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Anxiety Disorders in Childhood and Adolescence

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Title: Anxiety Disorders in Childhood and Adolescence


1
Anxiety Disorders in Childhood and Adolescence
  • Psy 610A
  • Gary S. Katz, Ph.D.

2
Anxiety Disorders
  • Generalized Anxiety Disorder
  • Panic Disorder With Agoraphobia
  • Panic Disorder Without Agoraphobia
  • Agoraphobia Without History of Panic Disorder
  • Obsessive-Compulsive Disorder
  • Acute Stress Disorder
  • Posttraumatic Stress Disorder
  • Social Phobia
  • Specific Phobia
  • Substance-Induced Anxiety Disorder
  • Anxiety Disorder Due to General Medical Condition
  • Anxiety Disorder NOS

3
Presenting Complaints of Anxiety Disorders in
Childhood
  • Anxiety
  • Tachycardia
  • Shortness of breath
  • Fear
  • Sense of going crazy
  • Separation problems
  • Scared
  • Repetitive play
  • Sleep difficulties
  • Shyness
  • Palpitation
  • Dizziness
  • School refusal
  • Sense of impending death
  • Nervousness and worry
  • Tremulousness
  • Avoidant behavior
  • Hypervigilance
  • Social withdrawal

4
Definitions and Symptoms
  • Anxiety is a normal response to sudden,
    threatening changes facing an individual which
    may include real danger or perceived loss of
    self-esteem or control.
  • Manifestations may very for different children,
    generally see signs of
  • Motor tension, autonomic hyperactivity, worry
    about future events, and wariness.
  • When symptoms of anxiety are persistent, there is
    a need for treatment.
  • Can also see chronic anxiety accompanied by
    suicidal feelings, substance abuse, or other
    self-destructive behaviors. This implies serious
    risk requiring immediate attention.
  • Often see anxiety symptoms comorbid with
    depression.

5
Definitions
  • Dissociation The capability or process of
    separating thoughts, emotions, affects, or
    experiences from one another either purposely or
    involuntarily.
  • Derealization The dissociative experience of
    unreality or of loss of reality.
  • Depersonalization The dissociative experience of
    loss of identity as a person.
  • Paresthesia a sensation of numbness or tingling
    on the skin, sometimes described as pins and
    needles.

6
Generalized Anxiety Disorder (300.02)
  • Includes Overanxious Disorder of Childhood
  • Essential feature excessive anxiety and worry
    (apprehensive expectation), occurring more days
    than not for a period of at least 6 months.
  • Intensity, duration, or frequency of the anxiety
    and worry is far out of proportion to the actual
    likelihood or impact of the fear event.
  • Children 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.

7
Generalized Anxiety Disorder (300.02)
  • A. Excessive anxiety and worry (apprehensive
    expectation), occurring more days than not for at
    least 6 months, about a number of events or
    activities (such as work or school performance).
  • B. The person finds it difficult to control the
    worry.
  • C. The anxiety and worry are associated with
    three (or more) of the following six symptoms
    (with at least some symptoms present for more
    days than not for the past 6 months). Note Only
    one item is required in children.
  • (1) restlessness or feeling keyed up or on edge
  • (2) being easily fatigued
  • (3) difficulty concentrating or mind going blank
  • (4) irritability
  • (5) muscle tension
  • (6) sleep disturbance (difficulty falling or
    staying asleep, or restless unsatisfying sleep)

8
Generalized Anxiety Disorder (300.02)
  • D. The focus of the anxiety and worry is not
    confined to features of an Axis I disorder, e.g.,
    the anxiety or worry is not about having a Panic
    Attack (as in Panic Disorder), being embarrassed
    in public (as in Social Phobia), being
    contaminated (as in Obsessive-Compulsive
    Disorder), being away from home or close
    relatives (as in Separation Anxiety Disorder),
    gaining weight (as in Anorexia Nervosa), having
    multiple physical complaints (as in Somatization
    Disorder), or having a serious illness (as in
    Hypochondriasis), and the anxiety and worry do
    not occur exclusively during Posttraumatic Stress
    Disorder.
  • E. The anxiety, worry, or physical symptoms cause
    clinically significant distress or impairment in
    social, occupational, or other important areas of
    functioning.
  • F. The disturbance is not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition (e.g., hyperthyroidism) and does not
    occur exclusively during a Mood Disorder, a
    Psychotic Disorder, or a Pervasive Developmental
    Disorder.

9
Associated Features and Disorders
  • Associated with muscle tension, may see
  • trembling, twitching, feeling shaky, muscle
    aches, soreness.
  • Somatic symptoms
  • sweating, nausea, or diarrhea
  • Exaggerated startle response
  • Autonomic hyperarousal symptoms are less
    prominent in GAD than in other anxiety disorders
  • e.g., tachycardia, shortness of breath, dizziness
  • Depressive symptoms also common.

10
Associated Features and Disorders
  • GAD frequently co-occurs with
  • Mood Disorders (e.g., Major Depressive Disorder,
    Dysthymic Disorder).
  • Other Anxiety Disorders (e.g., Panic Disorder,
    Social Phobia)
  • Substance-Related Disorders (e.g., Alcohol or
    Sedative, Hypnotic, or Anxiolytic Dependence or
    Abuse).
  • Other conditions associated with stress (e.g.,
    irritable bowel syndrome, headaches) frequently
    accompany GAD.

11
Culture, Age, Gender Features
  • Considerable cultural variation in the expression
    of anxiety (e.g., some cultures focus on
    somaticization, others are more cognitive).
  • Important to consider the cultural context in
    evaluating anxious symptoms.
  • In children, worries often concern the quality of
    their performance, competence at school, or in
    sporting events, even when their performance is
    not being evaluated by others.
  • May be excessive concerns about punctuality,
    catastrophic events (e.g., nuclear war,
    earthquakes).
  • Children with GAD may be overconforming,
    perfectionistic, unsure of themselves, and may
    redo tasks because of excessive dissatisfaction
    with less-than-perfect performance.
  • Children with GAD may be overzealous in seeking
    approval or require excessive reassurance about
    their performance.

12
Culture, Age, Gender Features
  • GAD may be overdiagnosed in children.
  • Need to conduct a thorough diagnostic evaluation
    to determine if the anxiety-related concerns are
    truly GAD or better accounted for by one of the
    other Anxiety Disorders.
  • In adults, GAD appears more prevalent in females.
  • In clinical settings, about 55-60 of those
    presenting with GAD are female.
  • In community epidemiological studies, about 66
    of the GAD cases are female.
  • Epidemiology of child GAD is currently being
    studied.
  • Links with behavioral inhibition and shyness
  • Role of the amygdala (hypersensitivity)

13
Common Developmental Presentations
  • Infancy
  • Rarely diagnosed
  • During second year of life, fears and distress
    occurring in situations not ordinarily associated
    with expected anxiety that is not amenable to
    traditional soothing and has an irrational
    quality about it may suggest GAD.

14
Common Developmental Presentations
  • Early Childhood
  • Rarely diagnosed
  • May be expressed by crying, tantrums, freezing,
    or clinging, or staying close to a familiar
    person.
  • Young children may appear excessively timid in
    unfamiliar social settings, shrink from contact
    with others, refuse to participate in group play,
    remain on the periphery of social activities, and
    attempt to remain close to familiar adults to the
    extent that family life is disrupted.

15
Common Developmental Presentations
  • Middle Childhood to Adolescence
  • Symptoms generally include physiologic symptoms
    associated with anxiety (e.g., restlessness,
    sweating, tension) and avoidance behaviors such
    as refusing to attend school, lack of
    participation in school, decline in classroom
    performance or social functions.
  • Can also see increase in worries and sleep
    disturbance.
  • These developmental presentations are common to
    many Anxiety Disorders

16
Prevalence Course
  • In adults
  • 1yr prevalence rate approx 3
  • Lifetime prevalence 5
  • In children?
  • Up to 25 of individuals presenting at anxiety
    clinics present with GAD.
  • Many individuals with GAD report that they have
    been anxious all their lives.
  • Half of those presenting for treatment report
    onset in childhood or adolescence.
  • Onset after 20yrs of age is not uncommon.
  • Course is generally chronic but fluctuating,
    worsening during periods of stress.

17
Familial Pattern
  • Early studies show inconsistent findings
    regarding familial patterns for GAD.
  • More recent twin studies suggest a genetic
    contribution to the development of GAD.
  • Genetic factors influencing GAD may also
    influence Major Depressive Disorder.
  • Hettema, et. al., (2005) find that there may be
    common genetic factors for a range of anxiety
    disorders in a comprehensive twin study of nearly
    5000 twin pairs.

18
Differential Diagnosis
  • Anxiety Disorder Due to a General Medical
    Condition
  • Substance-Induced Anxiety Disorder
  • Need to be sure that the anxiety in GAD is
    unrelated to other Axis I disorders (e.g., eating
    disorders and fear of gaining weight).
  • OCD
  • PTSD
  • Nonpathological anxiety

19
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20
Panic Disorder
  • Essential feature the presence of recurrent,
    unexpected Panic Attacks followed by at least 1
    month of persistent concern about having another
    Panic Attack.
  • Unexpected Panic Attack
  • Not immediately associated with a situational
    trigger
  • out of the blue
  • Situationally-bound attacks are rare
  • Frequency and severity of Panic Attacks vary
    widely.
  • Once weekly, monthly
  • Limited-symptom attacks are typically reported in
    individuals with Panic Disorder

21
Panic Disorder
  • Fears are real in Panic Disorder
  • Individual believes that they are dying, having a
    heart attack, or have some undiagnosed,
    life-threatening illness.
  • Despite repeated medical testing showing no
    concerns, often the fear persists.
  • Adults with Panic Disorder will quit their jobs,
    avoid physical exertion all to prevent another
    Panic Attack. Can see school avoidance in kids
    with Panic Disorder.
  • This avoidant behavior may meet criteria for
    Agoraphobia, in which case Panic Disorder with
    Agoraphobia is diagnosed.

22
Panic Attack
  • Note A Panic Attack is not a codable disorder.
    Code the specific diagnosis in which the Panic
    Attack occurs (e.g., 300.21 Panic Disorder With
    Agoraphobia.
  • A discrete period of intense fear or discomfort,
    in which four (or more) of the following symptoms
    developed abruptly and reached a peak within 10
    minutes
  • (1) palpitations, pounding heart, or accelerated
    heart rate
  • (2) sweating
  • (3) trembling or shaking
  • (4) sensations of shortness of breath or
    smothering
  • (5) feeling of choking
  • (6) chest pain or discomfort
  • (7) nausea or abdominal distress
  • (8) feeling dizzy, unsteady, lightheaded, or
    faint
  • (9) derealization or depersonalization
  • (10) fear of losing control or going crazy
  • (11) fear of dying
  • (12) paresthesias (numbness or tingling
    sensations)
  • (13) chills or hot flushes

23
Agoraphobia
  • Note Agoraphobia is not a codable disorder.
    Code the specific disorder in which the
    Agoraphobia occurs (e.g., 300.21 Panic Disorder
    With Agoraphobia or 300.22 Agoraphobia Without
    History of Panic Disorder).
  • A. Anxiety about being in places or situations
    from which escape might be difficult (or
    embarrassing) or in which help may not be
    available in the event of having an unexpected or
    situationally predisposed Panic Attack or
    panic-like symptoms. Agoraphobic fears typically
    involve characteristic clusters of situations
    that include being outside the home alone being
    in a crowd or standing in a line being on a
    bridge and traveling in a bus, train, or
    automobile.
  • Note Consider the diagnosis of Specific Phobia
    if the avoidance is limited to one or only a few
    specific situations, or Social Phobia if the
    avoidance is limited to social situations.

24
Agoraphobia
  • B. The situations are avoided (e.g., travel is
    restricted) or else are endured with marked
    distress or with anxiety about having a Panic
    Attack or panic-like symptoms, or require the
    presence of a companion.
  • C. The anxiety or phobic avoidance is not better
    accounted for by another mental disorder, such as
    Social Phobia (e.g., avoidance limited to social
    situations because of fear of embarrassment),
    Specific Phobia (e.g., avoidance limited to a
    single situation like elevators),
    Obsessive-Compulsive Disorder (e.g., avoidance of
    dirt in someone with an obsession about
    contamination), Posttraumatic Stress Disorder
    (e.g., avoidance of stimuli associated with a
    severe stressor), or Separation Anxiety Disorder
    (e.g., avoidance of leaving home or relatives).

25
Associated Features and Disorders
  • Frequently experience constant or intermittent
    feelings of anxiety not focused on any specific
    situation or event. May not be able to get this
    information from children.
  • Can see individuals anticipate a catastrophic
    outcome from a mild physical symptom or
    medication side effect.
  • Loss or disruption of important interpersonal
    relationships is associated with the onset or
    exacerbation of Panic Disorder in adults.
  • Demoralization also common among adults and
    adolescents leading to school work drop-outs.

26
Associated Features and Disorders
  • Comorbid MDD ranges between 10 and 65 in
    individuals with Panic Disorder.
  • Other Anxiety Disorders 15 to 30 in
    individuals with Panic Disorder
  • Induced Panic Attacks with sodium lactate
    infusion or carbon dioxide inhalation are more
    common in individuals with Panic Disorders than
    controls or individuals with GAD.

27
Associated Physical Findings
  • During Panic Attacks
  • Transient tachycardia
  • Moderately elevated systolic BP
  • Numerous general medical conditions have been
    found to be comorbid
  • Dizziness, cardiac arrhythmias, hyperthyroidism,
    asthma, CPOD, irritable bowel
  • however, cause-and-effect relationship remains
    unclear.

28
Culture and Gender Features
  • In some cultures, may see Panic Attack associated
    with an intense fear of witchcraft or magic.
  • Panic Disorder has been found in epidemiological
    studies throughout the world.
  • Need to account for cultural restrictions in
    making the agoraphobia distinction
  • e.g., cultural restriction of women in public
    life is not agoraphobia
  • More common in adult women than in adult men
  • Without Agoraphobia 21 sex ratio
  • With Agoraphobia 31 sex ratio
  • In children?

29
Prevalence Course
  • Rare in childhood
  • Onset typically in late adolescence and mid-30s.
  • Bimodal distribution.
  • Usual course is chronic, but with some waxing and
    waning.

30
Familial Pattern
  • First degree biological relatives of positive
    probands have an 8x increased risk of Panic
    Disorder
  • If the age of onset is before 20, risk jumps to
    20x
  • In clinical settings, 50 to 75 of individuals
    with Panic Disorder do not have an affected
    first-degree biological relative with Panic
    Disorder.
  • Twin studies suggest a biological contribution to
    the development of Panic Disorder.

31
Common Developmental Presentations
  • Infancy not relevant
  • Early Childhood
  • Crying, tantrums, freezing, clinging, or staying
    close to a familiar person during a panic attack.
  • Middle Childhood
  • Panic attacks may be manifested by symptoms such
    as tachycardia, shortness of breath, spreading
    chest pain, and extreme tension
  • Adolescence
  • Symptoms similar to adults.
  • Sense of impending doom, fear of going crazy,
    feelings of unreality and somatic symptoms such
    as shortness of breath, palpitations, sweating,
    choking, and chest pain.

32
Differential Diagnosis
  • Anxiety Disorder Due to a General Medical
    Condition
  • Substance-Induced Anxiety Disorder
  • Other Axis I disorders
  • Other Anxiety Disorders
  • Social Phobia and Panic Disorder with Agoraphobia
    differential may be difficult
  • Focus on the nature of the fear and the
    subsequent panic attack
  • If the fears and panic attacks generalize, may
    warrant a Panic Disorder diagnosis. Otherwise,
    Social Phobia may be more appropriate.
  • Can Dx multiple Anxiety/Mood Disorders
  • Self-medication leading to Substance-Related
    Disorders is common.

33
Panic Disorder With Agoraphobia (300.21)
  • A. Both (1) and (2)
  • (1) recurrent unexpected Panic Attacks
  • (2) at least one of the attacks has been followed
    by 1 month (or more) of one (or more) of the
    following
  • (a) persistent concern about having additional
    attacks
  • (b) worry about the implications of the attack or
    its consequences (e.g., losing control, having a
    heart attack, "going crazy")
  • (c) a significant change in behavior related to
    the attacks
  • B. The presence of Agoraphobia.

34
Panic Disorder With Agoraphobia (300.21)
  • C. The Panic Attacks are not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition (e.g., hyperthyroidism).
  • D. The Panic Attacks are not better accounted for
    by another mental disorder, such as Social Phobia
    (e.g., occurring on exposure to feared social
    situations), Specific Phobia (e.g., on exposure
    to a specific phobic situation),
    Obsessive-Compulsive Disorder (e.g., on exposure
    to dirt in someone with an obsession about
    contamination), Posttraumatic Stress Disorder
    (e.g., in response to stimuli associated with a
    severe stressor), or Separation Anxiety Disorder
    (e.g., in response to being away from home or
    close relatives).

35
Panic Disorder Without Agoraphobia (300.01)
  • A. Both (1) and (2)
  • (1) recurrent unexpected Panic Attacks
  • (2) at least one of the attacks has been followed
    by 1 month (or more) of one (or more) of the
    following
  • (a) persistent concern about having additional
    attacks
  • (b) worry about the implications of the attack or
    its consequences (e.g., losing control, having a
    heart attack, "going crazy")
  • (c) a significant change in behavior related to
    the attacks
  • B. Absence of Agoraphobia.

36
Panic Disorder Without Agoraphobia (300.01)
  • C. The Panic Attacks are not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition (e.g., hyperthyroidism).
  • D. The Panic Attacks are not better accounted for
    by another mental disorder, such as Social Phobia
    (e.g., occurring on exposure to feared social
    situations), Specific Phobia (e.g., on exposure
    to a specific phobic situation),
    Obsessive-Compulsive Disorder (e.g., on exposure
    to dirt in someone with an obsession about
    contamination), Posttraumatic Stress Disorder
    (e.g., in response to stimuli associated with a
    severe stressor), or Separation Anxiety Disorder
    (e.g., in response to being away from home or
    close relatives).

37
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38
Agoraphobia Without History of Panic Disorder
(300.22)
  • Essential feature focus of ones fear is on the
    occurrence of incapacitating or extremely
    embarrassing panic-like symptoms or
    limited-symptom attacks rather than full Panic
    Attacks.

39
Culture Gender Features
  • Need to consider cultural restrictions on
    participation of women in public life not
    agoraphobia.
  • Agoraphobia diagnosed far more frequently in
    females than in males.
  • Children?

40
Prevalence Course
  • Vast majority of individuals with Agoraphobia
    also present with current (or history of) Panic
    Disorder.
  • Unknown in childhood.
  • Little known about course assumed to be
    persistent and associated with considerable
    impairment.

41
Differential Diagnosis
  • Panic Disorder with Agoraphobia
  • Social Phobia
  • Specific Phobia
  • Major Depressive Disorder
  • Persecutory fears in OCD or Delusional Disorder
  • Separation Anxiety Disorder

42
Agoraphobia Without History of Panic Disorder
(300.22)
  • A. The presence of Agoraphobia related to fear of
    developing panic-like symptoms (e.g., dizziness
    or diarrhea).
  • B. Criteria have never been met for Panic
    Disorder.
  • C. The disturbance is not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition.
  • D. If an associated general medical condition is
    present, the fear described in Criterion A is
    clearly in excess of that usually associated with
    the condition.

43
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44
Obsessive-Compulsive Disorder (300.3)
  • Essential feature recurrent obsessions or
    compulsions.
  • Obsessions persistent ideas, thoughts,
    impulses, or images that are experienced as
    intrusive and inappropriate, causing anxiety or
    distress
  • Compulsions repetitive behaviors (e.g., hand
    washing, ordering, checking) or mental acts
    (e.g., praying, counting, repeating words
    silently) the goal of which is to prevent or
    reduce anxiety or distress, not to provide
    pleasure or gratification.
  • While adults may recognize that the obsessions or
    compulsions are excessive or unreasonable,
    children may not.

45
Associated Features and Disorders
  • Avoidance of situations involving the content of
    the obsessions (e.g., dirt, germs leading to
    avoding public restrooms or shaking hands with
    strangers).
  • Can see dermatologic problems caused by excessive
    washing with water or caustic clearning agents.

46
Cultural Features
  • Culturally-prescribed ritual behavior is not OCD
    unless it exceed cultural norms, occurs at times
    and places judged inappropriate by others of the
    same culture, and interferes with social role
    functioning.
  • Life transitions and mourning may lead to an
    intensification of ritualized behavior.

47
Age and Gender Features
  • Washing, checking, and ordering rituals are
    common in children.
  • Children generally experience OCD as
    ego-syntonic.
  • More often, the problem is identified by parents.
  • Gradual declines in schoolwork, secondary to
    impaired concentration has been reported.
  • A small subset of children with Group A
    beta-hemolytic strep (e.g., scarlet fever and
    strep throat) may develop OCD.
  • This form of OCD also associated with other
    movement and neurological abnormalities.
  • Childhood onset OCD more common in boys than in
    girls.

48
Common Developmental Presentations
  • Infancy rarely present at this age
  • Early Childhood
  • Child evidences a higher degree of compulsive and
    ritualistic behavior, from holding onto certain
    objects, watching certain videos, or lining up
    toys in certain sequences. These rigidities are
    less responsive to soothing and interaction than
    at the problem level.

49
Common Developmental Presentations
  • Middle Childhood and Adolescence
  • Child presents with obsessions and compulsions
    such as repetitive hand washing, ordering,
    checking, counting, repeating words silently,
    repetitive praying.
  • The obsessions or compulsions interfere with
    listening or attending in class and frequently
    grades worsen because the child cannot sit still
    during tests or lectures.
  • Child may fear harming himself or herself or
    others if compulsion is not performed and has
    problems with task completion.

50
Prevalence and Course
  • Community studies of children and adolescents
    estimated lifetime prevalence of 1 to 2.3 and a
    1-year prevalence of 0.7.
  • Research suggests that prevalence is consistent
    in many different cultures.
  • Usually, OCD begins in adolescence or adulthood.
  • May begin in early childhood.
  • Modal age at onset is earlier in males (6y-16y)
    than for females (20-29).
  • Onset is usually gradual, acute onset has been
    noted.
  • Majority of individuals have a chronic waxing and
    waning, exacerbated by stress.
  • 15 show progressive deterioration in
    occupational and social functioning.
  • 5 of episodic course with minimal or no symptoms
    between episodes.

51
Familial Pattern
  • Concordance rates for OCD higher in monozygotic
    twins than in dizygotic twins.
  • Rate of OCD in first-degree biological relatives
    of OCD positive probands is higher.
  • Also see familial clustering of OCD in
    individuals with first-degree biological
    relatives with Tourettes Disorder.

52
Differential Diagnosis
  • Anxiety Disorder Due to a General Medical
    Condition
  • Substance-Induced Anxiety Disorder
  • Recurrent or intrusive thoughts with other Axis I
    disorders
  • Body Dysmorphic Disorder
  • Specific or Social Phobia
  • Trichotillomania
  • Major Depressive Disorder
  • GAD
  • Hypochondriasis

53
Differential Diagnosis
  • With loose reality testing re obsessions and
    compulsions, consider Delusional Disorder or
    Psychotic Disorder NOS
  • Schizophrenia
  • Tic Disorder
  • Eating Disorders
  • Paraphilias
  • OCPD
  • Pervasive pattern of preoccupation with
    orderliness. NOT OCD
  • Superstitions or repetitive checking behaviors.

54
Obsessive-Compulsive Disorder (300.3)
  • A. Either obsessions or compulsions
  • Obsessions as defined by (1), (2), (3), and (4)
  • (1) recurrent and persistent thoughts, impulses,
    or images that are experienced, at some time
    during the disturbance, as intrusive and
    inappropriate and that cause marked anxiety or
    distress
  • (2) the thoughts, impulses, or images are not
    simply excessive worries about real-life problems
  • (3) the person attempts to ignore or suppress
    such thoughts, impulses, or images, or to
    neutralize them with some other thought or action
  • (4) the person recognizes that the obsessional
    thoughts, impulses, or images are a product of
    his or her own mind (not imposed from without as
    in thought insertion)

55
Obsessive-Compulsive Disorder (300.3)
  • A. Either obsessions or compulsions
  • Compulsions as defined by (1) and (2)
  • (1) repetitive behaviors (e.g., hand washing,
    ordering, checking) or mental acts (e.g.,
    praying, counting, repeating words silently) that
    the person feels driven to perform in response to
    an obsession, or according to rules that must be
    applied rigidly
  • (2) the behaviors or mental acts are aimed at
    preventing or reducing distress or preventing
    some dreaded event or situation however, these
    behaviors or mental acts either are not connected
    in a realistic way with what they are designed to
    neutralize or prevent or are clearly excessive

56
Obsessive-Compulsive Disorder (300.3)
  • B. At some point during the course of the
    disorder, the person has recognized that the
    obsessions or compulsions are excessive or
    unreasonable. Note This does not apply to
    children.
  • C. The obsessions or compulsions cause marked
    distress, are time consuming (take more than 1
    hour a day), or significantly interfere with the
    person's normal routine, occupational (or
    academic) functioning, or usual social activities
    or relationships.

57
Obsessive-Compulsive Disorder (300.3)
  • D. If another Axis I disorder is present, the
    content of the obsessions or compulsions is not
    restricted to it (e.g., preoccupation with food
    in the presence of an Eating Disorders hair
    pulling in the presence of Trichotillomania
    concern with appearance in the presence of Body
    Dysmorphic Disorder preoccupation with drugs in
    the presence of a Substance Use Disorder
    preoccupation with having a serious illness in
    the presence of Hypochondriasis preoccupation
    with sexual urges or fantasies in the presence of
    a Paraphilia or guilty ruminations in the
    presence of Major Depressive Disorder).
  • E. The disturbance is not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition.
  • Specify if
  • With Poor Insight if, for most of the time
    during the current episode the person does not
    recognize that the obsessions and compulsions are
    excessive or unreasonable

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Acute Stress Disorder (308.3)
  • Essential feature the development of
    characteristic anxiety, dissociative, and other
    symptoms that occurs within 1 month after
    exposure to an extreme traumatic stressor.
  • As a response to the traumatic event, the
    individual develops dissociative symptoms.
  • Individuals with Acute Stress Disorder may
  • have a decrease in emotional responsiveness
  • feel guilty about pursuing usual life tasks
  • experience difficulty concentrating
  • experience the world as unreal or dreamlike
  • have difficulty recalling details from the
    traumatic event
  • yet re-experience the traumatic event
  • avoid reminders of the trauma
  • experience hyperarousal hypervigilance

60
Associated Features and Disorders
  • Symptoms of despair and hopelessness may present
    sufficiently to warrant a diagnosis of Major
    Depressive Disorder (can be comorbid)
  • Survivors guilt
  • Problems may result from a lack of attention to
    the individuals basic health and safety needs
    following the trauma
  • Increased risk for PTSD
  • 80 of victims of auto crash survivors, victims
    of violent crime who meet criteria for Acute
    Stress Disorder go on to meet criteria for PTSD
  • Impulsive and risk-taking behavior also common
    after the trauma.

61
Specific Culture Features
  • Need to consider culturally-bound events
    regarding loss as being processed differently by
    different cultures.
  • Different cultures may have different prescribed
    coping behaviors.
  • Dissociative behaviors that are
    culturally-sanctioned are not Acute Stress
    Disorder

62
Prevalence Course
  • Prevalence in the general population (adults)
    ranges from 14 to 33 in individuals exposed to
    severe trauma (i.e., being in a motor vehicle
    accident, being a bystander at a mass shooting)
  • Prevalence in children?
  • Symptoms, by definition, start during or
    immediately after the trauma, last for 2 days,
    and either resolves within 4 weeks or the
    diagnosis changes (PTSD).
  • Severity, duration, and proximity of exposure to
    the traumatic event predict the likelihood of
    developing Acute Stress Disorder
  • Other factors include social supports, family
    history, childhood experiences, personality
    variables, and preexisting mental disorders may
    have a role in developing Acute Stress Disorder.

63
Differential Diagnosis
  • Mental Disorder Due to a General Medical
    Condition
  • Substance-Induced Disorder
  • If psychotic symptoms are present, consider Brief
    Psychotic Disorder
  • Major Depressive Disorder can develop afterwards
    as well
  • If symptoms persist beyond 4 weeks, PTSD
  • Adjustment Disorder
  • Malingering (if financial remuneration, benefit
    eligibility, or forensic determinations play a
    role).

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Acute Stress Disorder (308.3)
  • A. The person has been exposed to a traumatic
    event in which both of the following were
    present
  • (1) the person experienced, witnessed, or was
    confronted with an event or events that involved
    actual or threatened death or serious injury, or
    a threat to the physical integrity of self or
    others
  • (2) the person's response involved intense fear,
    helplessness, or horror
  • B. Either while experiencing or after
    experiencing the distressing event, the
    individual has three (or more) of the following
    dissociative symptoms
  • (1) a subjective sense of numbing, detachment, or
    absence of emotional responsiveness
  • (2) a reduction in awareness of his or her
    surroundings (e.g., "being in a daze")
  • (3) derealization
  • (4) depersonalization
  • (5) dissociative amnesia (i.e., inability to
    recall an important aspect of the trauma)

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Acute Stress Disorder (308.3)
  • C. The traumatic event is persistently
    reexperienced in at least one of the following
    ways recurrent images, thoughts, dreams,
    illusions, flashback episodes, or a sense of
    reliving the experience or distress on exposure
    to reminders of the traumatic event.
  • D. Marked avoidance of stimuli that arouse
    recollections of the trauma (e.g., thoughts,
    feelings, conversations, activities, places,
    people).
  • E. Marked symptoms of anxiety or increased
    arousal (e.g., difficulty sleeping, irritability,
    poor concentration, hypervigilance, exaggerated
    startle response, motor restlessness).

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Acute Stress Disorder (308.3)
  • F. The disturbance causes clinically significant
    distress or impairment in social, occupational,
    or other important areas of functioning or
    impairs the individual's ability to pursue some
    necessary task, such as obtaining necessary
    assistance or mobilizing personal resources by
    telling family members about the traumatic
    experience.
  • G. The disturbance lasts for a minimum of 2 days
    and a maximum of 4 weeks and occurs within 4
    weeks of the traumatic event.
  • H. The disturbance is not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition, is not better accounted for by Brief
    Psychotic Disorder, and is not merely an
    exacerbation of a preexisting Axis I or Axis II
    disorder.

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Posttraumatic Stress Disorder (309.81)
  • Essential feature the development of
    characteristic symptoms following exposure to an
    extreme traumatic stressor involving direct
    personal experience of an event that involves
    actual or threatened death or serious injury, or
    a threat to the physical integrity of another
    person or learning about similar threats
    experienced by a family member or a close
    associate.
  • Examples of traumatic events
  • Military combat, violent personal assault, being
    kidnapped, taken hostage, terrorist attack,
    torture, incarceration as a POW, natural or
    manmade disasters
  • For children
  • sexually traumatic events (e.g., developmentally
    inappropriate sexual experiences without
    threatened or actual violence or injury).
  • Witnessing events involving serious injury or
    unnatural death of another person

69
Associated Features and Disorders
  • Survivor guilt
  • Avoidance patterns
  • Can see auditory hallucinations and/or paranoid
    ideation
  • In child survivors of sexual or physical abuse
  • Impaired affect modulation
  • Self-destructive and impulsive behavior
  • Dissociative symptoms
  • Somatic complaints
  • Feelings of ineffectiveness
  • Shame, despair, or hopelessness
  • Feeling permanently damaged
  • A loss of previously sustained beliefs
  • Hostility
  • Social withdrawal
  • Feeling constantly threatened
  • Impaired relationships with others
  • Change from the individuals original personality
    characteristics

70
Associated Features and Disorders
  • PTSD is associated with increased rates of
  • Major Depressive Disorder
  • Substance-Related Disorders
  • Panic Disorder
  • Agoraphobia
  • OCD
  • GAD
  • Social Phobia
  • Specific Phobia
  • Bipolar Disorder
  • These conditions can either precede, follow, or
    emerge concurrently with the onset of PTSD

71
Culture Features
  • Recent immigrants from areas of social unrest and
    civil conflict may have elevated rates of PTSD.
  • These individuals may be reluctant to divulge
    these experiences of torture and trauma due to
    their vulnerable political immigrant status.
  • Specific assessments for these individuals are
    warranted.

72
Age Features
  • In younger children, can see distressing dreams
    of the event may within weeks change into
    generalized nightmares of monsters, rescuing
    others, or of threats to self or others.
  • Young children usually do not have the sense that
    they are reliving the trauma rather, this may
    occur through repetitive play.
  • Diminished interest in significant activities,
    affect constriction not usually reported by
    children need to interview collateral sources
    (parents, teachers) for this information.
  • Foreshortened future may include a prediction
    that they will never be an adult.
  • Omen formation belief in an ability to
    foresee future untoward events
  • Also see physical symptoms such as stomachaches
    and headaches.

73
Prevalence
  • Community-based samples lifetime prevalence of
    8 in adults
  • Children?
  • Higher rates of PTSD prevalence (between 33 and
    50) seen in survivors of rape, military combat
    and captivity, and ethnically or politically
    motivated internment and genocide.

74
Course
  • PTSD can begin at any age, including childhood.
  • Rarely diagnosed in infancy
  • May take the form of extra fears or aggressive
    behaviors in response to stress
  • Symptoms usually begin with 3 months after the
    trauma, although may be a delay of months or even
    years.
  • Frequently individuals progress from Acute Stress
    Disorder to PTSD
  • Duration of symptoms vary
  • Complete recovery within 3 months for 50 of the
    cases
  • Many others having symptoms persist for longer
    than 12 months
  • Course can be waxing and waning
  • Symptom reactivation response to reminders of
    the original trauma
  • Severity, duration, and proximity of an
    individuals exposure to the traumatic event are
    the most important factors affecting the
    likelihood of developing PTSD.
  • Some evidence that social supports, family
    history, childhood experiences, personality
    variables, and preexisting mental disorders may
    influence the development of PTSD.

75
Familial Pattern
  • Evidence of a heritable component to the
    transmission of PTSD
  • History of depression in first-degree relatives
    linked to increased vulnerability to developing
    PTSD
  • Twin study published in 2003 showed an increase
    concordance rate of PTSD in a study of twins who
    were Vietnam veterans.

76
Differential Diagnosis
  • Adjustment Disorder (low intensity stressor)
  • Acute Stress Disorder (duration criterion)
  • OCD
  • Illusions, hallucinations, perceptual
    disturbances also seen in
  • Schizophrenia, other Psychotic Disorders
  • Mood Disorder with Psychotic Features
  • Delirium
  • Substance-Induced Disorders
  • Malingering (if financial remuneration, benefit
    eligibility, or forensic determinations are in
    play).

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Posttraumatic Stress Disorder (309.81)
  • A. The person has been exposed to a traumatic
    event in which both of the following were
    present
  • (1) the person experienced, witnessed, or was
    confronted with an event or events that involved
    actual or threatened death or serious injury, or
    a threat to the physical integrity of self or
    others
  • (2) the person's response involved intense fear,
    helplessness, or horror. Note In children, this
    may be expressed instead by disorganized or
    agitated behavior

78
Posttraumatic Stress Disorder (309.81)
  • B. The traumatic event is persistently
    reexperienced in one (or more) of the following
    ways
  • (1) recurrent and intrusive distressing
    recollections of the event, including images,
    thoughts, or perceptions. Note In young
    children, repetitive play may occur in which
    themes or aspects of the trauma are expressed.
  • (2) recurrent distressing dreams of the event.
    Note In children, there may be frightening
    dreams without recognizable content.
  • (3) acting or feeling as if the traumatic event
    were recurring (includes a sense of reliving the
    experience, illusions, hallucinations, and
    dissociative flashback episodes, including those
    that occur on awakening or when intoxicated).
    Note In young children, trauma-specific
    reenactment may occur.
  • (4) intense psychological distress at exposure to
    internal or external cues that symbolize or
    resemble an aspect of the traumatic event
  • (5) physiological reactivity on exposure to
    internal or external cues that symbolize or
    resemble an aspect of the traumatic event

79
Posttraumatic Stress Disorder (309.81)
  • C. Persistent avoidance of stimuli associated
    with the trauma and numbing of general
    responsiveness (not present before the trauma),
    as indicated by three (or more) of the following
  • (1) efforts to avoid thoughts, feelings, or
    conversations associated with the trauma
  • (2) efforts to avoid activities, places, or
    people that arouse recollections of the trauma
  • (3) inability to recall an important aspect of
    the trauma
  • (4) markedly diminished interest or participation
    in significant activities
  • (5) feeling of detachment or estrangement from
    others
  • (6) restricted range of affect (e.g., unable to
    have loving feelings)
  • (7) sense of a foreshortened future (e.g., does
    not expect to have a career, marriage, children,
    or a normal life span)

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Posttraumatic Stress Disorder (309.81)
  • D. Persistent symptoms of increased arousal (not
    present before the trauma), as indicated by two
    (or more) of the following
  • (1) difficulty falling or staying asleep
  • (2) irritability or outbursts of anger
  • (3) difficulty concentrating
  • (4) hypervigilance
  • (5) exaggerated startle response
  • E. Duration of the disturbance (symptoms in
    Criteria B, C, and D) is more than 1 month.

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Posttraumatic Stress Disorder (309.81)
  • F. The disturbance causes clinically significant
    distress or impairment in social, occupational,
    or other important areas of functioning.
  • Specify if
  • Acute if duration of symptoms is less than 3
    months
  • Chronic if duration of symptoms is 3 months or
    more
  • Specify if
  • With Delayed Onset if onset of symptoms is at
    least 6 months after the stressor

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Social Phobia (300.23)
  • Also known as Social Anxiety Disorder
  • Essential feature marked and persistent fear of
    social or performance situations in which
    embarrassment may occur.
  • Individuals often afraid of being judged to be
    anxious, weak, crazy, or stupid.
  • Almost always experience symptoms of anxiety
  • Adults may realize that the fear is unusual or
    excessive, children may not.
  • Symptom duration of 6mos for those under the age
    of 18.

84
Associated Features and Disorders
  • Hypersensitivity to criticism, negative
    evaluation, or rejection
  • Difficulty being assertive
  • Low self-esteem or feelings of inferiority
  • Can see poor social skills (e.g., poor eye
    contact) or observable signs of anxiety (e.g.,
    cold clammy hands)
  • Often see underachievement in school due to test
    anxiety or avoidance of classroom participation
  • In severe cases, these individuals may drop out
    of school, have no friends or cling to
    unfulfilling relationships, completely refrain
    from dating, or remain with their family of
    origin
  • Can see suicidal ideation when other comorbid
    disorders are present.

85
Cultural Features
  • Clinical presentation may vary across cultures,
    depending upon social demands.
  • In certain cultures, fear of offending others may
    pervade (e.g., Japan and Korea)

86
Age Features
  • In children crying, tantrums, freezing, clinging,
    or staying close to a familiar person and
    inhibited interactions to the point of mutism may
    be present.
  • Young children may appear excessively timid in
    unfamiliar social settings, shrink from others,
    refuse to participate in group play, stay on the
    periphery of social activities, and attempt to
    remain close to familiar adults.
  • Unlike adults, children usually do not have the
    option of avoiding feared situations altogether
    and may be unable to identify the nature of their
    anxiety.
  • Decline in school performance, school refusal,
    avoidance of age-appropriate social activities
    and dating.
  • Need to see capacity to have social relationships
    with familiar people to make diagnosis in
    children.

87
Age Features
  • Early onset and chronic course leads to failure
    to achieve at expected level of functioning,
    rather than a decline from optimal functioning.
  • With onset in adolescence, can see decrements in
    social and academic performance.

88
Gender Features and Prevalence
  • Epidemiological studies suggest Social Phobia is
    more common in women than in men.
  • In most clinical samples, equal sex
    representation or majority males.
  • Children?
  • UK sample .4 to 1.8 prevalence

89
Course
  • Typical onset in mid-teens, sometimes emerging
    out of a childhood history of social inhibition
    or shyness.
  • Some individuals report onset in early childhood.
  • Onset may follow an abruptly humiliating
    experience.
  • Course is usually continuous, lifelong, although
    severity may attenuate or remit in adulthood.
  • May diminish after marriage and reemerge after
    death of a spouse.

90
Familial Pattern
  • Occurs more frequently among first-degree
    biological relatives of those with Social Phobia
    than in the general population.
  • Evidence strongest for the generalized subtype.

91
Differential Diagnosis
  • Panic Disorder with Agoraphobia
  • Separation Anxiety Disorder
  • SAD Children usually comfortable at home, SP
    children may not be.
  • Generalized Anxiety Disorder
  • Pervasive Developmental Disorder
  • Performance anxiety, stage fright, shyness

92
Social Phobia (300.23)
  • A. A marked and persistent fear of one or more
    social or performance situations in which the
    person is exposed to unfamiliar people or to
    possible scrutiny by others. The individual fears
    that he or she will act in a way (or show anxiety
    symptoms) that will be humiliating or
    embarrassing.
  • Note In children, there must be evidence of the
    capacity for age-appropriate social relationships
    with familiar people and the anxiety must occur
    in peer settings, not just in interactions with
    adults.
  • B. Exposure to the feared social situation almost
    invariably provokes anxiety, which may take the
    form of a situationally bound or situationally
    predisposed Panic Attack. Note In children, the
    anxiety may be expressed by crying, tantrums,
    freezing, or shrinking from social situations
    with unfamiliar people.

93
Social Phobia (300.23)
  • C. The person recognizes that the fear is
    excessive or unreasonable. Note In children,
    this feature may be absent.
  • D. The feared social or performance situations
    are avoided or else are endured with intense
    anxiety or distress.

94
Social Phobia (300.23)
  • E. The avoidance, anxious anticipation, or
    distress in the feared social or performance
    situation(s) interferes significantly with the
    person's normal routine, occupational (academic)
    functioning, or social activities or
    relationships, or there is marked distress about
    having the phobia.
  • F. In individuals under age 18 years, the
    duration is at least 6 months

95
Social Phobia (300.23)
  • G. The fear or avoidance is not due to the direct
    physiological effects of a substance (e.g., a
    drug of abuse, a medication) or a general medical
    condition and is not better accounted for by
    another mental disorder (e.g., Panic Disorder
    With or Without Agoraphobia, Separation Anxiety
    Disorder, Body Dysmorphic Disorder, a Pervasive
    Developmental Disorder, or Schizoid Personality
    Disorder).
  • H. If a general medical condition or another
    mental disorder is present, the fear in Criterion
    A is unrelated to it, e.g., the fear is not of
    Stuttering, trembling in Parkinson's dsease, or
    exhibiting abnormal eating behavior in Anorexia
    Nervosa or Bulimia Nervosa.
  • Specify if Generalized if the fears include
    most social situations (also consider the
    additional diagnosis of Avoidant Personality
    Disorder)

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Specific Phobia (300.29)
  • A. Marked and persistent fear that is excessive
    or unreasonable, cued by the presence or
    anticipation of a specific object or situation
    (e.g., flying, heights, animals, receiving an
    injection, seeing blood).
  • B. Exposure to the phobic stimulus almost
    invariably provokes an immediate anxiety
    response, which may take the form of a
    situationally bound or situationally predisposed
    Panic Attack.
  • Note In children, the anxiety may be expressed
    by crying, tantrums, freezing, or clinging.

98
Specific Phobia (300.29)
  • C. The person recognizes that the fear is
    excessive or unreasonable. Note In children,
    this feature may be absent.
  • D. The phobic situation(s) is avoided or else is
    endured with intense anxiety or distress.
  • E. The avoidance, anxious anticipation, or
    distress in the feared situation(s) interferes
    significantly with the person's normal routine,
    occupational (or academic) functioning, or social
    activities or relationships, or there is marked
    distress about having the phobia.

99
Specific Phobia (300.29)
  • F. In individuals under age 18 years, the
    duration is at least 6 months.
  • G. The anxiety, Panic Attacks, or phobic
    avoidance associated with the specific object or
    situation are not better accounted for by another
    mental disorder, such as Obsessive-Compulsive
    Disorder (e.g., fear of dirt in someone with an
    obsession about contamination), Posttraumatic
    Stress Disorder (e.g., avoidance of stimuli
    associated with a severe stressor), Separation
    Anxiety Disorder (e.g., avoidance of school),
    Social Phobia (e.g., avoidance of social
    situations because of fear of embarrassment),
    Panic Disorder with Agoraphobia, or Agoraphobia
    Without History of Panic Disorder.
  • Specify type
  • Animal Type
  • Natural Environment Type (e.g., heights, storms,
    water)
  • Blood-Injection-Injury Type
  • Situational Type (e.g., airplanes, elevators,
    enclosed places)
  • Other Type (e.g., phobic avoidance of situations
    that may lead to choking, vomiting, or
    contracting an illness in children, avoidance of
    loud sounds or costumed characters)

100
Specific Phobia Comments relevant to Children
and Adolescents
  • Children may not be aware that the fear is
    excessive or unreasonable.
  • Animal Type, Natural Environment Type generally
    has a childhood onset.
  • Childrens anxiety may be expressed by
  • Crying, tantrums, freezing, or clinging.
  • Diagnosis is not warranted unless fears lead to
    clinically significant impairment (e.g., fears
    going to school) as transient fears are common in
    childhood.

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Substance-Induced Anxiety Disorder
  • A. Prominent anxiety, Panic Attacks, or
    obsessions or compulsions predominate in the
    clinical picture.
  • B. There is evidence from the history, physical
    examination, or laboratory findings of either (1)
    or (2)
  • (1) the symptoms in Criterion A developed during,
    or within 1 month of, Substance Intoxication or
    Withdrawal
  • (2) medication use is etiologically related to
    the disturbance

103
Substance-Induced Anxiety Disorder
  • C. The disturbance is not better accounted for by
    an Anxiety Disorder that is not substance
    induced. Evidence that the symptoms are better
    accounted for by an Anxiety Disorder that is not
    substance induced might include the following
    the symptoms precede the onset of the substance
    use (or medication use) the symptoms persist for
    a substantial period of time (e.g., about a
    month) after the cessation of acute withdrawal or
    severe intoxication or are substantially in
    excess of what would be expected given the type
    or amount of the substance used or the duration
    of use or there is other evidence suggesting the
    existence of an independent non-substance-induced
    Anxiety Disorder (e.g., a history of recurrent
    non-substance-related episodes).
  • D. The disturbance does not occur exclusively
    during the course of a Delirium.

104
Substance-Induced Anxiety Disorder
  • E. The disturbance causes clinically significant
    distress or impairment in social, occupational,
    or other important areas of functioning.
  • Note This diagnosis should be made instead of a
    diagnosis of Substance Intoxication or Substance
    Withdrawal only when the anxiety symptoms are in
    excess of those usually associated with the
    intoxication or withdrawal syndrome and when the
    anxiety symptoms are sufficiently severe to
    warrant independent clinical attention.
  • Code Specific Substance-Induced Anxiety
    Disorder
  • (291.89 Alcohol 292.89 Amphetamine (or
    Amphetamine-Like Substance) 292.89 Caffeine
    292.89 Cannabis 292.89 Cocaine 292.89
    Hallucinogen 292.89 Inhalant 292.89
    Phencyclidine (or Phencyclidine-Like Substance)
    292.89 Sedative, Hypnotic, or Anxiolytic 292.89
    Other or Unknown Substance)

105
Substance-Induced Anxiety Disorder
  • Specify if
  • With Generalized Anxiety if excessive anxiety
    or worry about a number of events or activities
    predominates in the clinical presentation
  • With Panic Attacks if Panic Attacks predominate
    in the clinical presentation
  • With Obsessive-Compulsive Symptoms if
    obsessions or compulsions predominate in the
    clinical presentation
  • With Phobic Symptoms if phobic symptoms
    predominate in the clinical presentation
  • Specify if
  • With Onset During Intoxication if the criteria
    are met for Intoxication with the substance and
    the symptoms develop during the intoxication
    syndrome
  • With Onset During Withdrawal if criteria are
    met for Withdrawal from the substance and the
    symptoms develop during, or shortly after, a
    withdrawal syndrome

106
Anxiety Disorder Due to a General Medical
Condition (293.84)
  • A. Prominent anxiety, Panic Attacks, or
    obsessions or compulsions predominate in the
    clinical picture.
  • B. There is evidence from the history, physical
    examination, or laboratory findings that the
    disturbance is the direct physiological
    consequence of a general medical condition.
  • C. The disturbance is not better accounted for by
    another mental disorder (e.g., Adjustment
    Disorder With Anxiety in which the stressor is a
    serious general medical condition).

107
Anxiety Disorder Due to a General Medical
Condition (293.84)
  • D. The disturbance does not occur exclusively
    during the course of a Delirium.
  • E. The disturbance causes clinically significant
    distress or impairment in social, occupational,
    or other important areas of functioning.
  • Specify if
  • With Generalized Anxiety if excessive anxiety
    or worry about a number of events or activities
    predominates in the clinical presentation
  • With Panic Attacks if Panic Attacks predominate
    in the clinical presentation
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