What are the diagnostic criteria and treatment options for anxiety disorders as categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM)?

DSM Diagnostic Criteria for Anxiety Disorders

The DSM-5 categorizes anxiety disorders into distinct entities including separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder, each with specific diagnostic criteria that require clinically significant distress or functional impairment to distinguish pathological anxiety from normal developmental fears. 1

Core Diagnostic Framework

All anxiety disorders share fundamental requirements that differentiate clinical pathology from normal human experience 1:

• Excessive fear or worry that is developmentally inappropriate and out of proportion to the actual threat 1
• Clinically significant distress or functional impairment in social, occupational, or academic domains 1
• Duration criteria that vary by specific disorder (typically 6 months for most anxiety disorders in adults) 1
• Exclusion of other causes including substance/medication effects, medical conditions, or better explanation by another mental disorder 1

Specific Anxiety Disorder Criteria

Generalized Anxiety Disorder (GAD)

GAD is characterized by excessive, uncontrollable worry about multiple life circumstances for at least 6 months, accompanied by at least 3 of 6 associated symptoms (restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance). 2

The FDA-approved definition specifies that GAD involves unrealistic or excessive anxiety and worry about two or more life circumstances, present more days than not for 6 months or longer 2. Key diagnostic features include:

• Motor tension: trembling, muscle aches, restlessness, easy fatigability 2
• Autonomic hyperactivity: shortness of breath, palpitations, sweating, dizziness, gastrointestinal distress 2
• Vigilance and scanning: feeling keyed up, exaggerated startle, concentration difficulty, sleep disturbance, irritability 2

Panic Disorder

Panic disorder requires recurrent unexpected panic attacks (discrete periods of intense fear peaking within 10 minutes) plus at least 1 month of persistent concern about additional attacks or maladaptive behavioral changes related to the attacks. 2

A panic attack involves at least 4 of 13 symptoms 2:

• Palpitations or accelerated heart rate
• Sweating
• Trembling or shaking
• Shortness of breath or smothering sensations
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Dizziness, lightheadedness, or faintness
• Derealization or depersonalization
• Fear of losing control
• Fear of dying
• Paresthesias
• Chills or hot flushes

Specific Phobia

Specific phobia requires marked, intense fear of a specific object or situation that almost invariably provokes immediate fear, is actively avoided or endured with intense distress, is out of proportion to actual danger, and persists for at least 6 months in individuals under 18 years. 1

The DSM-IV-TR criteria (with proposed DSM-5 refinements) include 1:

• Criterion A: Marked and persistent fear cued by specific object or situation (e.g., flying, heights, animals, injections, blood) 1
• Criterion B: Exposure almost invariably provokes immediate anxiety response (may manifest as panic attack) 1
• Criterion C: Recognition that fear is excessive or unreasonable (may be absent in children) 1
• Criterion D: Active avoidance or endurance with intense anxiety 1
• Criterion E: Significant interference with normal routine, occupational/academic functioning, or social activities, OR marked distress about having the phobia 1

Social Anxiety Disorder (Social Phobia)

Social anxiety disorder is characterized by marked, persistent fear of social or performance situations involving unfamiliar people or possible scrutiny, with fears of acting in humiliating or embarrassing ways. 3

Diagnostic requirements include 3:

• Exposure to feared social situations almost always provokes anxiety
• Recognition that the fear is excessive or unreasonable
• Feared situations are avoided or endured with intense anxiety
• Avoidance and anticipatory anxiety cause functional impairment or marked distress

Agoraphobia

Agoraphobia involves excessive fear or worry about being in situations (crowds, enclosed spaces, public transportation) where escape might be difficult or help unavailable should panic-like or overwhelming symptoms occur. 1

The evidence suggests agoraphobia can exist independently of panic attacks and should be diagnosed separately from panic disorder 1.

Separation Anxiety Disorder

Separation anxiety disorder is characterized by developmentally inappropriate, excessive worry or distress associated with separation from primary caregivers or major attachment figures. 1

Selective Mutism

Selective mutism involves consistent absence of speech in specific social situations despite speaking in other situations (typically at home). 1

Critical Diagnostic Considerations

Developmental Context

Normal developmental fears must be distinguished from pathological anxiety—stranger anxiety in infants, separation concerns in toddlers, supernatural fears in preschoolers, physical safety worries in school-age children, and social/existential concerns in adolescents are all normative. 1

Comorbidity Assessment

Systematically assess for commonly co-occurring conditions including major depressive disorder, other anxiety disorders, substance use disorders, and in panic disorder specifically, agoraphobia. 4

Medical Exclusions

Rule out medical conditions that mimic anxiety symptoms, particularly for panic disorder where asthma and other cardiopulmonary conditions must be excluded. 4

Screening Tools

Use the GAD-7 as an initial screening instrument, with scores ≥10 indicating moderate to severe anxiety requiring comprehensive diagnostic evaluation. 4

The APA Level 1 Cross-Cutting Symptom Measures provide standardized screening across multiple psychiatric domains including anxiety 1.

Common Diagnostic Pitfalls

The most frequent source of diagnostic disagreement (62% of cases) involves determining whether sufficient impairment and distress exist to warrant diagnosis, particularly for additional versus principal diagnoses. 1

Terms like "excessive," "unreasonable," "marked," and "persistent" lack operational definitions and create reliability problems—clinicians should use clinical judgment to determine if fear is out of proportion to actual danger rather than relying solely on patient self-assessment. 1

Elderly patients with phobias are frequently under-diagnosed due to over-attribution of fears to age-related constraints, requiring clinician judgment rather than patient self-recognition of excessiveness. 1

Distinguishing GAD from adjustment disorder with anxious mood, subthreshold social phobia, and undifferentiated somatization disorder requires emphasis on predominant psychic anxiety symptoms and chronicity. 5