Anxiety Disorders

CHAPTER 4

Anxiety Disorders

Quick Guide to the Anxiety Disorders

One or more of the following conditions may be diagnosed in patients who present with prominent anxiety symptoms; a single patient may have more than one anxiety disorder. As usual, link indicates where a more detailed discussion begins.

Primary Anxiety Disorders

Panic disorder . These patients experience repeated panic attacks—brief episodes of intense dread accompanied by a variety of physical and other symptoms, together with worry about having additional attacks and other related mental and behavioral changes.

Agoraphobia . Patients with this condition fear situations or places such as entering a store, where they might have trouble obtaining help if they became anxious.

Specific phobia . In this condition, patients fear specific objects or situations. Examples include animals; storms; heights; blood; airplanes; being closed in; or any situation that may lead to vomiting, choking, or developing an illness.

Social anxiety disorder . These patients imagine themselves embarrassed when they speak, write, or eat in public or use a public urinal.

Selective mutism . A child elects not to talk, except when alone or with select intimates.

Generalized anxiety disorder . Although they experience no episodes of acute panic, these patients feel tense or anxious much of the time and worry about many different issues.

Separation anxiety disorder . The patient becomes anxious when separated from a parent or other attachment figure.

Anxiety disorder due to another medical condition . Panic attacks and generalized anxiety symptoms can be caused by numerous medical conditions.

Substance/medication-induced anxiety disorder . Use of a substance or medication has caused panic attacks or other anxiety symptoms.

Other specified, or unspecified, anxiety disorder . Use these categories for disorders with prominent anxiety symptoms that don’t fit neatly into any of the groups above.

Other Causes of Anxiety and Related Symptoms

Obsessive–compulsive disorder . These patients are bothered by repeated thoughts or behaviors that can appear senseless, even to them.

Posttraumatic stress disorder . A severely traumatic event, such as combat or a natural disaster, is relived over and over.

Acute stress disorder . This condition is much like posttraumatic stress disorder, except that it begins during or immediately after the stressful event and lasts a month or less.

Avoidant personality disorder . These timid people are so easily wounded by criticism that they hesitate to become involved with others.

With anxious distress specifier for major depressive disorder . Some patients with major depressive disorder have much accompanying tension and anxiety.

Somatic symptom disorder  and  illness anxiety disorder . Panic and other anxiety symptoms are often part of somatic symptom disorder and illness anxiety disorder.

INTRODUCTION

The conditions discussed in this chapter are characterized by anxiety and the behaviors by which people try to ward it off. Panic disorder, the various phobias, and generalized anxiety disorder are collectively among the most frequently encountered of all mental disorders listed in DSM-5. Yet, in discussing them, we must also keep in mind three other facts about anxiety.

The first of these is that a certain amount of anxiety isn’t just normal, but adaptive and perhaps vital for our well-being and normal functioning. For example, when we are about to take an examination or speak in public (or write a book), the fear of failure spurs us on to adequate preparation. Similarly, normal fear lies behind our healthy regard for excessive debt, violent criminals, and poison ivy.

Anxiety is also a symptom—one that’s encountered in many, perhaps most, mental disorders. Because it is so dramatic, we sometimes focus our attention on the anxiety to the exclusion of historical data and other symptoms (depression, substance use, and problems with memory, to name just a few) that are crucial to diagnosis. I’ve interviewed countless patients whose anxiety symptoms have masked mood, somatic symptom, or other disorders—conditions that are often not only highly treatable when they are recognized, but deadly when they are not.

The third issue I want to emphasize is that anxiety symptoms can sometimes indicate the presence of a substance use problem, another medical condition, or even a different mental disorder altogether (such as a mood, somatic symptom, cognitive, or substance-related disorder). These conditions should be considered for any patient who presents with anxiety or avoidance behavior.

Once again, I’ve eschewed DSM-5’s organization, which seems to rely on the typical age of onset (most anxiety disorders begin when the patient is relatively young). Rather, I’ve started with panic attacks, because they are pervasive throughout the anxiety (and many other) disorders.

Panic Attack

Someone in the throes of a panic attack feels foreboding—a sense of disaster that is usually accompanied by cardiac symptoms (such as irregular or rapid heartbeat) and trouble breathing (shortness of breath, chest pain). The attack usually begins abruptly and builds rapidly to a peak; the whole, miserable experience usually lasts less than half an hour.

Here are several important facts about panic attacks:

•  They are common (perhaps 30% of all adults have experienced at least one). In a 12-month period, over 10% of Americans will have one (though they are apparently about a third as common among Europeans).

•  Women are more often affected than men.

•  They can occur as isolated experiences in normal adults; in such cases, there is no diagnosis at all.

•  Panic attacks may occur within a broad spectrum of frequency, from just a few episodes in the lifetime of some individuals to many times per week in others. Some people even awaken at night with nocturnal attacks.

•  Untreated, they can be severely debilitating. Many patients change their behavior in reaction to the fear that the attacks mean they are psychotic or physically ill.

•  Treatment is sometimes easy, perhaps just by providing a little reassurance or a paper bag to breathe into.

•  But sometimes panic attacks mask other illnesses that range from mood disorders to heart attacks.

•  Some panic attacks are triggered by specific situations, such as crossing a bridge or roaming a crowded supermarket. Such attacks are said to be cued or situationally bound. Others have no relationship to a specific stimulus but arise spontaneously, as in panic disorder. These are termed unexpected or uncued. A third type, situationally predisposed attacks, consists of attacks in which the patient often (but not invariably) becomes panic-stricken when confronted by the stimulus.

•  The patient can be calm or anxious when the upswing in panic symptoms begins.

•  By themselves, panic attacks are not codable. The criteria are given so that they can be identified and applied as a specifier to whatever disorder may be appropriate. Of course, they always occur in panic disorder, but there you don’t have to specify them: they go with the territory.

Pathological panic attacks usually begin in a person’s 20s. Panic attacks may occur without other symptoms (when they may qualify for a diagnosis of panic disorder) or in connection with a variety of other disorders, which may include agoraphobia, social anxiety disorder, specific phobia, posttraumatic stress disorder (PTSD), mood disorders, and psychotic disorders. They can also feature in anxiety disorder due to another medical condition and in substance-induced anxiety disorder.

Essential Features of Panic Attack

A panic attack is fear, sometimes stark terror, that begins suddenly and is accompanied by a variety of classic “fight-or-flight” symptoms, plus a few others—chest pain, chills, feeling too hot, choking, shortness of breath, rapid or irregular heartbeat, tingling or numbness, excessive perspiration, nausea, dizziness, and tremor. As a result, these people may feel unreal or be afraid that they are losing their minds or dying. At least four of the somatic sensations are required.

Coding Notes

Panic attack is not a codable disorder. It provides the basis for panic disorder, and it can be attached as a specifier to other diagnoses. These include posttraumatic stress disorder, other anxiety disorders, and other mental disorders (including eating, mood, psychotic, personality, and substance use disorders). They are even found in medical conditions affecting the heart, lungs, and gastrointestinal tract.

Shorty Rheinbold

Seated in the clinician’s waiting room, Shorty Rheinbold should have been relaxed. The lighting was soft, the music soothing; the sofa on which he was sitting was comfortably upholstered. Angel fish swam lazily in their sparkling glass tank. But Shorty felt anything but calm. Perhaps it was the receptionist—he wondered whether she was competent to handle an emergency with his sort of problem. She looked something like a badger, holed up behind her computer. For several minutes he had been feeling worse with every heartbeat.

His heart was the key. When Shorty first sat down, he hadn’t even noticed it, quietly ticking away, just doing its job inside his chest. But then, without any warning, it had begun to demand his attention. At first it had only skipped a beat or two, but after a minute, it had begun a ferocious assault on the inside of his chest wall. Every beat had become a painful, bruising thump that caused him to clutch at his chest. He tried to keep his hands under his jacket so as not to attract too much attention.

The pounding heart and chest pain could mean only one thing—after 2 months of attacks every few days, Shorty was beginning to get the message. Then, right on schedule, the shortness of breath began. It seemed to arise from his left chest area, where his heart was doing all the damage. It clawed its way up through his lungs and into his throat, gripping him around the neck so he could breathe only in the briefest of gulps.

He was dying! Of course, the cardiologist Shorty consulted the week before had assured him that his heart was as sound as a brass bell, but this time he knew it was about to fail. He couldn’t fathom why he hadn’t died before; he had feared it with every attack. Now it seemed impossible that he would survive this one. Did he even want to? That thought made him suddenly want to retch.

Shorty leaned forward so he could grip both his chest and his abdomen as unobtrusively as possible. He could hardly hold anything at all: The familiar tingling and numbness had started up in his fingers, and he could sense the shaking of his hands as they tried to contain the various miseries that had taken over his body.

He glanced across the room to see whether Miss Badger had noticed. No help was coming from that quarter; she was still pounding away at her keyboard. Perhaps all the patients behaved this way. Perhaps—suddenly, there was an observer. Shorty was watching himself! Some part of him had floated free and seemed to hang suspended, halfway up the wall. From this vantage point, he could look down and view with pity and scorn the quivering flesh that was, or had been, Shorty Rheinbold.

Now the Spirit Shorty saw that Shorty’s face had become fiery red. Hot air had filled his head, which seemed to expand with every gasp. He floated farther up the wall and the ceiling melted away; he soared out into the brilliant sunshine. He squeezed his eyes shut but could not keep out the blinding light.

Depression is so often found in patients who complain of recurrent panic attacks that the association cannot be overemphasized. Some studies suggest that over half the patients with panic disorder also have major depressive disorder. Clearly, we must carefully evaluate for symptoms of a mood disorder everyone who presents with panic symptoms.

Evaluation of Shorty Rheinbold

Shorty’s panic attack was typical: It began suddenly, developed rapidly, and included a generous helping of the required symptoms. His shortness of breath (criterion A4) and heart palpitations (A1) are classical panic attack symptoms; he also had chest pain (A6), lightheadedness (A8), and numbness in his fingers (A10). Shorty’s fear that he would die (A13) is typical of the fears that patients have during an attack. The sensation of watching himself (depersonalization—A11) is a less common symptom of panic. He needed only four of these symptoms to substantiate the fact of panic attack.

Shorty’s panic attack was uncued, which means that it seemed to happen spontaneously, without provocation. He was unaware of any event, object, or thought that triggered it. Uncued attacks are typical of panic disorder, which can also include cued (or situationally bound) attacks. The panic attacks that develop in social anxiety disorder and specific phobia are cued to the stimuli that repeatedly and predictably pull the trigger.

Panic attacks can occur in several medical conditions. One of these is acute myocardial infarction, the very condition many panic patients fear the most. Of course, when indicated patients with symptoms like Shorty’s should be evaluated for myocardial infarction and other medical disorders. These include low blood sugar, irregular heartbeat, mitral valve prolapse, temporal lobe epilepsy, and a rare adrenal gland tumor called a pheochromocytoma. Panic attacks also occur during intoxication with several psychoactive substances, including amphetaminesmarijuana, and caffeine. (Note that in addition, some patients misuse alcohol or sedative drugs in an effort to reduce the severity of their panic attacks.)

There is no code number associated with panic attack. I’ll give Shorty’s complete diagnosis below.

F41.0 [300.01] Panic Disorder

Panic disorder is a common anxiety disorder in which the patient experiences unexpected panic attacks (usually many, but always more than one) and worries about having another. Though the panic attacks are usually uncued, situationally predisposed attacks and cued/situationally bound attacks also occur (see definitions, above). A strong minority will have nocturnal panic attacks as well as those that occur while awake. Perhaps half of patients with panic disorder also have symptoms of agoraphobia, though many do not.

Panic disorder typically begins during the patient’s early 20s. It is one of the most common anxiety disorders, found in 1–4% of the general adult population (10% is the approximate figure for panic attacks in general). It is especially common among women.

Essential Features of Panic Disorder

As a result of surprise panic attacks (see the preceding description), the patient fears that they will happen again or tries to avert further attacks by taking (ineffective) action, such as abandoning an once-favored activities or avoiding places where attacks have occurred.

The Fine Print

Don’t forget the D’s: • Duration (1+ months) • Distress or disability (as above) • Differential diagnosis (substance use and physical disorders, other anxiety disorders, mood and psychotic disorders, obsessive–compulsive disorder [OCD], PTSD, actual danger)

Shorty Rheinbold Again

Shorty opened his eyes to discover that he was lying on his back on the waiting room floor. Two people were bending over him. One was the receptionist. He didn’t recognize the other, but he guessed it must be the mental health clinician who was supposed to interview him.

“I feel like you saved my life,” he said.

“Not really,” the clinician replied. “You’re just fine. Does this happen often?”

“Every 2 or 3 days now.” Shorty cautiously sat up. After a moment or two, he allowed them to help him to his feet and into the inner office.

Just when his problem had begun wasn’t quite clear at first. Shorty was 24 and had spent 4 years in the Coast Guard. Since his discharge, he’d knocked around a bit, and then moved in with his folks while he worked in construction. Six months ago, he’d gotten a job as cashier in a filling station.

That was just fine, sitting in a glassed-in booth all day making change, running credit cards through the electronic scanner, and selling chewing gum. The wages weren’t exciting, but he didn’t have to pay rent. Even with eating out almost every evening, Shorty still had enough at the end of the week to take his girl out on Saturday nights. Neither one of them drank or used drugs, so even that didn’t set him too far back.

The problem had begun the day after Shorty had been working for a couple of months, when the boss told him to go out on the wrecker with Bruce, one of the mechanics. They had stopped along the eastbound Interstate to pick up an old Buick Skylark with a blown head gasket. For some reason, they had trouble getting it into the sling. Shorty was on the traffic side of the truck, trying to manipulate the hoist in response to Bruce’s shouted directions. Suddenly, a caravan of tractor-trailer trucks roared past. The noise and the blast of wind caught Shorty off guard. He spun around into the side of the wrecker, fell, and rolled to a stop, inches from huge tires rolling by.

Shorty’s color and heart rate had returned to normal. The remainder of his story was easy enough to tell. He continued to go out on the wrecker, even though he felt scared, near panic every time he did so. He’d only go when Bruce was along, and he carefully avoided the traffic side of the vehicles.

But that wasn’t the worst of the problem—he could always quit and get another job. Lately, Shorty had been having these attacks at other times, when he was least expecting them. Now nothing seemed to trigger the attacks; they just happened, though not when he was at home or in his glass cage at work. When he was shopping last week, he’d had to abandon the cart full of groceries he was buying for his mother. Now he didn’t even want to go to the movies with his girl. For the last few weeks he had suggested that they spend Saturday night at her place watching TV instead. She hadn’t complained yet, but he knew it was only a matter of time.

“I have just about enough strength to tough it out through the work day,” Shorty said. “But I’ve got to get a handle on this thing. I’m too young to spend the rest of my life like a hermit in a cave.”

Further Evaluation of Shorty Rheinbold

The fact that Shorty experienced panic attacks has already been established. They were originally associated with the specific situation of working around the wrecker. For months now, they occurred every few days, usually catching him unaware (panic disorder criterion A). Undoubtedly worried and concerned (B1), he had altered his activities with his girlfriend (B2). A number of medical conditions can cause panic attacks; however, a cardiologist had recently pronounced Shorty to be medically fit. Substance-induced anxiety disorder (C) is also eliminated by the history: Shorty didn’t use drugs or alcohol. (However, watch out for patients who “medicate” their panic attacks with drugs or alcohol.) With no other mental disorder more likely (D), his symptoms fully support a diagnosis of panic disorder.

But wait, as they say, there’s more, for which we’ll have to consider the symptoms of agoraphobia. Recently, Shorty feared all sorts of other situations that involved being away from home—driving, shopping, even going to the movies (agoraphobia criterion A)—which nearly always provoked panic (C). As a result, he either avoided the situations or had to be accompanied by Bruce or by his girlfriend (D). Shorty’s life space had already begun to contract as a result of his fears; without treatment, it would seem to be only a matter of time before he would have to quit his job and remain at home (G). These symptoms are typical; we won’t quibble about the exact duration, because they are so severe (F). They’ll fulfill the requirements for agoraphobia, provided that we can rule out other etiologies for his symptoms (H, I). Sure, we should ask to determine that driving him was the fear that help would be unavailable or that escape would be difficult (B), but knowing Shorty, I’m pretty sure of the answer.

The diagnosis of specific phobia or social anxiety disorder would seem unlikely, because the focus of Shorty’s anxiety was not a single issue (such as enclosed places) or a social situation. Patients with somatic symptom disorder also complain of anxiety symptoms (though they aren’t a diagnostic feature), but this is an unlikely diagnosis for a physically healthy man.

Although the vignette doesn’t address this possibility, major depressive disorder is comorbid with panic disorder in half of the cases. The danger lies in the often dramatic anxiety symptoms overshadowing subtle depressive symptoms, so that the clinician overlooks them completely. When the criteria for both an anxiety and a mood disorder are met, they should both be listed. Other anxiety disorders can be comorbid in panic disorder patients; these include generalized anxiety disorder and specific phobia.

Shorty’s mood was anxious, not depressed or irritable. I’d give him a GAF score of 61. His diagnosis would be as follows:

F41.0 [300.01] Panic disorder
F40.00 [300.22] Agoraphobia

It can be really hard to differentiate panic disorder and agoraphobia from other anxiety disorders that involve avoidance (especially specific phobia and social anxiety disorder). The final decision often comes down to clinical judgment, though the following sorts of information can help:

1.  How many panic attacks does the patient have, and what type are they (cued, uncued, situationally predisposed)? Uncued attacks suggest panic disorder; cued attacks suggest specific phobia or social anxiety disorder. (But they can be intermixed.)

2.  In how many situations do they occur? Limited situations suggest specific phobia or social anxiety disorder; attacks that occur in a variety of situations suggest panic disorder and agoraphobia.

3.  Does the patient awaken at night with panic attacks? This is more typical of panic disorder.

4.  What is the focus of the fear? If it is having a subsequent panic attack, panic disorder may be the correct diagnosis—unless the panic attacks occur only when the patient is, say, riding in an airplane, in which case you might correctly diagnose specific phobia, situational type.

5.  Does the patient constantly worry about having panic attacks, even when in no danger of facing a feared situation (such as riding in an elevator)? This would suggest panic disorder and agoraphobia.

F40.00 [300.22] Agoraphobia

The agora was the marketplace to ancient Greeks. In contemporary usage, agoraphobia refers to the fear some people have of any situation or place where escape seems difficult or embarrassing, or where help might be unavailable if anxiety symptoms should occur. Open or public places such as theaters and crowded supermarkets qualify; so does travel from home. Persons with agoraphobia either avoid the feared place or situation entirely, or, if they must confront it, suffer intense anxiety or require the presence of a companion. In any event, agoraphobia is a concept the Greeks didn’t have a word for; it was first used in 1873.

Agoraphobia usually involves such situations as being away from home; standing in a crowd; staying home alone; being on a bridge; or traveling by bus, car, or train. Agoraphobia can develop rapidly, within just a few weeks, in the wake of a series of panic attacks, when fear of recurrent attacks causes the patient to avoid leaving home or participating in other activities. Some patients develop agoraphobia without any preceding panic attacks.

In recent years, estimates of the prevalence of agoraphobia have risen to the neighborhood of 1–2%. As with panic disorder, women are more susceptible than men; the disorder usually begins in the teens or 20s, though some patients have their first symptoms after the age of 40. Often panic attacks precede the onset of the agoraphobia. It is strongly heritable.

Essential Features of Agoraphobia

These patients almost invariably experience inordinate anxiety or dread when they have to be alone or away from home. Potentially, there’s an abundance of opportunity: riding a bus (or other mass transit), shopping, attending a theatrical entertainment. For some, it’s as ordinary as walking through an open space (flea market, playground), being part of a crowd, or standing in a queue. When you explore their thinking, these people are afraid that escape would be impossible or that help (in the event of panic) unavailable. So they avoid such situations or confront them only with a trusted friend or, if all else fails, endure them with lots of suffering.

The Fine Print

Don’t duck the D’s: • Duration (6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, other anxiety disorders, mood and psychotic disorders, OCD, PTSD, social and separation anxiety disorders, situational phobias, panic disorder)

Lucy Gould

“I’d rather have her with me, if that’s all right.” Lucy Gould was responding to the clinician’s suggestion that her mother wait outside the office. “By now, I don’t have any secrets from her.”

Since age 18, Lucy hadn’t gone anywhere without her mother. In fact, in those 6 years she’d hardly been anywhere at all. “There’s no way I could go out by myself—it’s like entering a war zone. If someone’s not with me, I can barely stand to go to doctor appointments and stuff like that. But I still feel awfully nervous.”

The nervousness Lucy complained of hadn’t included actual panic attacks; she never felt that she couldn’t breathe or was about to die. Rather, she experienced an intense motor agitation that had caused her to flee from shopping malls, supermarkets, and movie theaters. Nor could she ride on public transportation; buses and trains both terrified her. She had the feeling, vague but always present, that something awful would happen there. Perhaps she would become so anxious that she would pass out or wet herself, and no one would be able to help her. She hadn’t been alone in public since the week before her high school commencement. She had only been able to go up onto the platform to receive her diploma because she was with her best friend, who would know what to do if she needed help.

Lucy had always been a timid, rather sensitive girl. The first week of kindergarten, she had cried each time her mother left her by herself at school. But her father had insisted that she “toughen up,” and within a few weeks she had nearly forgotten her terror. She’d subsequently maintained a nearly perfect attendance record at school. Then, shortly after her 17th birthday, her father died of leukemia. Her terror of being away from home had begun within a few weeks of his funeral.

To make ends meet, her mother had sold their house, and they had moved into a condominium across the street from the high school. “It’s the only way I got through my last year,” Lucy explained.

For several years, Lucy had kept house while her mother assembled circuit boards at an electronics firm outside town. Lucy was perfectly comfortable in that role, even though her mother was away for hours at a time. Her physical health had been good; she had never used drugs or alcohol; and she had never had depression, suicidal ideas, delusions, or hallucinations. But a year ago Lucy had developed insulin-dependent diabetes, which required frequent trips to the doctor. She had tried to take the bus by herself, but after several failures—once, in the middle of traffic, she had forced the rear door open and sprinted for home—she had given up. Now her mother was applying for disability assistance so that she could remain at home to provide the aid and attendance Lucy required.

Evaluation of Lucy Gould

Because of her fears, which were inordinate and out of proportion to the actual danger (criterion E), Lucy avoided a variety of situations and places, including supermarkets, malls, buses, and trains (A). If she did go, she required a companion (D). She couldn’t state exactly what might happen—only that it would be awful and embarrassing (she might even lose bladder control) and that help might not be available (B). It is not unusual that her symptoms only came to light when another problem (diabetes) prevented her from staying at home; diabetes itself isn’t associated with agoraphobic fears (H). OK, you’ll have to read between the lines of the vignette to verify criteria C (the situations almost always provoke anxiety) and G (the patient experiences clinically important distress or impairment).

Lucy’s symptoms were too varied for specific phobia or social anxiety disorder. (Note also that in agoraphobia, the perceived danger emanates from the environment; in social anxiety disorder, it comes from the relationship with other people.) Her problem wasn’t that she feared being left alone, as would be the case with separation anxiety disorder (although when she was five she clearly had had elements of that diagnosis). She hadn’t had a major trauma, as would be the case in PTSD (the death of her father was traumatic, but her own symptoms didn’t focus on reliving this experience). There is no indication that she had OCD. And so (finally!) we have disposed of criterion I.

Agoraphobia can accompany a variety of diagnoses, the most important of which are mood disorders that involve major depressive episodes. However, Lucy denied having symptoms of depression, psychosis, and substance use. Although she had diabetes, it developed many years after her agoraphobia symptoms became apparent. Besides, it’s hard to imagine a physiological connection between agoraphobia and diabetes, and her anxiety symptoms were far more extensive than the realistic concerns you’d expect from the average diabetic individual.

Because Lucy had never experienced a discrete panic attack, she would not meet the criteria for panic disorder in addition to her agoraphobia. By the way, the fact that she was housebound would net her a low GAF score (31).

F40.00 [300.22] Agoraphobia
E10.9 [250.01] Insulin-dependent diabetes mellitus

Specific Phobia

Patients with specific phobias have unwarranted fears of specific objects or situations. The best recognized are phobias of animals, blood, heights, travel by airplane, being closed in, and thunderstorms. The anxiety produced by exposure to one of these stimuli may take the form of a panic attack or of a more generalized sensation of anxiety, but it is always directed at something specific. (However, these patients can also worry about what they might do—faint, panic, lose control—if they have to confront whatever it is they are afraid of.) Generally, the closer they are to the feared stimulus (and the more difficult it would be to escape), the worse they feel.

Patients usually have more than one specific phobia. A person who is about to face one of these feared activities or objects will immediately begin to feel nervous or panicky—a condition known as anticipatory anxiety. The degree of discomfort is often mild, however, so most people do not seek professional help. When it causes a patient to avoid feared situations, anticipatory anxiety can be a major inconvenience; it can even interfere with working. Patients with specific phobias involving blood, injury, or injection often experience what is called a vasovagal response; this means that reduced heart rate and blood pressure actually do cause the patients to faint.

In the general population, specific phobia is one of the most frequently reported anxiety disorders. Up to 10% of U.S. adults have suffered to some degree from one of these specific phobias. However, by no means would all of these people qualify for a DSM-5 diagnosis: The clinical significance of these reported fears is so hard to judge.

Onset is usually in childhood or adolescence; animal phobias especially tend to begin early. Some begin after a traumatic event, such as being bitten by an animal. A situational fear (such as being closed in or traveling by air) is more likely than other types of specific phobia to have a comorbid disorder such as depression and substance misuse, though comorbidity with a wide range of mental disorders is the rule. Females outnumber males, perhaps by a 2:1 ratio.

Essential Features of Specific Phobia

A specific situation or thing habitually causes such immediate, inordinate (and unreasonable) dread or anxiety that the patient avoids it or endures it with much anxiety.

The Fine Print

The D’s: • Duration (6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, agoraphobia, social anxiety disorder, separation anxiety disorder, mood and psychotic disorders, anorexia nervosa, OCD, PTSD)

Coding Notes

Specify all types that apply with individual ICD-10 codes:

F40.218 [300.29] Animal type (snakes, spiders)

F40.228 [300.29] Natural environment type (thunderstorms, heights)

Blood–injection–injury type (syringes, operations):

F40.230 [300.29] Blood

F40.231 [300.29] Injections and transfusions

F40.232 [300.29] Other medical care

F40.233 [300.29] Injury

F40.248 [300.29] Situational type (traveling by air, being closed in)

F40.298 [300.29] Other type (situations where the person could vomit or choke; for children, loud noises or people wearing costumes)

Esther Dugoni

A slightly built woman of nearly 70, Esther Dugoni was healthy and fit, though in the last year or two she had developed a tremor characteristic of early Parkinson’s disease. For the several years since she had retired from her job teaching horticulture in junior college, she had concentrated on her own garden. At the flower show the year before, her rhododendrons had won first prize.

But 10 days earlier, her mother had died in Detroit, over halfway across the country. She and her sister had been appointed co-executors. The estate was large, and she would have to make several trips to probate the will and dispose of the house. That meant flying, and this was why she had sought help from the mental health clinic.

“I can’t fly!” she had told the clinician. “I haven’t flown anywhere for 20 years.”

Esther had been reared during the Depression; as a child, she had never had the opportunity to fly. With five children of her own to care for on her husband’s schoolteacher pay, she hadn’t traveled much as an adult, either. She had made a few short hops years ago, when two of her children were getting married in different cities. On one of those trips, her plane had circled the field for nearly an hour, trying to land in Omaha between thunderstorms. The ride was wretchedly bumpy; the plane was full; and many of the passengers were airsick, including the men seated on either side of her. There was no one to help—the flight attendants had to remain strapped in their seats. She had kept her eyes closed and breathed through her handkerchief to try to filter out the odors that filled the cabin.

They finally landed safely, but it was the last time Esther had ever been up in an airplane. “I don’t even like to go to the airport to meet someone,” she reported. “Even that makes me feel short of breath and kind of sick to my stomach. Then I get sort of a dull pain in my chest and I start to shake—I feel that I’m about to die, or something else awful will happen. It all seems so silly.”

Esther really had no alternatives to flying. She couldn’t stay in Detroit until all of the business had been taken care of; it would take months. The train didn’t connect, and the bus was impossible.

Evaluation of Esther Dugoni

Esther’s anxiety symptoms were cued by the prospect of airplane travel (criterion A); even going to the airport inevitably produced anxiety (B), and she had avoided plane travel for years (C, E). She recognized that this fear was unreasonable (“silly”), and it embarrassed her (D); it was about to interfere with how she conducted her personal business (F).

Specific phobia is not usually associated with any general medical condition or substance-induced disorder. In response to delusions, patients with schizophrenia will sometimes avoid objects or situations (a telephone that is “bugged,” food that is “poisoned”), but such patients do not have the required insight that their fears are unfounded. Of course, specific phobias must be differentiated from fears associated with other disorders (such as agoraphobiaOCDPTSDsocial anxiety disorder—G). Esther’s clinician should ask about possible comorbid diagnoses. Pending that, and with a GAF score of 75, her diagnosis would be as given below. (Esther had only one phobia, a situational one; the average is three, each of which would be listed on a separate line with its own number.)

F40.248 [300.29] Specific phobia, situational (fear of flying)
G20 [332.0] Parkinson’s disease, primary
Z63.4 [V62.82] Uncomplicated bereavement

Fears involving animals of one sort or another are remarkably common. Children are especially susceptible to animal phobias, and many adults don’t much care for spiders, snakes, or cockroaches. But a diagnosis of specific phobia, animal type, should not be made unless a patient is truly impaired by the symptoms. For example, you wouldn’t diagnose a snake phobia in a prisoner serving a life sentence—under which circumstances confrontation with snakes and activity restriction as a result would be unlikely.

F40.10 [300.23] Social Anxiety Disorder

Social anxiety disorder (SAD) is a fear of appearing clumsy, silly, or shameful. Patients dread social gaffes such as choking when eating in public, trembling when writing, or being unable to perform when speaking or playing a musical instrument. Using a public urinal will cause anxiety for some men. Fear of blushing affects especially women, who may not be able to put into words what’s so terrible about turning red. Fear of further choking is often acquired after an episode of choking on food; it can occur any time from childhood to old age. Some patients fear (and avoid) multiple such public situations.

Many people, men and women, have noticeable physical symptoms with SAD: blushing, hoarseness, tremor, and perspiration. Such patients may have actual panic attacks. Children may express their anxiety by clinging, crying, freezing, shrinking back, throwing tantrums, or refusing to speak.

Studies of general populations report a lifetime occurrence of SAD ranging from 4% to as high as 13%. However, if we consider only those patients who are truly inconvenienced by their symptoms, prevalence figures are probably lower. Whatever the actual figure, these findings contradict previous impressions that SAD is rare. Perhaps interviewers tend to overlook a common condition that patients silently endure. Though males outnumber females in treatment settings, women predominate in general population samples.

Onset is typically in the middle teens. The symptoms of SAD overlap with those of avoidant personality disorder; the latter is more severe, but both begin early, tend to last for years, and have some commonalities in family history. Indeed, SAD is reported to have a genetic basis.

Essential Features of Social Anxiety Disorder

Inordinate anxiety is attached to circumstances where others could closely observe the patient—public speaking or performing, eating or having a drink, writing, perhaps just speaking with another person. Because these activities almost always provoke disproportionate fear of embarrassment or social rejection, the patient avoids these situations or endures them with much anxiety.

The Fine Print

For children, these “others” must include peers, not just adults.

The D’s: • Duration (6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood and psychotic disorders, anorexia nervosa, OCD, avoidant personality disorder, normal shyness, and other anxiety disorders—especially agoraphobia)

Coding Notes

Specify if:

Performance only. The patient fears public speaking or performing, but not other situations.

Valerie Tubbs

“It starts right here, and then it spreads like wildfire. I mean, like real fire!” Valerie Tubbs pointed to the right side of her neck, which she kept carefully concealed with a blue silk scarf. “It” had been happening for almost 10 years, any time she was with people; it was worse if she was with a lot of people. Then she felt that everybody noticed.

Although she had never tried, Valerie didn’t think that her reaction was something she could control. She just blushed whenever she thought people were watching her. It had started during a high school speech class, when she had to give a talk. She had become confused about the difference between a polyp and a medusa, and one of the boys had commented on the red spot that had appeared on her neck. She had quickly flushed all over and had to sit down, to the general amusement of the class.

“He said it looked like a bull’s-eye,” she said. Since then, Valerie had tried to avoid the potential embarrassment of saying anything to more than a handful of people. She had given up her dream of becoming a fashion buyer for a department store, because she couldn’t tolerate the scrutiny the job would entail. Instead, for the last 5 years she had worked dressing mannequins for the same store.

Valerie said that it seemed “stupid” to be so afraid. It wasn’t just that she turned red; she turned beet-red. “I can feel prickly little fingers of heat crawling out across my neck and up my cheek. My face feels like it’s on fire, and my skin is being scraped with a rusty razor.” Whenever she blushed, she didn’t feel exactly panicky. It was a sense of anxiety and restlessness that made her wish her body belonged to someone else. Even the thought of meeting new people caused her to feel irritable and keyed up.

Evaluation of Valerie Tubbs

For years, Valerie had feared being embarrassed by the blushing that occurred whenever she spoke with other people (criteria A, B, C, and F in one sentence). Her fear was excessive (E), and she knew it—though insight isn’t required for the diagnosis. With her reluctance to speak publicly (and her scarf), she avoided exposure to scrutiny (D). Her anxiety also prevented her from working at the job she would have preferred (G).

With no actual panic attacks, and in the absence of anxiety disorder due to another medical condition and substance-induced anxiety disorder (H), determining her disorder would come down to the differential diagnosis of phobias (I). In the absence of a typical history, we can quickly dismiss specific phobia. People who have agoraphobia may avoid dining out because they fear the embarrassment of having a panic attack in a public restaurant. Then you would only diagnose SAD if it had been present prior to the onset of the agoraphobia and was unrelated to it. (Sometimes even clinicians who specialize in diagnosing and treating the anxiety disorders can have trouble deciding between these two diagnoses.) Patients with anorexia nervosa avoid eating, but the focus is on their weight, not on the embarrassment that might result from gagging or leaving food on their lips.

It is important to differentiate SAD from the ordinary shyness that is so common among children and other young people; this shows the value of the criterion that symptoms must be present for at least half a year, required by DSM-5 for adults as well as for children. Also keep in mind that many people worry about or feel uncomfortable with social activities such as speaking in public (stage fright or microphone fright). They should not receive this diagnosis unless it in some important way affects their working, social, or personal functioning.

Social phobia (as SAD used to be called) is often associated with suicide attempts and mood disorders. Anyone with SAD may be at risk for self-treatment with drugs or alcohol; Valerie’s clinician should ask carefully about these conditions. SAD has elements in common with avoidant personality disorder, which, often comorbid in these patients, may be a warranted diagnosis in a patient who is generally inhibited socially, is overly sensitive to criticism, and feels inadequate. Other mental disorders you might sometimes need to rule out—no problem for Valerie—would include panic disorderseparation anxiety disorderbody dysmorphic disorder, and autism spectrum disorder.

Valerie’s fears involved far more than performances, so the specifier wouldn’t apply. With a GAF score of 61, her diagnosis would be as follows:

F40.10 [300.23] Social anxiety disorder

F94.0 [313.23] Selective Mutism

Selective mutism denotes children who remain silent except when alone or with a small group of intimates. The disorder typically begins during preschool years (ages 2–4), after normal speech has developed. Such a child, who speaks appropriately at home among family members but becomes relatively silent when among strangers, may not attract clinical attention until formal schooling begins. Although often shy, most such children have normal intelligence and hearing. When they do speak, they tend to use normal articulation, sentence structure, and vocabulary. The condition often improves spontaneously within weeks or months, though no one knows how to identify such a patient in advance of improvement.

Selective mutism is uncommon, with a prevalence of under 1 in 1,000; it appears to affect girls and boys about equally. Family history is often positive for social anxiety disorder and relatives with selective mutism. Comorbid conditions include other anxiety disorders (especially separation anxiety disorder and social anxiety disorder). They do not tend to have externalizing disorders, such as oppositional defiant or conduct disorder.

Essential Features of Selective Mutism

Despite speaking normally at other times, the patient regularly doesn’t speak in certain situations where speech is expected, such as in class.

The Fine Print

The first month of a child’s first year in school is often fraught with anxiety; exclude behaviors that occur during this time.

The D’s: • Duration (1+ months) • Distress or disability (social or work/academic impairment) • Differential diagnosis (unfamiliarity with the language to be used, a communication disorder such as stuttering, psychotic disorders, autism spectrum disorder, social anxiety disorder)

F93.0 [309.21] Separation Anxiety Disorder

For years, separation anxiety disorder (SepAD) was diagnosed in childhood—and stayed there. More recently, however, evidence has accumulated that the condition also affects adults. This can happen in two ways. Perhaps one-third of children with SepAD continue to have symptoms of the disorder well into their adult years. However, some patients develop symptoms de novo in their late teens or even later—sometimes even beginning in old age. SepAD has a lifetime prevalence of about 4% for children and 6% for adults; for adults, the 12-month prevalence is nearly 2%. It is more common in females than in males, though boys are more likely to be referred for treatment.

In children, SepAD may begin with a precipitant such as moving to a new home or school, a medical procedure or serious physical diagnosis, or the loss of an important friend or pet (or a parent). Symptoms often show up as school refusal, but younger children may even show reluctance at being left with a sitter or at day care. Children may enlist physical complaints, imagined or otherwise, as justification for remaining home with parents.

Adults, too, may fear that something horrible will happen to an important attachment figure—perhaps a spouse, or even a child. As a result, they are reluctant to leave home (or any place of safety); they may fear even sleeping alone, and they experience nightmares about separation. When apart from the principal attachment figure, they may need to telephone or otherwise touch base several times a day. Some may try to ensure safety by setting up a routine of following the other person.

When the onset is early in childhood, this condition is likely to remit; with later onset, symptoms are more likely to continue into adulthood and to confer more severe disability (though the intensity may wax and wane). Children with SepAD tend to drift into subclinical forms or nonclinical status. Most adults and children also have other disorders (especially mood, anxiety, and substance use disorders), though SepAD is often the condition present the longest.

Children with SepAD often have parents with an adult form of the same disorder, and, as with most anxiety disorders, there is a strong genetic component.

Essential Features of Separation Anxiety Disorder

Because they fear what might happen to a parent or someone else important in their lives, these patients resist being alone. They imagine that the parent will die or become lost (or that they will), so that even the thought of separation can cause anxiety, nightmares, or perhaps vomiting spells or other physical complaints. They are therefore reluctant to attend school, go out to work, or to sleep away from home—perhaps even in their own beds.

The Fine Print

The D’s: • Duration (6+ months in adults, though extreme symptoms—such as total school refusal—could justify diagnosis after a shorter duration; 4+ weeks in children) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (mood disorders, other anxiety disorders, PTSD)

Nadine Mortimer

At age 24, Nadine Mortimer still lived at home. The only reason for her evaluation, she told the clinician, was that her mother and stepfather had just signed on to join the Peace Corps; she, Nadine, would be left behind. “I just know I won’t be able to stand it.” She sobbed into her Kleenex.

Being alone had frightened Nadine from the time she was very small. She thought she could trace it back to her father’s death: He was a mechanic who drove a racing car for fun until the weekend he encountered a wall at the far turn of their hometown track. Her mother’s response was strangely stoic. “I think I took on the job of grieving for both of us,” Nadine commented. Within the year, her mother had remarried.

Her first day of first grade, Nadine had been so fearful that her mother had stayed in the classroom. “I was afraid something terrible would happen to her too, and I wanted to be there, for safety.” After several weeks, Natalie had been able to tolerate being left, but the following year, she threw up when Labor Day rolled around. After a few miserable weeks in second grade, she was withdrawn and home-schooled.

In 10th grade, she was reading and doing math at 12th-grade level. “But my socialization skills were near nil. I’d never even been to a sleepover at another girl’s house,” she said. So her parents bribed her with a cell phone and a promise that she could call any time. By the time Nadine was in junior college—hardly farther away than her high school—she’d negotiated for a smart phone with a GPS device; now she could track her mother’s whereabouts to within a few feet. With that, she said, she could “roam comfortably, stores and whatnot, as long as I could check Mom’s location whenever I wished.” Once, when her battery died, she had suffered a panic attack.

Nonetheless, she still didn’t graduate from junior college, and after a semester she returned home to be with her mother. “I know it seems weird,” she told the interviewer, “but I always imagine that someday she won’t come home to me. Just like Daddy.”

Evaluation of Nadine Mortimer

From the time she started school (criterion B), Nadine had had clear symptoms of SepAD. She worried that harm might befall her mother and was severely distressed when they were separated; she’d vomited at the mere prospect of a new school year (A). As a result, she had almost no friends and had never slept away from home (C). There was no sign of other disorders to exclude (D).

Modified by her adult status, many of these same symptoms persisted—panic symptoms when she couldn’t keep close tabs on her mother, from whom she refused to live apart. She even retained the same fear of harm befalling her mother if they ever were separated. The prospect of her parents’ leaving for a new career deeply affected her. Even if Nadine hadn’t had symptoms as a child, her adult disorder was troubling enough to qualify for the diagnosis of SepAD.

A significant problem remains in the differential diagnosis of SepAD: How does one distinguish it from agoraphobia? There is some overlap, but patients with SepAD are afraid of being away from a parent or other significant person, whereas the fear for a person with agoraphobia is of being in a place from which escape will be difficult. The mute testimony of her smart phone suggests that Nadine’s anxiety was of the former type, not the latter. I would put her current GAF score at 45.

F93.0 [309.21] Separation anxiety disorder

The DSM-IV criteria for SepAD employed a number of behaviors only appropriate to children; perhaps this explains why it wasn’t recognized in adults earlier. Even now, panic symptoms may sometimes draw clinicians off the scent of adult SepAD.

F41.1 [300.02] Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) can be hard to diagnose. The symptoms are relatively unfocused; the nervousness is low-key and chronic; panic attacks are not required. Furthermore, it is, after all, just worry, and that’s something that touches all of us. But there are differences. Ordinary worry is somehow less serious; we are able (well, most of the time) to put it aside and concentrate on other, more immediate issues. The worry of GAD often starts of its own accord, seemingly without cause. And GAD worry is at times hard to control. It carries with it a collection of physical symptoms that pile onto the sense of agitated restlessness in a cascade of misery.

Although some patients with GAD may be able to state what it is that makes them nervous, others cannot. GAD worry is typically about far more issues (“everything”) than objective facts can justify. The disorder typically begins at about 30 years of age; many patients with GAD have been symptomatic for years without coming to the attention of a clinician. Perhaps this is because the degree of impairment in GAD is often not all that severe. Genetic factors play an important role in the development of GAD. It is found in up to 9% of the general adult population (lifetime risk), and, as with nearly every other anxiety disorder, females predominate.

Essential Features of Generalized Anxiety Disorder

Hard-to-control, excessive worrying about a variety of issues—health, family problems, money, school, work—results in physical and mental complaints: muscle tension, restlessness, becoming easily tired and irritable, experiencing poor concentration, and trouble with insomnia.

The Fine Print

The D’s: • Duration (on most days for 6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood disorders, other anxiety disorders, OCD, PTSD, realistic worry)

Bert Parmalee

For most of his adult life, Bert had been “a worry-wart.” At age 35, he still had dreams that he was flunking all of his college electrical engineering courses. But recently he had felt that he was walking a tightrope. For the past year he had been the administrative assistant to the chief executive officer of a Fortune 500 company, where he had previously worked in product engineering.

“I took the job because it seemed a great way to move up the corporate ladder,” he said, “but almost every day I have the feeling my foot’s about to slip off the rung.”

Each of the company’s six ambitious vice-presidents saw Bert as a personal pipeline to the CEO. His boss was a hard-driving workaholic who constantly sparked ideas and wanted them implemented yesterday. Several times he had told Bert that he was pleased with his performance. In fact, Bert was doing the best job of any administrative assistant he had ever had, but that didn’t seem to reassure Bert.

“I’ve felt uptight just about every day since I started this job. My chief expects action and results. He has zero patience for thinking about how it should all fit together. Our vice-presidents all want to have their own way. Several of them hint pretty broadly that if I don’t help them, they’ll put in a bad word with the boss. I’m always looking over my shoulder.”

Bert had trouble concentrating at work; at night he was exhausted but had trouble getting to sleep. Once he did, he slept fitfully. He had become chronically irritable at home, yelling at his children for no reason. He had never had a panic attack, and he didn’t think he was depressed. In fact, he still took a great deal of pleasure in the two activities he enjoyed most: Sunday afternoon football on TV and Saturday night lovemaking with his wife. But recently, she had offered to take the kids to her mother’s for a few weeks, to relieve some of the pressure. This only resurrected some of his old concerns that he wasn’t good enough for her—that she might find someone else and leave him.

Bert was slightly overweight and balding, and he looked apprehensive. He was carefully dressed and fidgeted a bit; his speech was clear, coherent, relevant, and spontaneous. He denied having obsessions, compulsions, phobias, delusions, or hallucinations. On the MMSE, he scored a perfect 30. He said that his main problem—his only problem—was his nagging uneasiness.

Valium made him drowsy. He had tried meditating, but it only allowed him to concentrate more effectively on his problems. For a few weeks he had tried having a cocktail before dinner; that had both relaxed him and prompted worries about alcoholism. Once or twice he even went with his brother-in-law to an Alcoholics Anonymous meeting. “Now I’ve decided to try dreading one day at a time.”

Evaluation of Bert Parmalee

Bert worried about multiple aspects of his life (his job, being an alcoholic, losing his wife); each of these worries was excessive for the facts (criterion A). The excessiveness of his worries would differentiate them from the usual sort of anxiety that is not pathological. Despite repeated efforts (meditation, medication, reassurance), he had been unable to control these fears (B). In addition, he had at least four physical or mental symptoms (only three are required): trouble concentrating (C3), fatigue (C2), irritability (C4), and sleep disturbance (C6). He had been having difficulty nearly every day for longer than the required 6 months (A). And his symptoms caused him considerable distress, perhaps even more than is usual for patients with GAD (D).

One of the difficulties in diagnosing GAD is that so many other conditions must be excluded (E). A number of physical conditions can cause anxiety symptoms; a complete workup of Bert’s anxiety would have to consider these possibilities. From the information contained in the vignette, a substance-induced anxiety disorder would appear unlikely.

Anxiety symptoms can be found in nearly every category of mental disorder, including psychotic, mood (depressed or manic), eatingsomatic symptom, and cognitive disorders. From Bert’s history, none of these would seem remotely likely (F). For example, an adjustment disorder with anxiety would be eliminated because Bert’s symptoms met the criteria for another mental disorder.

It is important that the patient’s worry and anxiety not focus solely on feature of another mental disorder, especially another anxiety disorder. For example, it shouldn’t be “merely” worry about weight gain in anorexia nervosa, about contamination (OCD), separation from attachment figures (separation anxiety disorder), public embarrassment (social anxiety disorder), or having physical symptoms (somatic symptom disorder). Nevertheless, note that a patient can have GAD in the presence of another mental disorder—most often, mood and other anxiety disorders—provided that the symptoms of GAD are independent of the other condition.

The only specifier for GAD is is the optional with panic attacks. Bert’s diagnosis, other than a GAF score of 70, would be a plain vanilla:

F41.1 [300.02] Generalized anxiety disorder

It is reasonable to ask this question: Does diagnosing GAD in a depressed patient help with your evaluation? After all, the anxiety symptoms may disappear once the depression has been sufficiently treated. The value, I suppose, is that flagging the anxiety symptoms gives a more complete picture of the patient’s pathology. Also, you may have to treat the anxiety symptoms independently later on.

Substance/Medication-Induced Anxiety Disorder

When the symptoms of anxiety or panic can be attributed to the use of a chemical substance, make the diagnosis of substance/medication-induced anxiety disorder. It can occur during acute intoxication (or heavy use, as with caffeine) or during withdrawal (as with alcohol or sedatives), but the symptoms must be more severe that you’d expect for ordinary intoxication or withdrawal, and they must be serious enough to warrant clinical attention.

Many substances can produce anxiety symptoms, but those most commonly associated are marijuana, amphetamines, and caffeine. See Table 15.1 in Chapter 15 for a summary of the substances for which intoxication or withdrawal can be expected to create anxiety. If more than one substance is involved, you’d code each separately. Quite frankly, these disorders are probably rare.

Essential Features of Substance/Medication-Induced Anxiety Disorder

The use of some substance appears to have caused the patient to experience anxiety symptoms or panic attacks.

The Fine Print

For tips on identifying substance-related causation, see sidebar.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (ordinary substance intoxication or withdrawal, delirium, physical disorders, mood disorders, and other anxiety disorders)

Coding Notes

Specify:

With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.

With onset after medication use. You can use this in addition to other specifiers.

For specific coding procedures, see Tables 15.2 and 15.3 in Chapter 15.

Bonita Ramirez

Bonita Ramirez, a 19-year-old college freshman, was brought to the emergency room by two friends. Alert, intelligent, and well informed, she cooperated fully in providing the following information.

Bonita’s parents both held graduate degrees and were well established in their professions. They lived in a well-to-do suburb of San Diego. Bonita was their oldest child and only daughter. Strictly reared in the Catholic faith, she hadn’t been allowed to date until a year before. Until sorority rush week, the only alcohol she had tasted had been Communion wine. By her account and that of her companions, she had been happy, healthy, and vivacious when she arrived on campus a fortnight earlier.

Two weeks had made a remarkable difference. Bonita now sat huddled on the examination table, feet drawn up beneath her. With her arms wrapped around her knees, she trembled noticeably. Although it was only September, she wore a sweater and complained of feeling cold. She kept reaching for the emesis basin beside her, as though she might need it again.

Her voice quavered as she said that nothing like this had ever happened to her before. “I had some beer last week. It didn’t bother me at all, except I had a headache the next morning.”

This evening there had been a “big sister, little sister” party at the sorority Bonita had just pledged. She had drunk some beer, and that had prompted her to take a few hits from the marijuana cigarette they were passing around. The beer must have numbed her throat, because she had been able to draw the smoke deep into her lungs and hold it, the way her friends had showed her.

For about 10 minutes Bonita hadn’t noticed anything at all. Then her head began to feel tight, as though her hair was a wig that didn’t fit right. Suddenly, when she tried to inhale, her chest “screamed in pain,” and she became instantly aware that she was about to die. She tried to run, but her rubbery legs refused to support her.

The other girls hadn’t had much experience with drug reactions, but they called one of the men from the fraternity house next door, who came over and tried to talk Bonita down. After an hour, she still felt the panicked certainty that she would die or go mad. That was when they decided to bring her to the emergency room.

At length she said, “They said it would relax me and expand my consciousness. I just want to contract it again.”

Evaluation of Bonita Ramirez

Bonita’s history—she was healthy until the ingestion of a substance that is known to produce anxiety symptoms, especially in a naïve user—is a dead giveaway for the diagnosis (criteria A, B). Other drugs that commonly produce anxiety symptoms include amphetamines, which can also produce panic attack symptoms, and caffeine when used heavily. However, because anxiety symptoms can be encountered at some point during the use of most substances, you can code an anxiety disorder secondary to the use of nearly any of them, provided that the anxiety symptoms are worse than you would expect for ordinary substance withdrawal or intoxication. Because she required emergency evaluation and treatment, we would judge this to be the case for Bonita (E).

Despite the proximity of the development of her symptoms to substance use (C), her clinician would want to be sure that she did not have another medical condition (or treatment with medication for a medical condition) that could also explain her anxiety symptoms.

Although she was severely panicked when she arrived at the emergency room, I would score Bonita’s GAF as a relatively high 80, because her symptoms had caused her no actual disability (plenty of distress) and should be transient; other diagnosticians might disagree. She had not used pot before, so she had no use disorder, and her code comes from the “none” row for cannabis in Table 15.3.

F12.980 [292.89] Cannabis-induced anxiety disorder, with onset during intoxication

F06.4 [293.84] Anxiety Disorder Due to Another Medical Condition

Many medical disorders can produce anxiety symptoms, which will usually resemble those of panic disorder or generalized anxiety disorder. Occasionally, they may take the form of obsessions or compulsions. Most anxiety symptoms won’t be caused by a medical disorder, but it is supremely important to identify those that are. The symptoms of an untreated medical disorder can evolve from anxiety to permanent disability (consider the dangers of a growing brain tumor).

Essential Features of Anxiety Disorder Due to Another Medical Condition

A physical medical condition appears to have caused panic attacks or marked anxiety.

The Fine Print

For pointers on deciding when a physical condition may have caused a disorder, see sidebar.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, delirium, mood disorders, other anxiety disorders, adjustment disorder)

Coding Notes

In recording the diagnosis, use the name of the responsible medical condition, and list first the medical condition, with its code number.

Millicent Worthy

“I wonder if we could just leave the door open.” Millicent Worthy got up from the chair and opened the examining room door. She had fidgeted throughout the first part of the interview. Part of that time, she had hardly seemed to be paying attention at all. “I feel better not being so closed in.” Once she finally settled down, she told this story.

Millicent was 24 and divorced. She had never touched drugs or alcohol. In fact, until about 4 months ago, she’d been well all her life. She had visited a mental health clinic only once before, when she was 12: Her parents were having marital problems, and the entire family had gone for family counseling.

She had first felt nervous while tending the checkout counter at the video rental outlet where she worked. She felt cramped, hemmed in, as if she needed to walk around. One afternoon, when she was the only employee in the store and she had to stay behind the counter, her heart began to pound and she perspired and became short of breath. She thought she was about to die.

Over the next several weeks, Millicent gradually became aware of other symptoms. Her hand had begun to shake; she noticed it one day at the end of her shift when she was adding up the receipts from her cash register. Her appetite was voracious, yet in the past 6 weeks her weight had dropped nearly 10 pounds. She still loved watching movies, but lately she felt so tired at night that she could barely keep awake in front of the TV. Her mood had been somewhat irritable.

“As I thought about it, I realized that all this started about the time my boyfriend and I decided to get married. We’ve been living together for a year, and I really love him. But I’d been burned before, in my first marriage. I thought that might be what was bothering me, so I gave back his ring and moved out. If anything, I feel worse now than before.”

Several times during the interview Millicent shifted restlessly in her chair. Her speech was rapid, though she could be interrupted. Her eyes seemed to protrude slightly, and although she had lost weight, a fullness in her neck suggested a goiter. She admitted that she was having trouble tolerating heat. “There’s no air conditioner in our store. Last summer it was no problem—we kept the door open. But now it’s terrible! And if I wore any less clothing to work, they’d have to give me a desk in the adult video section.”

Millicent’s thyroid function studies proved to be markedly abnormal. Within 2 months an endocrinologist had brought her hyperactive thyroid under control, and her anxiety symptoms had disappeared completely. Six months later, she and her fiancé were married.

Evaluation of Millicent Worthy

Millicent had at least one panic attack (criterion A); her distress was palpable (E). The only remaining requirements would involve ruling out other causes of her problem.

If she had had repeated panic attacks and if the symptoms of her goiter had been overlooked, she could have been misdiagnosed as having panic disorder. Her restlessness could have been misinterpreted as generalized anxiety disorder; her feelings of being closed in sound like a specific phobia. (Even Millicent interpreted her own symptoms as psychological, C.) Such scenarios reinforce the wisdom of placing physical conditions at the top of the list of differential diagnoses.

Irritability, restless hyperactivity, and weight loss also suggest a manic episode, but these are usually accompanied by a subjective feeling of high energy, not fatigue. Millicent’s rapid speech could be interrupted; in bipolar mania, often it cannot. Her lack of previous depressions or manias would also militate against any mood disorders. Her history rules out a substance/medication-induced anxiety disorder. And her attention span and orientation were good, so that we can disregard delirium (D). Finally, we know that the physiological effects of hyperthyroidism can cause anxiety symptoms of the sort Millicent experienced (B).

The broken engagement was noted not because it seemed a cause of her anxiety symptoms, but because her relationship with her fiancé was a problem that should be addressed as part of the overall treatment plan. I’d put her GAF score at an almost-healthy, but still-needs-to-be-addressed 85.

E05.00 [242.00] Hyperthyroidism with goiter without thyroid storm
F06.4 [293.84] Anxiety disorder due to hyperthyroidism
Z63.0 [V61.10] Estrangement from fiancé

F41.8 [300.09] Other Specified Anxiety Disorder

Patients who have prominent symptoms of anxiety, fear, or phobic avoidance that don’t meet criteria for any specific anxiety disorder can be coded as having other specified anxiety disorder—and the reason for not including them in a better-defined category should be stated. DSM-5 suggests several different possibilities:

Insufficient symptoms. This would include panic attacks or GAD with too few symptoms.

The presentation is atypical.

Cultural syndromes. DSM-5 mentions several in an appendix on page 833.

F41.9 [300.00] Unspecified Anxiety Disorder

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