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Anxiety - DSM-IV Diagnosis


ANXIETY DISORDERS are diagnosed by psychiatrists and psychologists with the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision).


Anxiety Disorders are common in our modern societies. Up to 25% of adults will have an anxiety disorder sometime in their life. 10% of the population will experience an anxiety disorder this year. Anxiety disorders are the most common mental health problem in women, and second most common in men. Living with an anxiety disorder makes it is difficult to manage daily tasks, let alone personal finances, work or study. Normal social life is also hampered causing isolation when support is needed.


Generalized Anxiety Disorder (GAD)


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)

D. The focus of the anxiety and worry is not confined to features of a 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.


Panic Disorder (with and without Agoraphobia)


Note: The DSM-IV distinguishes Panic Disorder with Agoraphobia from Panic Disorder Without Agoraphobia. In the summary below, see criterion B.


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:
    • Persistent concern about having additional attacks
    • Worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)
    • A significant change in behaviour related to the attacks

B. Absence of Agoraphobia / Presence of Agoraphobia


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., exposure to a specific phobic situation)
  • Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination)
  • Post-Traumatic 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)

Panic Attack


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:

  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, light-headed, or faint
  • Sense of unreality or depersonalization
  • Fear of losing control or going crazy
  • Fear of dying
  • Numbing or tingling sensations
  • Chills or hot flushes

Post Traumatic Stress Disorder (PTSD)


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 behaviour

B. The traumatic event is persistently re-experienced 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 re-enactment may occur
  4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

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)

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. Hyper vigilance
  5. Exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.


F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Social Phobia


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 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.


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.


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.


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 fro by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety, 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 Disease, or exhibiting abnormal eating behavior in Anorexia Nervosa.



Obsessive-Compulsive Disorder (OCD)


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. he 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).

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.

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.


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 Disorder; 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.





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