CMN 552 Module 2 Primary
Study Guide Sadock,
Chapter 14
Section 14.1
DSM-5 Modifications in Anxiety Disorders
The major subtypes of anxiety disorders in the DSM-5 include panic disorder (with or without
agoraphobia), agoraphobia (without a history of panic disorder), specific phobia, social phobia, and generalized
anxiety disorder (GAD). Revisions to the classification of anxiety disorders in the DSM-involve removing
obsessive- compulsive disorder and posttraumatic disorder have been subsumed under newly created ―obsessive-
compulsive and related disorders‖ and ―trauma- and stressor-related disorders‖ categories, respectively. Therefore,
both obsessive–compulsive disorder and posttraumatic stress disorder are not considered in this chapter. Other
modifications to the proposed DSM-5 anxiety disorders category include the addition of separation anxiety disorder
(contained under Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence in the DSMIV), the
identification of agoraphobia as a distinct and codable disorder (Diagnosed only with reference to panic disorder in
the DSM-IV), minor revisions to criterion language to enhance clarity, objectivity, and consistency across the
anxiety disorders, and the relabeling of social phobia as social anxiety disorder (SAD). As such, the term ―social
phobia‖ will now be replaced with ―social anxiety disorder.‖
Section 14.2
PANIC DISORDER AND THE PANIC ATTACK SPECIFIER
Differential Diagnosis, Etiology, Course, and Treatment
Once full criteria have been met, the disorder tends to be chronic, though the course is often fluctuating.
Even after treatment to the point of remission, the rate of relapse is high. For example, naturalistic studies often
demonstrate a >50 percent relapse rate within 12 months of discontinuing an effective antidepressant.
Agoraphobia: Epidemiology
Similar to Panic Disorder, more women than men have agoraphobia and the age of onset peaks in the late
teens to early twenties. Agoraphobia in the absence of Panic Disorder is considered to be rarer than agoraphobia
with comorbid Panic Disorder. However, there is some variability in the prevalence data. The measured prevalence
of agoraphobia in specific clinical settings may evolve as the DSM-5‘s recognition of agoraphobia without Panic
Disorder will spur clinicians to screen and consider the disorder more frequently, even in patients who do not
present with panic attacks. Other anxiety disorders are seen alongside agoraphobia in comorbidity rates that often
exceed 50 percent. Comorbid depressive disorders are seen in 33 to 52 percent of cases, with some suggestion that
the presence of comorbid panic attacks increases the risk of comorbid depressive episodes.
Social Anxiety Disorder: Differential Diagnosis, Etiology, Course,
,Treatment
, As mentioned above, Avoidant Personality Disorder (described in more detail elsewhere in this book) has
been the subject of debate over whether it is distinct from Social Anxiety Disorder, with the DSM-5 separating the
two. Social Anxiety Disorder has a high comorbidity with other anxiety and affective disorders, as well. The use of
illicit anxiolytics and sedatives leads to the relatively high rate of comorbid substance use disorders. The
comorbidity between Social Anxiety Disorder and Selective Mutism is discussed elsewhere in this chapter. Social
Anxiety Disorder is a common comorbidity in children with an Autism Spectrum diagnosis and also appears at rates
above population baseline in patients with Schizophrenia. Risk factors for Social Anxiety Disorder include female
gender, family history, and childhood signs of behavioral inhibition. There is insufficient data on specific genetic
factors mediating the increased familial risk, but parenting styles may also contribute to this familiarity. The Mini-
Social Phobia Inventory (Mini-SPIN) is an appropriate screening tool for adults. One could see how agoraphobia
could be confused with Social Anxiety Disorder or PTSD, though the context-dependent fears in the same situation
would be different. For example, a patient with Social Anxiety Disorder might dislike a crowded party because they
feel that everybody is looking at them and judging them. A patient with agoraphobia might avoid the same crowded
party out of concern that, were they to develop anxiety, it would be difficult to sprint for the exit. A patient with
PTSD might find that their desire for hypervigilance is overwhelmed by the multiple stimuli in a crowded room.
There is a markedly increased rate of suicide attempt amongst patients with Social Anxiety Disorder. This,
along with the significant functional impairment associated with this disorder, should motivate clinicians to pursue
aggressive treatment for these patients. CBT has demonstrated efficacy for Social Anxiety Disorder. The first-line
pharmacologic treatments are serotonergic agents, but other, PRN medications, especially for the performance
subtype (beta blockers), have been used effectively. Social Anxiety Disorder is a chronic condition, with a high rate
of symptom re-emergence after symptom remission is achieved via selective serotonin reuptake inhibitors (SSRIs),
for example. However, durable remission, even after cessation of CBT and/or antidepressants, has been seen in a
small proportion of patients.
Epidemiology
Social Anxiety Disorder is more common than some of the other disorders described in this section, with
a cross-national prevalence rate of 2 to 3 percent. It is more common in women than in men, has peak onset in the
early teenage years (often associated with the move to junior high school or high school, or some other increase in
social context complexity), and is associated with an increased risk of depressive episodes. AKA late teens to early
20s
SPECIFIC PHOBIA
Definition, Diagnosis, and Clinical Features
Specific Phobias are fears of specific objects or situations, such as spiders or blood, that go beyond the true
threat of the stimulus and cause avoidance and functional impairment (Table 14.2–2). The patient is fearful nearly
every time they are confronted with the phobic stimulus. The phobia, by rule, lasts longer than 6 months. Many
patients have multiple phobic stimuli, in which case each would be coded separately. ICD-10 has specific codes for
phobias of animals, natural environment (heights, storms, water), fear of blood, fear of injections, fear of
transfusions, fear of other medical care, fear of injury, fear of a specific situation (elevators, airplanes, enclosed
spaces, etc.), and fear of other (anything that does not fit into one the above).
Differential Diagnosis, Etiology, Course, and Treatment
As was articulated previously, delineating between the context- dependent phobias can be a challenge
when getting a history from any specific patient. Though some patients develop a Specific Phobia only after a
traumatic event involving a threatening phobic stimulus, these patients, by definition, do not develop the breadth of
symptoms that meet the criteria for PTSD. Similarly, patients can develop a Specific Phobia to an event following a
panic attack, but Panic Disorder requires that at least some panic attacks that are unexpected, rather than just coming
from a known phobic stimulus. As articulated previously, agoraphobia and Specific Phobia may be difficult to
distinguish if the phobic stimulus is in a specific, public location. However, patients with agoraphobia ought to fear
multiple public situations. Moreover, patients with agoraphobia specifically fear the panic or shame that can
develop in public situations.
Some Specific Phobias, such as animal phobias, have a unique age of onset, suggesting a nontraumatic
etiology perhaps more based in evolutionary preparedness. Other Specific Phobias, such as blood- injury illness
, phobia, have a unique physiology (i.e., bradycardia and hypotension as opposed to the usual tachycardia and
hypertensive reaction) and a greater rate of familiality that suggest still another distinct etiology.
There is a genetic component, but heritability does not seem specific for the type of Specific Phobia, but
rather for the general risk of developing some kind of Specific Phobia. For many phobias, environmental factors,
such as trauma, may be more important. As with other anxiety disorders, cognitive factors and conditioning may
also play a role.
While the course of specific phobia may be especially chronic, there are effective treatments. Patients often
recognize that their anxiety exceeds the true threat of the stimulus and this insight can often motivate a patient to
pursue therapy. The treatment of choice for Specific Phobia is a behavioral therapy series that includes exposure-
based, systematic desensitization. There are small, placebo- controlled studies involving serotonergic
antidepressants or atypical antipsychotics, but the data is very limited. There is ongoing work on augmenting
exposure-based psychotherapy with d-cycloserine, though the data requires ongoing interpretation and study
replication to avoid harm via administration of this medication in the wrong context. There is very little long-term
data on the durability of remission in pharmacologic studies.
Generalized Anxiety Disorder: Epidemiology
GAD is characterized by an uncontrollable worry, more days than not, lasting greater than 6 months, and
causing significant impairment.
GAD has a lifetime prevalence rate of 5 percent, often begins in the late teens, and is more common in women as
men. The high lifetime psychiatric comorbidity has led some to view GAD as a prodromal or residual phase of a
major depression, though there is insufficient empirical support for this view. Other common comorbidities include
other anxiety spectrum disorders and substance use disorders.
Separation Anxiety Disorder: History/Comparative Nosology
The epidemiologic evidence documenting a high rate of onset occurring after 18 years old has led to a
removal of the age-of-onset restriction in the DSM-5. The inclusion of the adult-onset formulation has moved
Separation Anxiety Disorder from DSM-IV‘s ―Disorders Usually First Diagnosed in Infancy, Childhood or
Adolescence‖ to DSM-5‘s ―Anxiety Disorders.‖ As noted with Selective Mutism, the prominent symptom of worry
ties Separation Anxiety Disorder to the other, classical diagnoses in the Anxiety Disorders section.
‗
Section 14.3
Medical Symptoms/Disorders
Community samples have strongly confirmed the high magnitude of comorbidity of anxiety disorders with
several medical conditions that had been described in clinical samples. There is a growing body of evidence for
specific patterns of associations between anxiety disorders and a range of medical disorders including respiratory
conditions, cardiovascular diseases, gastrointestinal disorders, metabolic diseases, and musculoskeletal disorders.
For example, in the Australian National Survey of Health and Wellbeing, there was a two-fold greater rates of
physical conditions among those with anxiety disorders compared to those without anxiety. Similar to other mental
disorders, comorbid anxiety with physical disorders are associated with substantially greater disability than anxiety
disorders alone.
Investigation of comorbidity of physical disorders and anxiety is complicated by the role of physical
symptoms as a core feature of panic disorder and GAD. There is now evidence that anxiety disorders may represent
the initial manifestations of several physical conditions, and there are also numerous physical conditions that lead
to anxiety-like symptoms. In adults, anxiety disorders, particularly GAD and panic, are associated with
cardiovascular risk factors and diseases. For example, analyses of data from electronic medical records and direct
interviews regarding medical and mental disorders in the large Philadelphia Neurodevelopmental Cohort (PNC)
revealed that asthma was the only medical condition specifically associated with anxiety disorders in childhood and
adolescence. This link has been confirmed in a population based birth cohort study in Australia that found that
youth with more severe and persistent asthma at age 5 years were more likely to have anxiety problems from ages 5
to 17 years.
Therefore, some of the other comorbid physical disorders associated with anxiety may not emerge until later in life.
Similar to adults, rates of anxiety disorder in the PNC increased with the severity of aggregate physical conditions,
suggesting that physical–mental comorbidity is associated with greater impairment of both conditions. Prospective
documentation of the evolution of anxiety disorders and physical conditions will be critical to the understanding of
Study Guide Sadock,
Chapter 14
Section 14.1
DSM-5 Modifications in Anxiety Disorders
The major subtypes of anxiety disorders in the DSM-5 include panic disorder (with or without
agoraphobia), agoraphobia (without a history of panic disorder), specific phobia, social phobia, and generalized
anxiety disorder (GAD). Revisions to the classification of anxiety disorders in the DSM-involve removing
obsessive- compulsive disorder and posttraumatic disorder have been subsumed under newly created ―obsessive-
compulsive and related disorders‖ and ―trauma- and stressor-related disorders‖ categories, respectively. Therefore,
both obsessive–compulsive disorder and posttraumatic stress disorder are not considered in this chapter. Other
modifications to the proposed DSM-5 anxiety disorders category include the addition of separation anxiety disorder
(contained under Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence in the DSMIV), the
identification of agoraphobia as a distinct and codable disorder (Diagnosed only with reference to panic disorder in
the DSM-IV), minor revisions to criterion language to enhance clarity, objectivity, and consistency across the
anxiety disorders, and the relabeling of social phobia as social anxiety disorder (SAD). As such, the term ―social
phobia‖ will now be replaced with ―social anxiety disorder.‖
Section 14.2
PANIC DISORDER AND THE PANIC ATTACK SPECIFIER
Differential Diagnosis, Etiology, Course, and Treatment
Once full criteria have been met, the disorder tends to be chronic, though the course is often fluctuating.
Even after treatment to the point of remission, the rate of relapse is high. For example, naturalistic studies often
demonstrate a >50 percent relapse rate within 12 months of discontinuing an effective antidepressant.
Agoraphobia: Epidemiology
Similar to Panic Disorder, more women than men have agoraphobia and the age of onset peaks in the late
teens to early twenties. Agoraphobia in the absence of Panic Disorder is considered to be rarer than agoraphobia
with comorbid Panic Disorder. However, there is some variability in the prevalence data. The measured prevalence
of agoraphobia in specific clinical settings may evolve as the DSM-5‘s recognition of agoraphobia without Panic
Disorder will spur clinicians to screen and consider the disorder more frequently, even in patients who do not
present with panic attacks. Other anxiety disorders are seen alongside agoraphobia in comorbidity rates that often
exceed 50 percent. Comorbid depressive disorders are seen in 33 to 52 percent of cases, with some suggestion that
the presence of comorbid panic attacks increases the risk of comorbid depressive episodes.
Social Anxiety Disorder: Differential Diagnosis, Etiology, Course,
,Treatment
, As mentioned above, Avoidant Personality Disorder (described in more detail elsewhere in this book) has
been the subject of debate over whether it is distinct from Social Anxiety Disorder, with the DSM-5 separating the
two. Social Anxiety Disorder has a high comorbidity with other anxiety and affective disorders, as well. The use of
illicit anxiolytics and sedatives leads to the relatively high rate of comorbid substance use disorders. The
comorbidity between Social Anxiety Disorder and Selective Mutism is discussed elsewhere in this chapter. Social
Anxiety Disorder is a common comorbidity in children with an Autism Spectrum diagnosis and also appears at rates
above population baseline in patients with Schizophrenia. Risk factors for Social Anxiety Disorder include female
gender, family history, and childhood signs of behavioral inhibition. There is insufficient data on specific genetic
factors mediating the increased familial risk, but parenting styles may also contribute to this familiarity. The Mini-
Social Phobia Inventory (Mini-SPIN) is an appropriate screening tool for adults. One could see how agoraphobia
could be confused with Social Anxiety Disorder or PTSD, though the context-dependent fears in the same situation
would be different. For example, a patient with Social Anxiety Disorder might dislike a crowded party because they
feel that everybody is looking at them and judging them. A patient with agoraphobia might avoid the same crowded
party out of concern that, were they to develop anxiety, it would be difficult to sprint for the exit. A patient with
PTSD might find that their desire for hypervigilance is overwhelmed by the multiple stimuli in a crowded room.
There is a markedly increased rate of suicide attempt amongst patients with Social Anxiety Disorder. This,
along with the significant functional impairment associated with this disorder, should motivate clinicians to pursue
aggressive treatment for these patients. CBT has demonstrated efficacy for Social Anxiety Disorder. The first-line
pharmacologic treatments are serotonergic agents, but other, PRN medications, especially for the performance
subtype (beta blockers), have been used effectively. Social Anxiety Disorder is a chronic condition, with a high rate
of symptom re-emergence after symptom remission is achieved via selective serotonin reuptake inhibitors (SSRIs),
for example. However, durable remission, even after cessation of CBT and/or antidepressants, has been seen in a
small proportion of patients.
Epidemiology
Social Anxiety Disorder is more common than some of the other disorders described in this section, with
a cross-national prevalence rate of 2 to 3 percent. It is more common in women than in men, has peak onset in the
early teenage years (often associated with the move to junior high school or high school, or some other increase in
social context complexity), and is associated with an increased risk of depressive episodes. AKA late teens to early
20s
SPECIFIC PHOBIA
Definition, Diagnosis, and Clinical Features
Specific Phobias are fears of specific objects or situations, such as spiders or blood, that go beyond the true
threat of the stimulus and cause avoidance and functional impairment (Table 14.2–2). The patient is fearful nearly
every time they are confronted with the phobic stimulus. The phobia, by rule, lasts longer than 6 months. Many
patients have multiple phobic stimuli, in which case each would be coded separately. ICD-10 has specific codes for
phobias of animals, natural environment (heights, storms, water), fear of blood, fear of injections, fear of
transfusions, fear of other medical care, fear of injury, fear of a specific situation (elevators, airplanes, enclosed
spaces, etc.), and fear of other (anything that does not fit into one the above).
Differential Diagnosis, Etiology, Course, and Treatment
As was articulated previously, delineating between the context- dependent phobias can be a challenge
when getting a history from any specific patient. Though some patients develop a Specific Phobia only after a
traumatic event involving a threatening phobic stimulus, these patients, by definition, do not develop the breadth of
symptoms that meet the criteria for PTSD. Similarly, patients can develop a Specific Phobia to an event following a
panic attack, but Panic Disorder requires that at least some panic attacks that are unexpected, rather than just coming
from a known phobic stimulus. As articulated previously, agoraphobia and Specific Phobia may be difficult to
distinguish if the phobic stimulus is in a specific, public location. However, patients with agoraphobia ought to fear
multiple public situations. Moreover, patients with agoraphobia specifically fear the panic or shame that can
develop in public situations.
Some Specific Phobias, such as animal phobias, have a unique age of onset, suggesting a nontraumatic
etiology perhaps more based in evolutionary preparedness. Other Specific Phobias, such as blood- injury illness
, phobia, have a unique physiology (i.e., bradycardia and hypotension as opposed to the usual tachycardia and
hypertensive reaction) and a greater rate of familiality that suggest still another distinct etiology.
There is a genetic component, but heritability does not seem specific for the type of Specific Phobia, but
rather for the general risk of developing some kind of Specific Phobia. For many phobias, environmental factors,
such as trauma, may be more important. As with other anxiety disorders, cognitive factors and conditioning may
also play a role.
While the course of specific phobia may be especially chronic, there are effective treatments. Patients often
recognize that their anxiety exceeds the true threat of the stimulus and this insight can often motivate a patient to
pursue therapy. The treatment of choice for Specific Phobia is a behavioral therapy series that includes exposure-
based, systematic desensitization. There are small, placebo- controlled studies involving serotonergic
antidepressants or atypical antipsychotics, but the data is very limited. There is ongoing work on augmenting
exposure-based psychotherapy with d-cycloserine, though the data requires ongoing interpretation and study
replication to avoid harm via administration of this medication in the wrong context. There is very little long-term
data on the durability of remission in pharmacologic studies.
Generalized Anxiety Disorder: Epidemiology
GAD is characterized by an uncontrollable worry, more days than not, lasting greater than 6 months, and
causing significant impairment.
GAD has a lifetime prevalence rate of 5 percent, often begins in the late teens, and is more common in women as
men. The high lifetime psychiatric comorbidity has led some to view GAD as a prodromal or residual phase of a
major depression, though there is insufficient empirical support for this view. Other common comorbidities include
other anxiety spectrum disorders and substance use disorders.
Separation Anxiety Disorder: History/Comparative Nosology
The epidemiologic evidence documenting a high rate of onset occurring after 18 years old has led to a
removal of the age-of-onset restriction in the DSM-5. The inclusion of the adult-onset formulation has moved
Separation Anxiety Disorder from DSM-IV‘s ―Disorders Usually First Diagnosed in Infancy, Childhood or
Adolescence‖ to DSM-5‘s ―Anxiety Disorders.‖ As noted with Selective Mutism, the prominent symptom of worry
ties Separation Anxiety Disorder to the other, classical diagnoses in the Anxiety Disorders section.
‗
Section 14.3
Medical Symptoms/Disorders
Community samples have strongly confirmed the high magnitude of comorbidity of anxiety disorders with
several medical conditions that had been described in clinical samples. There is a growing body of evidence for
specific patterns of associations between anxiety disorders and a range of medical disorders including respiratory
conditions, cardiovascular diseases, gastrointestinal disorders, metabolic diseases, and musculoskeletal disorders.
For example, in the Australian National Survey of Health and Wellbeing, there was a two-fold greater rates of
physical conditions among those with anxiety disorders compared to those without anxiety. Similar to other mental
disorders, comorbid anxiety with physical disorders are associated with substantially greater disability than anxiety
disorders alone.
Investigation of comorbidity of physical disorders and anxiety is complicated by the role of physical
symptoms as a core feature of panic disorder and GAD. There is now evidence that anxiety disorders may represent
the initial manifestations of several physical conditions, and there are also numerous physical conditions that lead
to anxiety-like symptoms. In adults, anxiety disorders, particularly GAD and panic, are associated with
cardiovascular risk factors and diseases. For example, analyses of data from electronic medical records and direct
interviews regarding medical and mental disorders in the large Philadelphia Neurodevelopmental Cohort (PNC)
revealed that asthma was the only medical condition specifically associated with anxiety disorders in childhood and
adolescence. This link has been confirmed in a population based birth cohort study in Australia that found that
youth with more severe and persistent asthma at age 5 years were more likely to have anxiety problems from ages 5
to 17 years.
Therefore, some of the other comorbid physical disorders associated with anxiety may not emerge until later in life.
Similar to adults, rates of anxiety disorder in the PNC increased with the severity of aggregate physical conditions,
suggesting that physical–mental comorbidity is associated with greater impairment of both conditions. Prospective
documentation of the evolution of anxiety disorders and physical conditions will be critical to the understanding of
