Anxiety Disorders ____________________________________________________________________________
[3]. This fear or anxiety must be markedly stronger than the actual threat of the object or situation (e.g., likelihood of being stuck on a well-maintained elevator) [2]. The core features and different types of specific phobia remain unchanged from the DSM-IV, but the requirement was removed that individuals older than 18 years of age must recognize their fear and anxiety as excessive or unreasonable. The duration requirement of longer than six months now applies to all ages [102]. Specific phobias can develop after a traumatic event or from witnessing traumatic events. The fear or anxiety happens every time the person is exposed to the stimulus and may include panic attack symptoms. The median age of onset with specific phobia is 13 years [2]. According to the DSM-5, specific phobia is diagnosed when the following criteria are met [2]: • Marked fear or anxiety about a specific object or situation (e.g., flying, seeing blood) • Phobic object or situation almost always provokes immediate fear or anxiety and is actively avoided or endured with marked fear or anxiety • Fear or anxiety out of proportion to the actual danger posed by the specific object or situation • The fear, anxiety, or avoidance is persistent, typically at least six months • Marked distress or functional impairment Specific phobia subtypes are organized by phobia categories: • Animal: Dogs, snakes, insects • Natural environment: Storms, heights, dark • Blood-injection-injury: Injections, blood draws, medical procedures • Situational: Driving, flying, enclosed spaces • Other: Choking, vomiting, clowns Specific Phobia Coding Approximately 75% of individuals diagnosed with specific phobia fear more than one object. In the past, when this occurred, more than one ICD-10 code was given [2]. However, the ICD-11 eliminated this component. When individuals experience panic attacks in response to their phobia, clinicians should add “with panic attacks” to the diagnosis. SEPARATION ANXIETY DISORDER Separation anxiety is a basic human fear and readily observ- able in children. Close attachment to nurturing parental figures during infancy is necessary for survival, and close relationships throughout life are an important source of sup- port in times of stress. Separation anxiety does not vanish with development and maturation, but persistant separation anxiety in adulthood should not become an issue of clinical importance. Manifestations of pathologic separation anxiety include uncontrollable apprehension over losing important
attachment figures, intense fears of leaving home or going out unaccompanied, and nightmares around themes of separation. Persons with SEPAD have substantial impairments in many aspects of community life, although not all individuals show problems in attachment [118; 119]. Pathologic early childhood attachments can have far-reaching consequences in adulthood. These patients often have a grossly impaired ability to experience and internalize positive relation- ships or to develop mental capacities for self-soothing, anxiety tolerance, affect modulation, and individuation. Adults with SEPAD feel unable to function in the absence of a mother sur- rogate. Separation anxiety has long been considered the distal antecedent to panic disorder. In adults, separation anxiety may reflect excessive activation of fear circuits in response to separation and over-activation of reward circuits with reunion, likely the result of abnormalities or deficits in underlying social representation and cognition systems [98]. SEPAD is characterized by fear or anxiety concerning separa- tion from those to whom an individual is attached. Common features include excessive distress when experiencing or antici- pating separation from home, and persistent and excessive wor- ries about potential harms to attachment figures or untoward events that might result in separation [3]. The core features of SEPAD are mostly unchanged from DSM- IV, but the wording is modified to more adequately represent SEPAD expression in adulthood. For example, attachment figures may include the children of adults, and avoidance behaviors may occur in the workplace as well as at school. Diag- nostic criteria no longer require childhood history of SEPAD or onset before 18 years of age, because a substantial number of adults report onset later in life. Adults with the condition include those with adult-onset and those with childhood onset and symptom persistence into adulthood. A duration criterion of six months or longer was added [64; 102]. For a diagnosis of SEPAD, the persistent and excessive anxiety related to separa- tion or impending separation from a major attachment figure (e.g., spouse, close family member) must be evidenced by at least three of the following criteria [2]: • Recurrent excessive distress when anticipating or experiencing separation • Persistent and excessive worry about losing a major attachment figure or about possible harm to him or her • Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, kidnapped, into an accident) that causes separation from a major attachment figure • Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation • Persistent and excessive fear of or reluctance about being alone or without a major attachment figure
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