What are the DSM diagnostic criteria for anxiety disorders such as generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobia, and agoraphobia?

Diagnostic Criteria for Anxiety Disorders

Anxiety disorders are diagnosed when excessive fear or worry is developmentally inappropriate, out of proportion to actual threat, causes clinically significant distress or functional impairment, and persists for at least 6 months, with systematic exclusion of medical conditions, substance effects, and other mental disorders. 1, 2

Core Diagnostic Framework

All anxiety disorders share fundamental requirements that must be met for diagnosis:

• Excessive fear or worry that is developmentally inappropriate and out of proportion to the actual danger posed by the situation 1, 2
• Clinically significant distress or functional impairment in social, occupational, or academic domains—normal developmental fears without impairment do not qualify for diagnosis 1, 2
• Duration of at least 6 months for most anxiety disorders in adults (though this varies by specific disorder) 2
• Systematic exclusion of substance/medication-induced symptoms, medical conditions mimicking anxiety, and other mental disorders that better explain the presentation 1, 2

Critical Distinction from Normal Development

You must distinguish pathological anxiety from normal developmental fears, which are common at specific life stages: stranger anxiety in infants, separation concerns in toddlers, fears of supernatural creatures in preschoolers, worries about physical well-being in school-aged children, and social/existential concerns in adolescents 1. The key differentiator is whether the fear causes functional impairment and exceeds what is developmentally expected.

Specific Anxiety Disorder Criteria

Generalized Anxiety Disorder (GAD)

• Excessive, uncontrollable worries regarding numerous everyday situations or activities 1
• Worries are difficult to control and cause significant distress 1
• Associated with physical symptoms such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance 1
• Use GAD-7 for screening: scores ≥9 indicate likely GAD (positive likelihood ratio 4.3), with scores ≥10 requiring comprehensive diagnostic evaluation 1, 2, 3

Panic Disorder

• Recurrent unexpected panic attacks characterized by abrupt surge of intense fear reaching peak within minutes, with at least 4 of 13 symptoms: palpitations, sweating, trembling, shortness of breath, choking sensations, chest pain, nausea, dizziness, chills/heat sensations, paresthesias, derealization, depersonalization, fear of losing control, or fear of dying 3
• At least one panic attack followed by ≥1 month of persistent concern about additional attacks or their consequences, or significant maladaptive behavioral change 3
• Systematically rule out medical mimics: hyperthyroidism, hypoglycemia, cardiac arrhythmias, asthma, migraines, and other endocrine/cardiac/respiratory disorders 3
• Evaluate for substance effects: caffeine excess, illicit drugs, alcohol withdrawal, medication side effects 3
• Assess for comorbid agoraphobia (now a separate diagnosis that can co-occur) 3, 4

Social Anxiety Disorder (SAD)

• Marked, persistent fear of social or performance situations involving unfamiliar people or possible scrutiny by others 2
• Fear of acting in ways that will be humiliating or embarrassing 2
• Exposure to feared social situations almost always provokes anxiety 2
• The DSM-5 eliminated the requirement that adults recognize their fear as excessive or unreasonable, as insight varies and is not essential for diagnosis 5, 6
• Use Mini-SPIN for screening: scores ≥6 have 89% sensitivity and 90% specificity 1

Specific Phobia

• Marked, intense fear of a specific object or situation (animals, natural environment, blood-injection-injury, situational, or other) 1, 2
• The phobic object or situation almost invariably provokes immediate fear response 1
• The phobic stimulus is actively avoided or endured with intense distress 1, 5
• Fear is out of proportion to actual danger posed by the specific object or situation 1, 5
• Duration ≥6 months required for individuals under 18 years; no comparable adult duration threshold exists, creating diagnostic inconsistency 1, 5

Common pitfall: The functional impairment requirement can lead to under-diagnosis when individuals successfully avoid easily circumvented feared situations (e.g., snakes in urban settings, bridges with alternative routes) yet experience genuine intense fear 5.

Agoraphobia

• Excessive fear or worry about being in situations (crowds, enclosed spaces, public transportation, open spaces, being outside the home alone) where escape might be difficult or help unavailable should panic-like or overwhelming symptoms occur 1, 2
• Can exist independently of panic attacks—the DSM-5 separated agoraphobia from panic disorder into distinct diagnoses 1, 2, 4
• Fear or anxiety about ≥2 of the five agoraphobic situations 4
• Duration ≥6 months 4

Separation Anxiety Disorder

• Developmentally inappropriate, excessive worry or distress associated with separation from primary caregiver or major attachment figure 1
• Must cause clinically significant impairment 1

Selective Mutism

• Absence of speech in certain social situations despite presence of speech in other situations (usually at home) 1
• Interferes with educational or occupational achievement or social communication 1

Systematic Diagnostic Approach

Step 1: Initial Screening

• Deploy GAD-7 systematically in primary care or intake packets 1, 2
• Scores ≥9 warrant further evaluation; scores ≥10 indicate moderate to severe anxiety requiring comprehensive assessment 1, 2, 3
• Consider APA Level 1 Cross-Cutting Symptom Measures for broader psychiatric screening 1

Step 2: Structured Diagnostic Interview

• Use structured interviews such as the Anxiety Disorders Interview Schedule (ADIS) to confirm DSM-5 criteria 3
• For children and adolescents, use K-SADS-PL DSM-5 (freely available) 3
• Assess whether all diagnostic criteria are met, including duration, functional impairment, and exclusion criteria 1, 2

Step 3: Rule Out Medical Conditions

Systematically exclude medical mimics before finalizing anxiety disorder diagnosis:

• Endocrine: hyperthyroidism, hypoglycemia, pheochromocytoma 3
• Cardiac: arrhythmias, mitral valve prolapse, coronary artery disease 3
• Respiratory: asthma, chronic obstructive pulmonary disease 3
• Neurological: migraines, seizure disorders, vestibular dysfunction 3
• Other: anemia, electrolyte imbalances 3

Step 4: Evaluate Substance/Medication Effects

• Caffeine excess (>400 mg/day) 3
• Illicit drug use (cocaine, amphetamines, cannabis withdrawal) 3
• Alcohol withdrawal 3
• Medication side effects (corticosteroids, thyroid hormones, bronchodilators, stimulants) 3

Step 5: Assess for Comorbid Psychiatric Conditions

Systematically evaluate for commonly co-occurring disorders:

• Major depressive disorder 3
• Other anxiety disorders 3
• Substance use disorders 3
• Post-traumatic stress disorder 3
• Bipolar disorder 3
• Attention-deficit/hyperactivity disorder 3
• Obsessive-compulsive disorder 3
• Eating disorders 2

Common pitfall: Anxiety disorders frequently co-occur with each other and with depression, complicating differential diagnosis—address all conditions present rather than assuming a single diagnosis 3.

Step 6: Consider Developmental and Cultural Context

• Evaluate whether symptoms are age-appropriate before diagnosing a disorder 1, 2
• Consider sociocultural context when determining if anxious responses are out of proportion to actual threat 7
• The "unexpectedness" criterion for panic attacks may have limited cross-cultural validity 3

ICD-10 Codes for Documentation

• Separation Anxiety Disorder: F93.0 1
• Selective Mutism: F94.0 1
• Specific Phobia: F40.218 (animal), F40.228 (natural environment), F40.230-F40.233 (blood-injection-injury), F40.248 (situational), F40.298 (other) 1
• Social Anxiety Disorder: F40.10 1
• Panic Disorder: F41.0 1
• Agoraphobia: F40.00 1
• Generalized Anxiety Disorder: F41.1 1
• Anxiety Disorder Due to Another Medical Condition: F06.4 1