anxiety disorders in childhood and adolescence

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

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

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 � 2:1 sex ratio With Agoraphobia � 3:1 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).

38. Agoraphobia Without History of Panic Disorder (300.22) Essential feature: focus of one�s 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.

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 Tourette�s 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

59. 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) Survivor�s guilt Problems may result from a lack of attention to the individual�s 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).

64. 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)

65. 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).

66. 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.

68. 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 individual�s 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 individual�s 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).

77. 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)

80. 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.

81. 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

83. 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)

97. 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. Children�s 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.

102. 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 With Obsessive-Compulsive Symptoms: if obsessions or compulsions predominate in the clinical presentation Coding note: Include the name of the general medical condition on Axis I, e.g., Anxiety Disorder Due to Pheochromocytoma, With Generalized Anxiety (293.84); also code the general medical condition on Axis III.

108. Anxiety Disorder NOS (300.00) This category includes disorders with prominent anxiety or phobic avoidance that do not meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with Mixed Anxiety and Depressed Mood. Examples include: 1. Mixed anxiety-depressive disorder: clinically significant symptoms of anxiety and depression, but the criteria are not met for either a specific Mood Disorder or a specific Anxiety Disorder. 2. Clinically significant social phobic symptoms that are related to the social impact of having a general medical condition or mental disorder (e.g., Parkinson�s disease�) 3. Situations in which the disturbance is severe enough to warrant a diagnosis of an Anxiety Disorder but the individual fails to report enough symptoms for the full criteria for any specific Anxiety Disorder to have been met. 4. Situations in which the clinician has concluded that an Anxiety Disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.

109. Two More Anxiety Disorders to be Covered Later: Adjustment Disorder with Anxiety Adjustment Disorder with Mixed Anxiety and Depressed Mood