____________________________________________________________________________ Anxiety Disorders
SELECTIVE MUTISM Separation anxiety disorder and selective mutism were included in the DSM-IV section Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence, but were classed as anxi- ety disorders and moved to the anxiety disorder section in the DSM-5 [102]. The majority of children with selective mutism are anxious, and while selective mutism is now considered an anxiety disorder, it remains a disorder primarily of childhood and is beyond the scope of this course [102]. ASSESSMENT Effective anxiety disorder treatment relies on accurate diagnosis. Diagnosis is made when diagnostic criteria for a specific disorder are established and symptoms cannot be better explained by the effects of the patient’s other medical conditions, medications, substances, or pre-existing mental disorders [2]. The management of patients presenting with anxiety symptoms should initially follow the flow of these five components [120]: 1. Screen for anxiety and related symptoms. 2. Consider differential diagnosis and severity, impair- ment, and comorbidity. 3. Identify specific or multiple anxiety disorder(s), often in consultation with trained specialists using structured interview techniques. 4. Initiate psychologic and/or pharm-acologic treatment. 5. Perform follow-up. Evidence suggests that in primary care, patient tendency to ascribe pathologic anxiety symptoms to physical causes con- tributes to high rates of missed diagnoses and the misdiagnosis of GAD and panic disorder. To offset this requires a broad differential and caution to identify confounding variables and comorbid conditions [121].
• Persistent reluctance or refusal to sleep away from home or to go to sleep without major attachment figure near • Repeated nightmares involving the theme of separation • Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation occurs or is anticipated To meet the criteria for this disorder, the symptoms must cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. Symp- toms must not be better explained by another mental disorder (e.g., delusions or hallucinations concerning separation in psychotic disorders); refusal to go outside without a trusted companion (as in agoraphobia); worries about ill health or other harm befalling significant others (as with generalized anxiety disorder); or concerns about having an illness (as in illness anxiety disorder) [2]. Panic attacks commonly occur with youth and adult SEPAD. Differential Diagnosis In the past, adult SEPAD was often diagnosed as panic disor- der, and it shares features with other psychiatric conditions. Excessive attachment toward others is a feature of a dependent personality, and avoidance behavior is a predominant feature of agoraphobia. With SEPAD, the focus involves key attachment figures, unlike dependent personality disorder, which is more indiscriminate. Panic and phobic-like behavior in SEPAD is specific to fears of separation from, or harm to, attachment figures and not spontaneous or triggered by other factors. Social and occupational function is frequently impaired, but individuals with SEPAD do not show impaired function in family life compared to controls and often function well in family environments. Borderline personality disorder differs by pervasive mood and relationship instability uncharacteristic of SEPAD [61]. A study exploring whether SEPAD in patients with panic disorder/agoraphobia was a manifestation of anxious attach- ment, a form of agoraphobia, or a specific condition with clinically significant consequences found that patients with SEPAD had greater panic symptom severity and quality of life impairment than those without separation anxiety. A greater rate of symptoms suggestive of anxious attachment was found among patients with panic disorder and SEPAD versus those without SEPAD. However, the relationship between SEPAD and attachment style was weak, and SEPAD occurred in some patients who reported secure attachment style. There was also little evidence SEPAD was a form of agoraphobia. SEPAD was found to be a distinct condition associated with impairment in quality of life and should be better recognized and treated in patients with comorbid panic disorder [119].
The American Psychiatric Association recommends that the initial psychiatric evaluation of a patient include assessment of anxiety and panic attacks. (https://psychiatryonline.org/doi/10.1176/ appi.books.9780890426760.pe02. Last
accessed April 27, 2025.) Strength of Recommendation/Level of Evidence : 1C (Recommendation with low confidence that the evidence reflects the true effect)
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