ANXIETY DISORDERS

DSM-5 Criteria for Generalized Anxiety Disorder 

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).

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 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], 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.

DSM-5 Criteria for Separation Anxiety Disorder:

A) Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated. 

B) The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

C) The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

D) The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.

DSM-5 Criteria for Social Anxiety Disorder: 

A) Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). 

Note: In children, the anxiety must occur in peer settings and not just during interactions with adults. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

B) The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). 

C) The social situations almost always provoke fear or anxiety.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

D) The social situations are avoided or endured with intense fear or anxiety.

E) The fear,  anxiety, or avoidance is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

F) The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G) The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H) The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

I) The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J) If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if: Performance only: if the fear is restricted to speaking or performing in public.

DSM-5 Criteria for Panic Disorder:

A) Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time four (or more) of the following symptoms occur: 

Note: The abrupt surge can occur from a calm state or an anxious state. 

• 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 
• Chills or heat sensations 
• Paresthesias (numbness or tingling sensations) 
• Derealization (feelings of unreality) or depersonalization (being detached from oneself) 
• Fear of losing control of “going crazy” 
• Fear of dying 

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms. 

B) At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”). 
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, synch as avoidance of exercise or unfamiliar situations) 

C) The disturbance is not attributable to the physiological effects of substance (e.g. a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). 

D) The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phonic objects or situation, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder). 

DSM-5 Criteria for Agoraphobia: 

A) A marked fear or anxiety about two (or more) of the following five situations:

1. Using public transportation (e.g., automobiles, buses, trains, ships, planes) 
2. Being in open spaces  (e.g., parking lots, marketplaces, bridges)
3. Being in enclosed spaces (e.g., shops, theaters, cinemas)
4. Standing in line or being in a crowd.
5. Being outside the home alone.

B) The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear  of incontinence).

C) The agoraphobic situations almost always provoke fear or anxiety.

D) The agoraphobic situations are actively avoided, require the presence of a comparison or are endured with intense fear or anxiety. 

E) The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

F) The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more.

G) The fear, anxiety, or avoidance causes clinically significant distress or impairment in important areas of functioning.

H) If another medical condition  (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive.

I) The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder - for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations ( as in social anxiety disorder); and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder). 

Note: agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned. 

DSM-5 Criteria for Specific Phobia 

A) Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). 

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. 

B) The phobic object or situation almost always provokes immediate fear or anxiety. 

C) The phobic object or situation is actively avoided or endured with intense fear or anxiety. 

D) The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. 

E) The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. 

F) The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

G) The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of truamatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situation (as in social anxiety disorder). 

Specify if: 

Code based on the phobic stimulus: 

300.29 (F40.218) Animal (e.g., spiders, insects, dogs). 

300.29 (F40.228) Natural environment (e.g., heights, storms, water). 

300.29 (F40.23x) Blood-injection-injury (e.g., needles, invasive medical procedures). 

Coding note: Select specific ICD-10-CM code as follows: F40.230 fear of blood; 

F40.231 fear of injections and transfusions; F40.232 fear of other medical care; or F40.233 fear of injury. 

300.29 (F40.248) Situation (e.g., airplanes, elevators, enclosed places). 

300.29 (F40.298) Other (e.g., situations that may lead to choking or vomiting; in children, e.g., loud sounds or costumed characters). 

Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal and F40.248 specific phobia, situational).