ANXIETY DISORDERS
- Common features – excessive fear and anxiety and related
behavioral disturbances
- Fear – emotional response to real or perceived imminent
threat
More associated with surges of autonomic
arousal for fight/flight, thoughts of incoming
danger, and escape behaviors
- Anxiety – anticipation of future threat
More associated with muscle tension and
vigilance to prepare, and cautious or avoidant
behaviors
- Panic attacks – type of fear response; can be seen in other
d/o’s also
- Anxiety d/o’s differ – objects or situations that induce fear,
anxiety or avoidance behavior and associated thoughts;
highly comorbid
- Vs. developmentally normal fear or anxiety – persistent
than just stress-induced; excessive; usually develop in
childhood and persist if untreated
- Arranged by age of onset
Separation Anxiety Disorder 309.21
Diagnostic Criteria
A. Developmentally inappropriate and excessive fear or
anxiety on separation to those they’re attached
At least 3
1. Recurrent excessive distress when anticipating or
experiencing separation from home or figures
2. Persistent and excessive worry on losing major
attachment figures or possible harm to them
3. Persistent and excessive worry on experiencing
untoward event that causes separation
4. Persistent reluctance or refusal to go out, away from
home, to school or work, or elsewhere d/t fear of
separation
5. Persistent and excessive fear or reluctance of being
alone or without figures at home or other settings
6. Persistence reluctance or refusal to sleep away from
home or without figure
7. Repeated nightmares on theme of separation
8. Repeated complaints of physical sxs when separated
from major figure or is anticipated
B. Fear, anxiety or avoidance is persistent
Children and adolescents – at least 4 weeks
Adults – at least 6 months
C. Causes significant distress or impairment in social,
academic, occupational or other important areas of
functioning
D. NBE by another mental d/o
o Refusing to leave home d/t resistance to change
(autism spectrum d/o)
o Delusions or hallucinations on separation
(psychotic d/o’s)
o Refusal to go out without trusted companion
(agoraphobia)
o Worries on ill health or harm on significant
others (generalized anxiety d/o)
o Concerns of illness (illness anxiety d/o)
Diagnostic Features
- A2 – need to know whereabouts and want to stay in touch
- A3 – getting lost, kidnapped, accident
- A5 – children = unable to stay or go in room by
themselves; clingy behavior
- A6 – children = insist that someone stay until they fall
asleep; go to parent’s bed; reluctant to sleep anywhere
else or go on errands
Adults – uncomfortable traveling independently
- A8 – physical sxs = headaches, stomachaches, nausea,
vomiting
Adolescents and adults – palpitations, dizziness, feeling
faint = rare in children
Associated Features
- Children when separated – social withdrawal, sadness,
apathy, difficulty concentrating
- May have fears of animals, monsters, the dark, muggers,
burglars, kidnappers, car accidents, plane travel (perceived
danger) = depends on age
- Feel homesick and uncomfortable to the point of misery
- Show anger or aggression to those forcing separation
- Children alone – unusual perceptual experience
- Children – demanding, intrusive, needs constant attention
- Adults – dependent and overprotective
- Leads to frustration, resentment and conflict with others
Children – highly comorbid with GAD and specific phobia
Adults – specific phobia, PTS, panic d/o, GAD, social anxiety d/o,
agoraphobia, OCD and personality d/o’s; depressive and bipolar
d/o’s
Selective Mutism 312.23
Diagnostic Criteria
A. Consistent failure to speak in social situations with
expectation for speaking DESPITE speaking in other
situations
B. Interferes with educational or occupational achievement
OR
Social communication
C. At least 1 month
NOT LIMITED to first month of school
D. Not from lack of knowledge or comfort with required
spoken language
E. NBE by communication d/o
Doesn’t occur only during course of autism spectrum d/o,
schizophrenia or another psychotic d/o
Diagnostic Features
- Don’t initiate speech or respond when spoken
- Speak in home in presence of immediate family members
only
- Marked by high social anxiety
- Refuse to speak at school = leads to academic or
educational impairment – difficulty assessing reading skills
- Can sometimes use nonspoken or nonverbal means to
communicate
- May be willing or eager to engage in encounters when
speech isn’t required
Associated Features
- Excessive shyness, fear of social embarrassment, social
isolation and withdrawal, clinging, compulsive traits,
negativism, temper tantrums or mild oppositional
behavior
- Normally have language skills – can be associated with
communication d/o
- Clinical settings – children usually also given another dx of
anxiety d/o = usually social anxiety d/o
Specific Phobia
Diagnostic Criteria
A. Fear or anxiety of specific object or situation
Children – expressed by crying, tantrums, freezing or
clinging
B. Phobic object or situation almost always results in fear or
anxiety immediately
C. Phobics are actively avoided or endured with intense fear
or anxiety
D. Fear or anxiety is out of proportion to danger and
sociocultural context
E. Fear, anxiety or avoidance is persistent
Lasts for at least 6 months
F. Causes significant distress or impairment in social,
occupational or other important areas of functioning
G. NBE by sxs of another mental d/o
o Fear, anxiety and avoidance of situations
associated with panic-like sxs or incapaciting sxs
(agoraphobia)
o Objects/situations related to obsessions (OCD)
o Reminders of traumatic events (PTSD)
o Separation from home or figures (separation
anxiety d/o)
o Social situations (social anxiety d/o)
Specify if – code based on phobic stimulus
Animal 300.29
Natural environment 300.29
Blood-injection-injury 300.29
F40.230 Fear of blood
F40.231 Fear of injections and transfusions
F40.232 Fear of other medical care
F40.233 Fear of injury
Situational 300.29
Other 300.29
Specifiers
- Common to have multiple phobias – average of 3
- Record each code
Ex. fears thunderstorms and flying – specific
phobia, natural environment and
Specific phobia, situational
Diagnostic Features
- Key feature – presence of phobic stimulus = response
differs from normal, transient fears
- Amount of fear – varies with proximity to phobic stimulus;
can occur in anticipation or presence
- Fear or anxiety can take form of full or limited sx panic
attack = expected panic attack
- Degree of fear or anxiety – can vary across different
occasions of encountering phobic stimulus based on
contextual factors = presence of others, duration of
exposure, or other threatening elements
- Fear and anxiety expressed differently between children
and adults
- Active avoidance – intentionally behaving to prevent or
minimize contact with phobic stimulus
- Suffered many years and changed lifestyle to avoid it
- Usually know that reactions are disproportionate – tend to
overestimate danger; take sociocultural context into
account
- Duration criterion (E) should be taken as a guide = can be
flexible
Associated Features
- Increase in arousal in anticipation or presence = can vary
- Situational, natural environment and animal phobias – SNS
arousal
- Blood-injection-injury phobias – vasovagal fainting or near-
fainting response; initial brief acceleration of heart rate
and elevation of BP then both reducing
Social Anxiety Disorder (Social Phobia) 300.23
Diagnostic Criteria
A. Fear or anxiety of at least 1 social situation where they’re
exposed to possible scrutiny
Ex. social interactions, being observed, and
performing in front of others
Children – must occur in peer settings; not just interaction
with adults
B. Fears they will act in a way or show anxiety sxs that will be
negatively evaluated – humiliating or embarrassing; leads
to rejection or offense to others
C. Social situations almost always provoke fear or anxiety
Children – expressed by crying, tantrums, freezing,
clinging, shrinking or failing to speak in social situations
D. Social situations are avoided or endured with intense fear
or anxiety
E. Fear or anxiety is disproportioned to threat of social
situation and sociocultural context
F. Fear, anxiety or avoidance is persistent – lasts at least 6
months
G. Causes significant distress or impairment in social,
occupational or other important areas of functioning
H. Not from physiological effects of substance or another
medical condition
I. NBE by sxs of another mental d/o like panic d/o, body
dysmorphic d/o or autism spectrum d/o
J. If another medical condition present – fear, anxiety or
avoidance is unrelated or excessive
Specify if:
Performance only – fear only in speaking or performing in
public
Specifiers
- Performance only – have performance fears that impair
professional lives or roles requiring regular public speaking
- Can manifest in work , school, or academic settings
 - Don’t fear or avoid nonperformance social situations
Diagnostic Features
- Concerned they will be judged as anxious, weak, crazy,
stupid, boring, intimidating, dirty or unlikable
- Show anxiety sxs – blushing, trembling, sweating,
stumbling over words, or staring
- Fear of offending others – may be predominant fear in
strong collectivistic cultures
- Fear of trembling hands – may avoid drinking, eating,
writing or pointing n public
- Fear of sweating – avoid shaking hands, eating spicy foods
- Fear of blushing – avoid public performance, bright lights,
discussion of intimate topics
- Fear and avoid urinating in public restroom with others
present = paruresis/”shy bladder syndrome”
- Avoidance of social situations – extensive or subtle
- Overestimate negative consequences of social situations;
take sociocultural context into account
- (F) – helps distinguish from transient social fears = can be
used as general guide
- If public speaking not common in setting – not dx
- If avoiding or passing over for job or education they really
want because of sxs – G is met
Associated Features
- Inadequately assertive or excessively submissive; less
common – highly controlling of conversation
- Overly rigid body posture, inadequate eye contact, speak
with overly soft voice
- May be shy or withdrawn; less open in conversations;
disclose little on themselves
- Seek employment in jobs not requiring social contact – not
for performance only
- Live at home longer
- Men – delayed in marrying and having family; women –
want to work outside home = live as homemaker and
mother
- Self-medication with substances is common
- Social anxiety in older adults – can exacerbate sxs of
medical illness
- Blushing – hallmark response of d/o
Panic Disorder 300.1
Diagnostic Criteria
A. Recurrent unexpected panic attacks – abrupt surge of
intense fear or discomfort that reaches peak within
minutes; during which has at least 4 sxs:
Abrupt surge can occur from calm or anxious state
1. Palpitations, pounding heart or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed or faint
9. Chills or heat sensations
10. Paresthesias – numbness or tingling sensation
11. Derealization – feelings of unreality OR
Depersonalization – being detached from oneself
12. Fear of losing control or going crazy
13. Fear of dying
Culture specific sxs may be seen = doesn’t count as 4
required sxs
B. At least 1 of attacks followed by at least 1 month of at
least 1 of:
1. Persistent concern or worry about additional panic
attacks or consequences
2. Significant maladaptive change in behavior related to
attacks – behaving in a way to avoid panic attacks
C. Not from physiological effects of substance or another
medical condition
D. NBE by another mental d/o
Diagnostic Features
- Recurrent – more than one unexpected panic attack
- Unexpected – attack has no obvious cue or trigger
- Nocturnal panic attack – when relaxing or just waking up
- Expected panic attack – has obvious cue or trigger = based
on sequence of events leading up to attack or judgement
of reason; can be based on cultural expectations
- Indicate separate dx of agoraphobia if present
Associated Features
- Constant or intermittent feelings of anxiety broadly related
to health and mental health concerns = intolerant of
medication side effects
- Pervasive concerns on abilities to do daily tasks or
withstand daily stressors, excessive use of drugs to control
panic attacks, extreme behaviors to control panic attacks
Panic Attack Specifier – sxs present of panic attack = NOT a mental
d/o; noted as specifier if present
Can occur in any anxiety d/o and other mental d/o and some
medical conditions
Panic d/o – panic attack indicated in criteria and NOT used as
specifier
Abrupt surge of intense fear or discomfort that reaches peak within
minutes; during which has at least 4 sxs:
Abrupt surge can occur from calm or anxious state
1. Palpitations, pounding heart or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed or faint
9. Chills or heat sensations
10. Paresthesias – numbness or tingling sensation
11. Derealization – feelings of unreality OR
Depersonalization – being detached from oneself
12. Fear of losing control or going crazy
13. Fear of dying
Culture specific sxs may be seen = doesn’t count as 4
required sxs
Features
- 11 physical sxs and 2 cognitive sxs
 - Time to peak intensity – assessed independently from
preceding anxiety = starts when abrupt increase of
discomfort
- Can return to either anxious or calm state and can peak
again
- Vs ongoing anxiety – time to peak intensity (within mins);
discrete nature; greater severity
- Limited-symptom attacks – meet criteria but have fewer
than 4 sxs
- Two characteristic types – also based on cultural
interpretations
o Expected – have obvious cue or trigger
o Unexpected – no obvious cue or trigger at time
of occurrence
Associated Features
- Nocturnal panic attack – waking in state of panic
(unexpected); different from panicking after fully awake
- Related to higher rate of suicide attempts and ideation
Agoraphobia 300.22
Diagnostic Criteria
A. Marked fear or anxiety on at least 2 of 5 situations:
1. Using public transportation
2. Being in open spaces
3. Being in enclosed spaces
4. Standing in line or being in crowd
5. Being outside of home alone
B. Fear or avoid situations because they think escape might
be difficult or unavailable if they develop panic-like sxs or
other incapacitating or embarrassing sxs
C. Agoraphobic situations almost always provoke fear or
anxiety
D. Situations are actively avoided, require presence of
companion or endured with intense fear or anxiety
E. Fear or anxiety disproportionate to danger of situation and
sociocultural context
F. Fear, anxiety or avoidance is persistent – lasts at least 6
months
G. Causes significant distress or impairment in social,
occupational or other important areas of functioning
H. If another medical condition present – fear, anxiety or
avoidance is excessive
I. NBE by sxs of another mental d/o
o Perceived defects or flaws in physical
appearance (body dysmorphic d/o)
Dx regardless of panic d/o – meet both criteria = give both
dxs
Diagnostic Features
- Panic-like sxs – 13 sxs of panic attack
- Other incapacitating or embarrassing sxs – vomiting,
inflammatory bowel sxs
Older adults – fear of falling
Children – sense of disorientation and getting lost
- Amount of fear – can vary with proximity to situation and
can occur in anticipation or presence
- Active avoidance – currently behaves in ways to prevent or
minimize contact = behavioral or cognitive
Severe – completely homebound
- Can confront with companion
- Reasons why we need to distinguish it from reasonable
fears:
o Avoidance can be difficult to judge across
cultures and sociocultural contexts
o Older adults may overattribute fears as age-
related and less likely to judge as
disproportionate to risk
o Likely to overestimate danger in relation to
panic-like or bodily sxs
- Duration of at least 6 months – meant to exclude those
with transient problems; can be used as general guide
Associated Features
- Demoralization and depressive sxs, abuse of alcohol and
sedative medication = common as inappropriate self-
medication strategies
Generalized Anxiety Disorder 300.02
Diagnostic Criteria
A. Excessive anxiety or worry (apprehensive expectation)
occurring more days than not – at least 6 months
On number of events or activities – work or school
performance
B. Find it difficult to control worry
C. Associated with at least 3 of 6 sxs:
Only 1 for 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;
restless, unsatisfying sleep
D. Anxiety, worry or physical sxs cause significant distress or
impairment in social, occupational or other important
areas of functioning
E. Not from physiological effects of substance or another
medical condition
F. NBE by another mental d/o
o Gaining weight (anorexia nervosa)
o Physical complaints (somatic symptom disorder)
o Having serious illness (illness anxiety disorder)
o Content of delusional beliefs (schizophrenia or
delusional d/o)
Diagnostic Features
- Intensity, duration or frequency of anxiety or worry is
disproportionate to likelihood or impact of event
- Adults – worry on every day, routine life circumstances =
job responsibilities, health and finances, health of family,
misfortune to children or minor matters
- Children – worry on competence or quality of performance
- Focus of worry can shift concerns
- Vs. nonpathological anxiety
o Excessive and typically interfere with functioning
// not excessive and more manageable, can be
put off for more pressing matters
 o Worries are more pervasive, pronounced and
distressing, longer duration, occur without
precipitants
o Greater range of life circumstances of worry –
more likely sxs meet criteria for GAD
o // less likely paired with physical sxs
Associated Features
- Muscle tension – trembling, twitching, feeling shaky,
muscle aches or soreness
- Somatic sxs (sweating, nausea, diarrhea) and exaggerated
startle response
- Sxs of autonomic hyperarousal less common in GAD
- Sxs associated with stress – headaches, irritable bowel
syndrome
Substance/Medication-Induced Anxiety Disorder
Diagnostic Criteria
A. Panic attacks or anxiety predominates
B. Evidence from history, physical exam, or lab findings of
BOTH (1) and (2):
1. Sxs in A developed during or soon after substance
intoxication or withdrawal OR
After exposure to medication
2. Substance/medication is capable of producing sxs of A
C. NBE by anxiety d/o that isn’t substance/medication-
induced
Evidence of independent anxiety d/o
o Sxs precede onset of substance/medication use
o Persist for substantial period after cessation of
acute withdrawal or severe intoxication OR
o Other evidence of independent d/o
D. Not occur only during course of delirium
E. Causes distress or impairment in social, occupational or
other important areas of functioning
Use dx instead of substance intoxication or substance
withdrawal – ONLY when sxs of A predominate and are severe
enough
Specify if:
With onset during intoxication – criteria met for
intoxication and sxs develop during it
With onset during withdrawal – criteria met for
withdrawal from substance and sxs develop during or
shortly after
With onset after medication use – sxs can appear either at
initiation of medication or after change in use
Recording Procedures
- Specific substance – select code from table based on drug
class and presence or absence of comorbid substance use
d/o
- Substance that doesn’t fit in class – “other substance”
- Substance is etiological factor but specific class is unknown
– “unknown substance”
- List comorbid substance use d/o first then “with” name of
substance-induced depressive d/o
- Onset
- Occurs without comorbid substance-use d/o – not noted
- More than one substance – list separately
Ex. F15.280 severe methylphenidate use disorder with
methylphenidate-induced anxiety disorder, with onset during
intoxication; F19.980 salbutamol-induced anxiety disorder, with
onset after medication use
Diagnostic Features
- Treatment discontinued – panic or anxiety sxs usually
improve or remit within days to weeks to a month
- Given instead of substance intoxication or substance
withdrawal ONLY when sxs of A predominate and are
severe enough
Associated Features
- Associated with – alcohol, caffeine, cannabis,
phencyclidine, other hallucinogens, inhalants, stimulants
(including cocaine), and other/unknown substances
- With withdrawal – alcohol, opioids, sedatives, hypnotics,
anxiolytics, stimulants (+ cocaine), and other/unknown
substances
Anxiety Disorder Due to Another Medical Condition 293.84
Diagnostic Criteria
A. Panic attacks or anxiety predominate
B. Evidence from history, physical exam or lab findings that
it’s the direct pathophysiological consequence of another
medical condition
C. NBE by another mental d/o
D. Not occur only during course of delirium
E. Causes significant distress or impairment in social,
occupational or other important areas of functioning
Include name of other medical condition within name of d/o
Other medical condition coded and listed separately before
anxiety d/o d/t medical condition
Ex. 227.0 [D35.00] pheochromocytoma; 293.84 [F06.4]
anxiety disorder due to pheochromocytoma
Diagnostic Features
- Should first establish presence of a general medical
condition – determine if disturbance is etiologically related
to condition
- Consider:
o Presence of clear temporal association between
onset, exacerbation or remission of medical
condition and anxiety sxs
o Features atypical of primary anxiety d/o
 o Evidence in literature of physiological
mechanism causing anxiety
- NBE by primary anxiety d/o, substance/medication-
induced anxiety d/o, or another primary mental d/o

Associated Features
- Associated with endocrine disease, cardiovascular d/o’s,
respiratory illness, metabolic disturbances and
neurological illness = known to induce anxiety

Other Specified Anxiety Disorder 300.09 – applies when sxs of

anxiety d/o cause distress or impairment predominate but don’t
meet full criteria
Used when clinician chooses to specify reason it doesn’t meet
criteria
Record “other specified anxiety disorder” followed by reason
Examples of presentations:
1. Limited-symptom attacks
2. Generalized anxiety not occurring more days than not
3. Khyâl cap (wind attacks) – dizziness, palpitations, shortness
of breath, and cold extremities; sxs of anxiety and
autonomic arousal
Catastrophic cognitions based on concern that khyal
(wind-like substance) may rise in body and blood with
serious effects
Can occur w/o warning but can be triggered by worrisome
thoughts, standing up, specific odors with negative
associations, and agoraphobic-type cues
4. Ataque de nervios (attack of nerves)

Unspecified Anxiety Disorder 300.00 – applies when sxs of anxiety

d/o cause distress or impairment predominate but don’t meet full
criteria
Used when clinician chooses to not specify reason it doesn’t meet
criteria; when insufficient information provided for dx