced anxiety disorder is judged to be etiologically related to the substance/medication. Substance/medication-induced anxiety disorder is distinguished from a primary anxiety disorder based on the onset, course, and other factors with respect to substances/medications. For drugs of abuse, there must be evidence from the history, physical examination, or laboratory findings for use, intoxication, or withdrawal. Substance/medication-induced anxiety disorders arise only in association with intoxication or withdrawal states, whereas primary anxiety disorders may precede the onset of substance/medication use. The presence of features that are atypical of a primary anxiety disorder, such as atypical age at onset (e.g., onset of panic disorder after age 45 years) or symptoms (e.g., atypical panic attack symptoms such as true vertigo, loss of balance, loss of consciousness, loss of bladder control, headaches, slurred speech) may suggest a substance/medication-induced etiology. A primary anxiety disorder diagnosis is warranted if the panic or anxiety symptoms persist for a substantial period of time (about 1 month or longer) after the end of the substance intoxication or acute withdrawal or there is a history of an anxiety disorder.
Delirium. If panic or anxiety symptoms occur exclusively during the course of delirium, they are considered to be an associated feature of the delirium and are not diagnosed separately.
Anxiety disorder due to another medical condition. If the panic or anxiety symptoms are attributed to the physiological consequences of another medical condition (i.e., rather than to the medication taken for the medical condition), anxiety disorder due to another medical condition should be diagnosed. The history often provides the basis for such a judgment. At times, a change in the treatment for the other medical condition (e.g., medication substitution or discontinuation) may be needed to determine whether the medication is the causative agent (in which case the symptoms may be better explained by substance/medication-induced anxiety disorder). If the disturbance is attributable to both another medical condition and substance use, both diagnoses (i.e., anxiety disorder due to another medical condition and substance/medication-induced anxiety disorder) may be given. When there is insufficient evidence to determine whether the panic or anxiety symptoms are attributable to a substance/medication or to another medical condition or are primary (i.e., not attributable to either a substance or another medical condition), a diagnosis of other specified or unspecified anxiety disorder would be indicated.
1. Grant BF, Stinson FS, Dawson DA, et al: Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 61(8):807–816, 2004 15289279
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Diagnostic Criteria |
293.84 (F06.4) |
Coding note: Include the name of the other medical condition within the name of the mental disorder (e.g., 293.84 [F06.4] anxiety disorder due to pheochromocytoma). The other medical condition should be coded and listed separately immediately before the anxiety disorder due to the medical condition (e.g., 227.0 [D35.00] pheochromocytoma; 293.84 [F06.4] anxiety disorder due to pheochromocytoma.
The essential feature of anxiety disorder due to another medical condition is clinically significant anxiety that is judged to be best explained as a physiological effect of another medical condition. Symptoms can include prominent anxiety symptoms or panic attacks (Criterion A). The judgment that the symptoms are best explained by the associated physical condition must be based on evidence from the history, physical examination, or laboratory findings (Criterion B). Additionally, it must be judged that the symptoms are not better accounted for by another mental disorder, in particular, adjustment disorder, with anxiety, in which the stressor is the medical condition (Criterion C). In this case, an individual with adjustment disorder is especially distressed about the meaning or the consequences of the associated medical condition. By contrast, there is often a prominent physical component to the anxiety (e.g., shortness of breath) when the anxiety is due to another medical condition. The diagnosis is not made if the anxiety symptoms occur only during the course of a delirium (Criterion D). The anxiety symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E).
In determining whether the anxiety symptoms are attributable to another medical condition, the clinician must first establish the presence of the medical condition. Furthermore, it must be established that anxiety symptoms can be etiologically related to the medical condition through a physiological mechanism before making a judgment that this is the best explanation for the symptoms in a specific individual. A careful and comprehensive assessment of multiple factors is necessary to make this judgment. Several aspects of the clinical presentation should be considered: 1) the presence of a clear temporal association between the onset, exacerbation, or remission of the medical condition and the anxiety symptoms; 2) the presence of features that are atypical of a primary anxiety disorder (e.g., atypical age at onset or course); and 3) evidence in the literature that a known physiological mechanism (e.g., hyperthyroidism) causes anxiety. In addition, the disturbance must not be better explained by a primary anxiety disorder, a substance/medication-induced anxiety disorder, or another primary mental disorder (e.g., adjustment disorder).
A number of medical conditions are known to include anxiety as a symptomatic manifestation. Examples include endocrine disease (e.g., hyperthyroidism, pheochromocytoma, hypoglycemia, hyperadrenocortisolism), cardiovascular disorders (e.g., congestive heart failure, pulmonary embolism, arrhythmia such as atrial fibrillation), respiratory illness (e.g., chronic obstructive pulmonary disease, asthma, pneumonia), metabolic disturbances (e.g., vitamin B12 deficiency, porphyria), and neurological illness (e.g., neoplasms, vestibular dysfunction, encephalitis, seizure disorders). Anxiety due to another medical condition is diagnosed when the medical condition is known to induce anxiety and when the medical condition preceded the onset of the anxiety.
The prevalence of anxiety disorder due to another medical condition is unclear. There appears to be an elevated prevalence of anxiety disorders among individuals with a variety of medical conditions, including asthma, hypertension, ulcers, and arthritis2. However, this increased prevalence may be due to reasons other than the anxiety disorder directly causing the medical condition.
The development and course of anxiety disorder due to another medical condition generally follows the course of the underlying illness. This diagnosis is not meant to include primary anxiety disorders that arise in the context of chronic medical illness. This is important to consider with older adults, who may experience chronic medical illness and then develop independent anxiety disorders secondary to the chronic medical illness.
Laboratory assessments and/or medical examinations are necessary to confirm the diagnosis of the associated medical condition.
Delirium. A separate diagnosis of anxiety disorder due to another medical condition is not given if the anxiety disturbance occurs exclusively during the course of a delirium. However, a diagnosis of anxiety disorder due to another medical condition may be given in addition to a diagnosis of major neurocognitive disorder (dementia) if the etiology of anxiety is judged to be a physiological consequence of the pathological process causing the neurocognitive disorder and if anxiety is a prominent part of the clinical presentation.
Mixed presentation of symptoms (e.g., mood and anxiety). If the presentation includes a mix of different types of symptoms, the specific mental disorder due to another medical condition depends on which symptoms predominate in the clinical picture.
Substance/medication-induced anxiety disorder. If there is evidence of recent or prolonged substance use (including medications with psychoactive effects), withdrawal from a substance, or exposure to a toxin, a substance/medication-induced anxiety disorder should be considered. Certain medications are known to increase anxiety (e.g., corticosteroids, estrogens, metoclopramide), and when this is the case, the medication may be the most likely etiology, although it may be difficult to distinguish whether the anxiety is attributable to the medications or to the medical illness itself. When a diagnosis of substance-induced anxiety is being made in relation to recreational or nonprescribed drugs, it may be useful to obtain a urine or blood drug screen or other appropriate laboratory evaluation. Symptoms that occur during or shortly after (i.e., within 4 weeks of) substance intoxication or withdrawal or after medication use may be especially indicative of a substance/medication-induced anxiety disorder, depending on the type, duration, or amount of the substance used. If the disturbance is associated with both another medical condition and substance use, both diagnoses (i.e., anxiety disorder due to another medical condition and substance/medication-induced anxiety disorder) can be given. Features such as onset after age 45 years or the presence of atypical symptoms during a panic attack (e.g., vertigo, loss of consciousness, loss of bladder or bowel control, slurred speech, amnesia) suggest the possibility that another medical condition or a substance may be causing the panic attack symptoms.
Anxiety disorder (not due to a known medical condition). Anxiety disorder due to another medical condition should be distinguished from other anxiety disorders (especially panic disorder and generalized anxiety disorder). In other anxiety disorders, no specific and direct causative physiological mechanisms associated with another medical condition can be demonstrated. Late age at onset, atypical symptoms, and the absence of a personal or family history of anxiety disorders suggest the need for a thorough assessment to rule out the diagnosis of anxiety disorder due to another medical condition. Anxiety disorders can exacerbate or pose increased risk for medical conditions such as cardiovascular events and myocardial infarction and should not be diagnosed as anxiety disorder due to another medical condition in these cases1, 3, 4.
Illness anxiety disorder. Anxiety disorder due to another medical condition should be distinguished from illness anxiety disorder. Illness anxiety disorder is characterized by worry about illness, concern about pain, and bodily preoccupations. In the case of illness anxiety disorder, individuals may or may not have diagnosed medical conditions. Although an individual with illness anxiety disorder and a diagnosed medical condition is likely to experience anxiety about the medical condition, the medical condition is not physiologically related to the anxiety symptoms.
Adjustment disorders. Anxiety disorder due to another medical condition should be distinguished from adjustment disorders, with anxiety, or with anxiety and depressed mood. Adjustment disorder is warranted when individuals experience a maladaptive response to the stress of having another medical condition. The reaction to stress usually concerns the meaning or consequences of the stress, as compared with the experience of anxiety or mood symptoms that occur as a physiological consequence of the other medical condition. In adjustment disorder, the anxiety symptoms are typically related to coping with the stress of having a general medical condition, whereas in anxiety disorder due to another medical condition, individuals are more likely to have prominent physical symptoms and to be focused on issues other than the stress of the illness itself.
Associated feature of another mental disorder. Anxiety symptoms may be an associated feature of another mental disorder (e.g., schizophrenia, anorexia nervosa).
Other specified or unspecified anxiety disorder. This diagnosis is given if it cannot be determined whether the anxiety symptoms are primary, substance-induced, or associated with another medical condition.
1. Chen YH, Tsai SY, Lee HC, Lin HC: Increased risk of acute myocardial infarction for patients with panic disorder: a nationwide population-based study. Psychosom Med 71(7):798–804, 2009 19592516
2. Kessler RC, Ormel J, Demler O, Stang PE: Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: results from the National Comorbidity Survey. J Occup Environ Med 45(12):1257–1266, 2003 14665811
3. Martens EJ, de Jonge P, Na B, et al: Scared to death? Generalized anxiety disorder and cardiovascular events in patients with stable coronary heart disease: the Heart and Soul Study. Arch Gen Psychiatry 67(7):750–758, 2010 20603456
4. Scherrer JF, Chrusciel T, Zeringue A, et al: Anxiety disorders increase risk for incident myocardial infarction in depressed and nondepressed Veterans Administration patients. Am Heart J 159(5):772–779, 2010 20435185
This category 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 disorders 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. This is done by recording “other specified anxiety disorder” followed by the specific reason (e.g., “generalized anxiety not occurring more days than not”).
Examples of presentations that can be specified using the “other specified” designation include the following:
This category 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 disorders diagnostic class. The unspecified anxiety disorder category 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).