____________________________________________________________________________ Anxiety Disorders
GENERALIZED ANXIETY DISORDER GAD is characterized by excessive and inappropriate worry- ing that is persistent and not restricted to circumstance or situation. Patients have physical anxiety symptoms and key psychologic symptoms. GAD is often comorbid with major depressive disorder, panic disorder, phobia, health anxiety, and OCD [3]. The DSM-5 diagnostic criteria for GAD remain unchanged from previous editions [2; 102]: • Excessive anxiety and worry (apprehensive expectation) over a number of everyday concerns (e.g., school/work performance) • Individual finds it difficult to control the worry • Excessive anxiety and worry are associated with three or more of the following six symptoms, with at least some occurring more days than not for at least six months: ‒ Restlessness, feeling “on edge” ‒ Easily fatigued ‒ Difficulty concentrating ‒ Irritability ‒ Muscle tension ‒ Sleep disturbance (difficulty falling or staying asleep, restless sleep) • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • Symptoms not better explained by another mental disorder • The disturbance is not attributable to the physiologic effects of a substance or another medical condition Patients with GAD in the absence of current or lifetime comor- bidity are uncommon, and patients with GAD typically present to primary care with comorbid depression, anxiety disorders, or substance use disorders. The presence of comorbidity com- plicates diagnosis and treatment [2]. PANIC ATTACKS Panic attacks are abrupt, unexpected periods of intense fear or discomfort with multiple physical or psychologic anxiety symptoms, often peaking by 10 minutes and lasting around 30 to 45 minutes. Panic disorder is characterized by recurrent unexpected surges of severe anxiety (panic attacks). As noted, most patients develop a fear of having further panic attacks. The extent of anticipatory anxiety between attacks varies, and patients may alter their behavior to reduce the recurrence risk [2; 3]. The essential features of panic attacks are unchanged in the DSM-5, but the complicated DSM-IV terminology for describ- ing different types of panic attacks (i.e., situational-bound/ cued, situational-predisposed, and unexpected/uncued) is
replaced with unexpected and expected panic attacks. Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disor- ders, including but not limited to anxiety disorders. Hence, panic attack can be listed as a specifier, applicable to almost all DSM-5 disorders [102]. The DSM-5 criteria for panic attacks specify an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and includes four or more of the following symptoms [2]: • Palpitations, pounding heart, or accelerated heart rate • Sweating • Trembling or shaking • Sensations of shortness of breath or smothering • Feelings of choking • Chest pain or discomfort • Nausea or abdominal distress • Feeling dizzy, unsteady, light-headed, or faint • Chills or heat sensations • Paresthesias (numbness or tingling sensations) • Derealization (feelings of unreality) or depersonalization (being detached from oneself) • Fear of losing control or going crazy • Fear of dying Physical symptoms predominate. Panic attack is not classified as a mental disorder and does not have a diagnostic code. Instead, an attack can occur with other mental disorders, such as depressive and anxiety disorders, and also be extant with physical disorders. While panic attack is a specifier for both mental and physical disorders, the elements of panic attack are contained within the criteria for panic disorder, making the specifier unnecessary for that diagnosis. PANIC DISORDER Panic disorder in the DSM-5 has an added criterion for unex- pected panic attacks. This implies that expected panic attacks exist and that anticipated, situationally triggered panic attacks are somehow less pathologic than spontaneous panic attacks. This assumption is challenged on the basis that panic attacks are inherently pathologic, regardless of context or lack thereof, and individuals with panic disorder can have unexpected and expected panic attacks [18; 105]. Regardless, the DSM-5 diagnostic criteria for panic disorder require [2]: • Recurrent unexpected panic attacks • One or more of the attacks followed by at least one month of one or both of the following: ‒ Persistent concern or worry about additional panic attacks or their consequences ‒ Significant maladaptive change in behavior related to the attacks
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