Anxiety and Related Disorders

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) classifies the following types of anxiety disorders:

• separation anxiety disorder

• selective mutism

• specific phobia

• social anxiety disorder (social phobia)

• panic disorder

• agoraphobia

• generalized anxiety disorder

• substance/medication-induced anxiety disorder

• anxiety disorder due to another medical condition

• other specified anxiety disorder

• unspecified anxiety disorder

Note: Illness anxiety disorder (formerly known as hypochondriasis) was previously listed as an anxiety disorder but has now been classified as a somatic symptom and related disorder in the DSM-5. It is characterized by worrying specifically about having or acquiring a serious medical illness, and individuals may have no or mild somatic symptoms despite the degree of anxiety.

In this section, we focus on the following anxiety disorders:

• Phobias

• Panic disorder

• Generalized anxiety disorder

See the DSM-5-TR for information on other anxiety and related disorders.

Phobias

Phobias are characterized by an immediate and excessive anxiety reaction to a specific object or situation despite the affected person being aware in most cases that the reaction is excessive or unreasonable. Psychotherapeutic intervention with cognitive behavioral therapy (CBT) can help individuals to recognize and control symptoms through both exposure and coping strategies

Social Anxiety Disorder (Social Phobia)

Social phobia is characterized by fear and worry about social situations related to contact with or being scrutinized by others, lasting for 6 months or more. Anxiety-provoking situations may include conversations with new or unfamiliar persons, eating in front of others, or having to speak or perform in public. The fear or anxiety is considered out of proportion to the sociocultural context. Patients with this diagnosis should be evaluated for comorbid conditions (e.g., alcohol or substance use disorders).

Treatment: Selective serotonin-reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line treatments for social anxiety disorder. Beta-blockers and monoamine oxidase inhibitors (MAOIs) have shown promise in the treatment of performance anxiety.

Psychotherapeutic interventions focus on analysis of individual perception and interpretation and desensitization techniques and may involve both individual and group therapy.

Psychotherapeutic interventions with CBT may involve both individual and group therapy approaches that focus on analysis and interpretation of perception, desensitization techniques, and coping strategies.

Panic Disorder

Panic disorder is characterized by discrete and brief (often less than 20 minutes) episodes of anxiety and fear accompanied by highly disturbing physical symptoms such as chest pain, shortness of breath, rapid pulse, palpitations, and sweating.

Treatment: Antidepressants are first-line pharmacotherapy for panic disorder and typically involve selective serotonin-reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). In an acute presentation, where distress or symptoms of anxiety are prominent, benzodiazepines may be useful. Psychotherapeutic intervention with cognitive behavioral therapy can help individuals to recognize and control symptoms through both exposure and coping strategies.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by chronic worrying that is typically excessive and difficult to control. GAD can manifest in the form of somatic complaints and often coexists with depression.

Diagnosis: According to the DSM-5, all features listed in the following table must be present for at least 6 months to meet the diagnostic criteria for GAD.

Screening: Although the recommendations for routine screening for anxiety disorder are controversial, the Generalized Anxiety Disorder-7 (GAD-7) questionnaire can be used to assess the severity of symptoms and response to treatment.

(Source: Generalized Anxiety Disorder. N Engl J Med 2015.)

Management and Treatment: As with treatment of depression, treatment of GAD typically involves psychotherapy, pharmacotherapy, or a combination of the two approaches as described in the following two tables:

(Source: Generalized Anxiety Disorder. N Engl J Med 2015.)

(Source: Generalized Anxiety Disorder. N Engl J Med 2015.)