What are the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria for anxiety disorders?

DSM-5 Criteria for Anxiety Disorders

The DSM-5 requires that all anxiety disorders meet core criteria including excessive fear or worry that is developmentally inappropriate and out of proportion to actual threat, causes clinically significant distress or functional impairment in social/occupational/academic domains, persists for a specified duration (typically 6 months), and is not better explained by substance/medication effects, medical conditions, or another mental disorder. 1

Core Diagnostic Requirements Across All Anxiety Disorders

The fundamental framework applies universally to anxiety disorder diagnosis:

• Excessive fear or worry must be out of proportion to the actual threat posed by the situation and developmentally inappropriate for the patient's age 1
• Clinically significant distress or functional impairment in social, occupational, or academic functioning is mandatory—normal developmental fears without impairment do not qualify for diagnosis 1
• Duration criterion of at least 6 months is required for most anxiety disorders in adults, though this varies by specific disorder 1
• Exclusion criteria must be systematically applied: rule out substance/medication-induced symptoms, medical conditions mimicking anxiety, and other mental disorders that better explain the presentation 1

Specific Anxiety Disorder Criteria

Specific Phobia

The diagnosis requires all of the following 1:

• Marked, intense fear of a specific object or situation that almost invariably provokes immediate fear response
• The phobic stimulus is actively avoided or endured with intense distress
• Fear is out of proportion to actual danger posed by the object or situation
• Persists for at least 6 months in individuals under 18 years of age 1
• The fear must be intense, active, and durable over time to distinguish pathological phobia from normal developmental fears or successfully accommodated fears 2

Social Anxiety Disorder

Diagnostic criteria include 1:

• Marked, persistent fear of social or performance situations involving unfamiliar people or possible scrutiny by others
• Fears of acting in humiliating or embarrassing ways during social exposure
• Exposure to feared social situations almost always provokes anxiety
• Recognition that the fear is excessive or unreasonable (though this may be absent in children)
• The situations are avoided or endured with intense anxiety

Agoraphobia

This disorder is characterized by 1:

• Excessive fear or worry about being in situations where escape might be difficult or help unavailable should panic-like or overwhelming symptoms occur
• Can exist independently of panic attacks—DSM-5 simplified classification allows separate coding of panic disorder and agoraphobia with comorbid double diagnosis when both are present 3

Panic Disorder

Key diagnostic considerations include 4:

• Must systematically rule out medical conditions that mimic panic symptoms, particularly asthma, hyperthyroidism, hypoglycemia, cardiac arrhythmias, and migraines 5, 4
• Assess for commonly co-occurring conditions including major depressive disorder (present in 56% of cases), other anxiety disorders, substance use disorders, and agoraphobia 5, 4
• Use structured diagnostic interviews to confirm DSM-5 criteria 4

Critical Diagnostic Considerations

Developmental Context

• Normal developmental fears must be distinguished from pathological anxiety by considering the developmental stage and whether the fear is age-appropriate 1
• Criteria have been harmonized to be applicable across all age, gender, and cultural groups 3

Screening and Assessment

• The GAD-7 serves as an initial screening instrument, with scores ≥10 indicating moderate to severe anxiety requiring comprehensive diagnostic evaluation 1, 4
• Structured diagnostic interviews should be used to confirm diagnosis according to DSM-5 criteria 4

Comorbidity Assessment

Systematically evaluate for 1, 5:

• Major depressive disorder (present in 56% of anxiety disorder patients and significantly increases suicide risk)
• Other anxiety disorders (frequently co-occur)
• Substance use disorders (both as cause and comorbidity)
• PTSD, bipolar disorder, ADHD, OCD, and eating disorders

Medical Differential Diagnosis

Rule out medical conditions that mimic anxiety 5:

• Endocrine: Hyperthyroidism, hypoglycemia, diabetes
• Cardiac: Arrhythmias, other heart disorders causing palpitations
• Respiratory: Asthma with overlapping symptoms
• Neurological: Migraines with autonomic symptoms
• Pain: Chronic pain conditions

Substance-Induced Considerations

Evaluate for 2, 5:

• Caffeine excess directly provoking anxiety
• Medications inducing anxiety as side effect
• Illicit drug use (stimulants) or withdrawal states
• Alcohol withdrawal creating rebound anxiety
• The substance must be pharmacologically capable of producing the psychiatric symptoms 2

DSM-5 Structural Changes

The DSM-5 reorganized anxiety disorders significantly 3, 6:

• Obsessive-compulsive disorder and PTSD were removed from the anxiety disorders chapter and placed in separate chapters
• Selective mutism and separation anxiety disorder were added to the anxiety disorders chapter 3
• Disorders are now grouped with a developmental/life span viewpoint 6
• Panic disorder and agoraphobia can be separately coded with comorbid double diagnosis when both present 3