PSYCH 118: Anxiety Disorders - Clinical Features

Medlock Holmes enters the Grand Gallery of Anxious Minds.At the entrance, every patient appears to have the same complaint:“I am anxious.”But Holmes knows that this is only the beginning of the investigation.Anxiety is found across psychiatry.The diagnosis depends not simply on the presence of fear, but on what is feared, when it occurs, what the person predicts will happen, and what they do to prevent it.The gallery therefore separates into several chambers.The first is the Panic Chamber.A patient is sitting quietly when a warning bell suddenly erupts.Heart pounding.Sweating.Trembling.Breathlessness.Chest discomfort.Dizziness.Paresthesias.Derealisation.Fear of losing control.Fear of dying.A panic attack is an abrupt surge of intense fear or discomfort that peaks within minutes and includes at least four characteristic physical or cognitive symptoms.But Holmes writes an important distinction:Panic attack ≠ Panic disorder.Panic attacks occur in many psychiatric and medical conditions.Panic disorder requires recurrent unexpected attacks accompanied by persistent concern about future attacks or maladaptive behavioural change lasting at least a month.Patients may stop exercising because a rapid heartbeat reminds them of panic.Avoid unfamiliar places.Repeatedly attend emergency departments.Request medical investigations.The first attack lasts minutes.The fear of the next attack can reorganise an entire life.Holmes then enters the Agoraphobia Chamber.Here the anxiety is not necessarily about panic itself.It is about being somewhere from which escape may be difficult or help unavailable if something distressing occurs.Public transport.Open spaces.Enclosed places.Crowds.Queues.Being outside the home alone.The person begins calculating exits.Routes.Distances.Availability of help.DSM-5 separated agoraphobia from panic disorder because many people with agoraphobia have no history of recurrent panic attacks.The diagnostic clue is therefore not merely avoidance.It is the reason for the avoidance.A bridge may be avoided because of heights - specific phobia.Because escape feels difficult - agoraphobia.Because other people might notice anxiety - social anxiety disorder.Because it reminds someone of trauma - PTSD.Holmes repeatedly asks:“What do you think will happen if you stay?”The answer often reveals the diagnosis.The next chamber is the Social Theatre.A patient stands beneath the gaze of an audience.They fear humiliation.Embarrassment.Negative evaluation.Appearing foolish.Or visibly anxious.Social anxiety disorder persists for more than six months and causes significant impairment.Sometimes the fear centres on public speaking.But it can extend to ordinary acts:Writing a signature while watched.Eating in front of others.Meeting unfamiliar people.Entering a room.Speaking to authority figures.The person may fear not only performing badly, but being seen to be anxious.Avoidance then becomes self-reinforcing.The person never discovers that the feared judgement may not occur.Social anxiety often begins early, with peak incidence in adolescence, and may become chronic if untreated. The source reports approximately 8% 12-month prevalence and 13% lifetime prevalence in the United States.Holmes moves into a smaller chamber.A spider sits beneath glass.Another patient stands beside an aeroplane.Another beside a needle.Another at the edge of a height.This is specific phobia.The fear is tightly linked to a particular object or situation, occurs almost every time the stimulus is encountered, is out of proportion to actual danger, and leads to avoidance or intense distress.The source distinguishes animal, natural-environment, blood-injection-injury, situational, and other phobias.Most provoke sympathetic arousal.But blood-injection-injury phobia is unusual.Instead of the typical tachycardia and hypertension, some patients develop bradycardia and hypotension, creating the possibility of fainting.The treatment principle is equally distinctive:approach rather than avoidance.Exposure-based behavioural treatment is the treatment of choice, with virtual-reality exposure emerging as another method in selected situations.The next chamber contains no single feared object.Instead, every wall is covered with future possibilities.Money.Work.Health.Family.Time.Mistakes.Appointments.Ordinary responsibilities.This is generalized anxiety disorder.The defining feature is excessive, difficult-to-control worry occurring more days than not for at least six months across multiple areas of life.The worry is accompanied by symptoms such as:Restlessness.Fatigue.Poor concentration.Irritability.Muscle tension.Sleep disturbance.Holmes notices that the content of the worries is often ordinary.The abnormality lies in their breadth, persistence, catastrophic interpretation, and uncontrollability.The person treats every possible problem as though it deserves immediate priority.Minor uncertainty competes with genuine emergencies.The mind becomes unable to rank threats.GAD is often persistent, frequently presents in primary care through physical symptoms, and commonly coexists with depression and other anxiety disorders. The source estimates lifetime prevalence at approximately 5%.Holmes then enters the Silent Classroom.A child talks freely at home.At school, they cannot speak.This is selective mutism.The silence is not deliberate defiance.It occurs in particular social contexts despite intact capacity for speech elsewhere and causes educational or social impairment.The disorder often presents around age five and frequently overlaps with social anxiety.Behavioural and CBT approaches - especially those involving parents and schools - can produce substantial improvement, with long-term studies reporting full remission in more than half of treated children in some cohorts.The final major chamber is the Attachment Hall.A child refuses school because something might happen to their parent.An adult cannot travel because they fear harm may come to their partner while they are away.Another cannot sleep alone.Nightmares revolve around separation.This is separation anxiety disorder.DSM-5 removed the assumption that it belongs only to childhood.The source reports a lifetime prevalence of approximately 4.8%, with 43% of affected individuals experiencing onset after age 18.The fear resembles agoraphobia, panic, or GAD.Again, Holmes asks what the anxiety is about.In agoraphobia:“What if I cannot escape or obtain help?”In separation anxiety:“What if something happens to the person I need while we are apart?”The investigation then reaches a corridor marked:NOT EVERY ANXIETY DISORDER IS PRIMARY.Stimulants.Caffeine.Cannabis.Alcohol withdrawal.Medications.Hyperthyroidism.Cardiopulmonary illness.Neurological disease.Endocrine disorders.All can produce anxiety or panic.Temporal relationship is therefore crucial.Did symptoms begin after a substance was started?During intoxication?During withdrawal?With a new medical illness?If anxiety persists long after the physiological cause has resolved, Holmes reconsiders whether a primary anxiety disorder has emerged.At the end of the gallery, Holmes notices that every chamber is connected by hidden passageways.Panic appears in phobias.Agoraphobia overlaps with panic.Social anxiety overlaps with avoidant patterns.GAD coexists with depression.Separation anxiety accompanies other anxiety disorders.Comorbidity is the rule rather than the exception.The diagnostic categories remain useful.But the borders are porous.Holmes closes the final case file.The essential clinical task is not simply to identify anxiety.It is to identify its architecture:What is feared?How close is the threat?How predictable is it?What catastrophe is anticipated?What is avoided?And what does that avoidance prevent the person from learning?Key Takeaways* DSM-5 reorganised the former anxiety spectrum into anxiety disorders, trauma- and stressor-related disorders, and obsessive-compulsive and related disorders.* The DSM-5 anxiety-disorders section includes separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, agoraphobia, GAD, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder, and unspecified anxiety disorder.* PTSD is now classified among trauma- and stressor-related disorders.* OCD is classified among obsessive-compulsive and related disorders.* Despite separate diagnostic categories, anxiety symptoms occur across much of psychiatry.* Differential diagnosis depends strongly on the content, context, and function of fear and avoidance.* Panic attacks are abrupt surges of intense fear or discomfort that peak within minutes.* A panic attack includes at least four characteristic physical or cognitive symptoms.* Panic symptoms may include palpitations, sweating, trembling, dyspnoea, choking, chest discomfort, nausea, dizziness, temperature sensations, paresthesias, derealisation, depersonalisation, fear of losing control, and fear of dying.* Culture-specific panic symptoms may occur but do not replace the required core DSM symptoms.* A single panic attack does not establish panic disorder.* Panic attacks can occur in numerous psychiatric and medical conditions.* DSM-5 therefore permits a panic attack specifier to be applied to other disorders.* Panic disorder requires recurrent unexpected panic attacks.* At least one attack must be followed by at least one month of persistent concern about further attacks or maladaptive behavioural change.* Avoidance of exercise, unfamiliar environments, or other situations associated with feared panic sensations can occur.* Repeated emergency presentations and reassurance-seeking medical investigations may form part of panic-related behaviour.* Some attacks in panic disorder may be triggered, but at least some must occur unexpectedly or “out of the blue.”* Predictable panic occurring only in response to a specific feared stimulus does not establish panic disorder.* Panic disorder has a lifetime prevalence of approximately 1 in 25 people.* Panic attacks themselves are far more common, occurring in at least 1 in 7, with some estimates approaching one-third of the population.* Panic disorder commonly begins in the late teenage years or early twenties.* Women are affected approximately twice as often as men.* Panic disorder is highly comorbid with mood, substance-use, trauma-related, and other anxiety disorders.* Panic-like symptoms can be caused by temporal-lobe epilepsy, brain tumours, hyperthyroidism, pheochromocytoma, myocardial infarction, arrhythmia, asthma, and pulmonary embolism.* Corticosteroids, stimulants, some hormones, asthma medications, caffeine, marijuana, illicit stimulants, and hallucinogens can produce panic symptoms.* Estimated heritability of panic disorder is approximately 35–40%.* Stressful life events may trigger panic disorder in genetically vulnerable individuals.* Childhood trauma and anxious temperament are associated with greater risk.* Panic disorder often follows a chronic but fluctuating course.* Relapse may occur after apparently successful treatment.* Naturalistic studies cited in the source show relapse rates greater than 50% within 12 months after discontinuing an effective antidepressant.* Serotonergic antidepressants are a pharmacological mainstay of panic-disorder treatment.* Benzodiazepines are effective but carry risks that require careful consideration.* CBT has substantial evidence in panic disorder.* Agoraphobia is now diagnostically independent of panic disorder.* Agoraphobia involves fear, anxiety, or avoidance of situations where escape may be difficult or help unavailable if distressing symptoms occur.* Agoraphobic symptoms must persist for approximately six months or longer.* Agoraphobia may occur without full panic attacks.* More than half of some community samples with agoraphobia may have no clear history of panic attacks.* Agoraphobia can occur in children and adolescents.* Agoraphobia can produce profound functional restriction, including becoming largely or completely housebound.* Women are more commonly affected than men.* Onset commonly peaks in the late teens and early twenties.* Anxiety-disorder comorbidity in agoraphobia often exceeds 50%.* Depressive disorders occur in approximately 33–52% of cases in the source.* Differential diagnosis depends on why public situations are avoided.* Specific phobia involves fear of a circumscribed stimulus.* Agoraphobia requires a broader pattern involving at least two types of public situations.* Social anxiety disorder involves fear of judgement or humiliation.* Separation anxiety involves fear related to attachment figures.* PTSD avoidance centres on trauma reminders.* OCD avoidance may relate to obsessional concerns such as contamination.* Behavioural treatments have demonstrated efficacy for agoraphobia independent of panic disorder.* Social anxiety disorder involves persistent fear of negative evaluation in social or performance situations.* The fear or avoidance must produce clinically significant impairment.* Symptoms generally persist for at least six months.* Patients may fear embarrassment, humiliation, appearing incompetent, or visibly showing anxiety.* Social anxiety can involve ordinary activities such as writing, eating, meeting strangers, or speaking while observed.* The patient may develop anxiety about appearing anxious, amplifying self-consciousness.* DSM-5 removed the old “specific” versus “generalized” distinction.* Performance only is the principal DSM-5 specifier.* Avoidant personality disorder and social anxiety disorder overlap substantially but remain distinct diagnoses.* The source reports approximately 8% 12-month prevalence and 13% lifetime prevalence of social anxiety disorder in the United States.* Social anxiety commonly begins in early adolescence.* Women are affected more commonly than men.* Mood disorders and substance use commonly coexist with social anxiety disorder.* Alcohol, cannabis, sedatives, and nonprescribed anxiolytics may be used as self-medication.* Social anxiety is associated with autism-spectrum disorder at above-baseline rates.* Social anxiety also occurs more frequently among people with schizophrenia.* Risk factors include female sex, family history, and behavioural inhibition in childhood.* Parenting style may contribute alongside familial and genetic influences.* The Mini-SPIN can be used as an adult screening instrument.* A crowded party may be avoided in social anxiety because of fear of judgement, in agoraphobia because escape feels difficult, or in PTSD because hypervigilance is overwhelmed by multiple stimuli.* Suicide-attempt risk is elevated in social anxiety disorder.* CBT and IPT have demonstrated efficacy, with stronger evidence for CBT.* Serotonergic agents are first-line pharmacological treatments.* Beta-blockers can be useful for selected performance-only presentations.* Social anxiety is often chronic and may recur after treatment discontinuation.* Specific phobia involves marked fear of a particular object or situation.* The feared object or situation almost always produces immediate fear or anxiety.* The stimulus is actively avoided or endured with intense distress.* The fear is disproportionate to actual danger and sociocultural context.* Symptoms generally persist for six months or longer.* Specific phobia must cause clinically significant distress or impairment.* Main categories include animal, natural environment, blood-injection-injury, situational, and other phobias.* Multiple specific phobias commonly coexist.* Lifetime prevalence in older US data is approximately 9%.* Prevalence peaks in adolescence.* Female sex and younger age are associated with increased risk.* Specific phobia must be distinguished from PTSD, panic disorder, agoraphobia, social anxiety, OCD, and separation anxiety.* Panic occurring only during exposure to a particular phobic stimulus does not establish panic disorder.* Animal phobias may reflect evolutionary preparedness more strongly than traumatic learning.* Blood-injection-injury phobia has distinctive physiology.* Rather than the usual tachycardia and hypertension, blood-injection-injury phobia may produce bradycardia and hypotension.* This physiological response helps explain fainting in some patients.* Family and twin studies demonstrate familial risk for phobic disorders generally but not necessarily for the exact phobic subtype.* Conditioning, trauma, cognition, and environmental learning contribute to specific phobias.* Exposure-based behavioural therapy and systematic desensitisation are treatments of choice.* Virtual-reality exposure has demonstrated efficacy in selected phobias.* Pharmacological evidence for specific phobia is comparatively limited.* Generalized anxiety disorder involves excessive and difficult-to-control worry about multiple domains.* Worry occurs more days than not for at least six months.* Adults require at least three associated symptoms; children require only one.* Associated symptoms include restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance.* GAD worries often involve ordinary life domains such as finances, health, punctuality, school, or work.* The pathology lies in excessive probability estimation, catastrophic expectation, persistence, and difficulty controlling the worry.* Patients with GAD may have difficulty prioritising genuine immediate problems over less important hypothetical concerns.* GAD has an estimated lifetime prevalence of approximately 5%.* Incidence is elevated in both early adulthood and older adulthood.* Women are affected more frequently than men.* GAD commonly coexists with depression, other anxiety disorders, and substance-use disorders.* GAD often presents in primary care through physical symptoms.* Distinguishing GAD from anxiety occurring solely during major depression may require longitudinal observation during euthymic periods.* GAD can be persistent rather than episodic, although severity fluctuates.* Genetic associations have been described but do not currently guide treatment.* Childhood maltreatment and abuse increase risk.* New-onset or markedly changing GAD-like symptoms should prompt consideration of medical, neurological, medication, and substance causes.* Atypical age of onset, marked functional deterioration, or treatment resistance may warrant broader medical evaluation.* TCAs, SSRIs, and SNRIs have demonstrated efficacy in GAD.* Benzodiazepines and buspirone have historical evidence but should be understood in the context of changing diagnostic criteria and safety considerations.* GAD frequently relapses.* Greater baseline severity, prolonged avoidance, and high behavioural inhibition predict persistence.* Short follow-up after treatment can overestimate long-term remission.* Stepped-care and collaborative-care approaches can improve outcomes.* The GAD-7 is useful for screening and treatment monitoring.* GAD is associated with increased risk of suicide attempts.* CBT, relaxation, imagery exposure, and meditation-based strategies have evidence in GAD.* Long-term follow-up supports sustained benefit from CBT.* Selective mutism primarily affects children who can speak normally in some settings but cannot speak in particular social contexts.* The absence of speech commonly becomes apparent at school.* Symptoms must impair educational or social functioning for more than one month.* Mutism related solely to adjustment to a new school or unfamiliar language does not establish the diagnosis.* The historical term elective mutism was replaced by selective mutism to remove the implication that the child was deliberately refusing to speak.* DSM-5 placed selective mutism within anxiety disorders because anxiety, particularly social anxiety, commonly accompanies it.* Selective mutism usually presents around age five.* Prevalence is approximately 1% in many child studies.* Social anxiety disorder is probably its most common comorbidity.* Communication disorders, autism spectrum disorder, and developmental delay should be considered in the differential.* Genetic, temperamental, environmental, and neurodevelopmental factors may contribute.* CBT and behavioural interventions can be effective.* Parent and school involvement may strengthen treatment.* Some long-term CBT studies report full remission in more than 50% of children.* People with childhood selective mutism remain at increased later risk for phobic disorders.* SSRIs may provide partial benefit, but the evidence base is small.* Separation anxiety disorder involves excessive distress related to actual or anticipated separation from significant attachment figures.* Patients may fear that harm will occur to themselves or loved ones during separation.* Avoidance of school, work, travel, or independent activity may follow.* Patients may fear sleeping alone or experience nightmares involving separation.* Somatic anxiety symptoms can accompany separation fears.* Childhood symptoms need persist for only four weeks.* Adult symptoms generally need to persist for six months.* DSM-5 removed the previous requirement that separation anxiety begin before age 18.* Separation anxiety disorder can begin in adulthood.* The source reports a lifetime prevalence of approximately 4.8%.* Approximately 43% of affected individuals in the cited worldwide study experienced onset after age 18.* Childhood-onset separation anxiety is more common in girls.* Adult-onset cases have a more balanced female-to-male ratio.* More than half of affected people show remission within the first decade after onset.* Separation anxiety is associated with later or concurrent major depression, bipolar disorder, panic disorder, OCD, social anxiety, and specific phobia.* Comorbid separation anxiety may reduce CBT response in panic disorder, GAD, and social anxiety.* Treatment may therefore need to address separation fears directly rather than assuming they will resolve automatically.* Separation anxiety differs from agoraphobia because the feared catastrophe concerns the attachment figure rather than inability to escape or receive help.* Separation-related panic is usually context-linked rather than unexpected.* GAD involves broader worry themes than separation anxiety.* Some adult-onset separation anxiety may overlap phenomenologically with complicated grief or trauma-related disorders.* Separation anxiety aggregates in families, although genetic and environmental contributions remain uncertain.* Oxytocin, serotonin, dopamine, and other biological systems are being investigated.* Both adult separation anxiety disorder and panic disorder show associations with carbon-dioxide sensitivity.* Traumatic experience is associated with increased separation-anxiety prevalence.* CBT is commonly used for both childhood and adult presentations, although adult treatment evidence remains limited.* Childhood CBT may incorporate parental education and social-skills work.* SSRIs are sometimes used in children who do not respond adequately to CBT, but pharmacological evidence is mixed.* Substance/medication-induced anxiety disorder can present with generalized anxiety or panic.* Diagnosis requires a plausible temporal relationship between anxiety and intoxication, withdrawal, or medication exposure.* Relevant substances include alcohol, caffeine, cannabis, PCP, hallucinogens, inhalants, opioids, sedatives, stimulants, cocaine, and other agents.* Anxiety should generally resolve following removal of the offending substance or resolution of withdrawal.* Persistent anxiety months later should prompt consideration of an independent primary anxiety disorder.* Evidence for extremely prolonged toxic or withdrawal effects extending well beyond physiological exposure is limited in the source.* Anxiety disorder due to another medical condition requires a recognised medical condition capable of causing anxiety or panic.* Possible causes include endocrine, metabolic, neurological, cardiopulmonary, infectious, and oncological disorders.* Temporal relationship between medical illness and anxiety symptoms is an important diagnostic clue.* Modern anxiety nosology remains based primarily on clinical phenomenology rather than biomarkers.* Genetics, neuroimaging, epigenetics, pharmacogenetics, and other neuroscience tools have not yet been incorporated directly into routine DSM classification.* High comorbidity suggests that anxiety-disorder categories do not represent completely isolated biological entities.* Transdiagnostic CBT protocols can be effective across different anxiety disorders.* The boundaries between anxiety disorders remain clinically useful while also being biologically porous.* The most important diagnostic question is often not “Does this person have anxiety?” but “What exactly is the person afraid will happen, and what behaviour has developed to prevent it?” This is a public episode. 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