Anxiety Disorders

For all anxiety disorders, it is no longer required that affected individuals recognize that their anxiety is excessive or unreasonable. The anxiety must now be “out of proportion” to the actual danger the situation poses, depending on the environment and situation.

From the view of a clinician, this change appears to be useful. For example, in contrast to patients with other anxiety disorders, who are sometimes afraid of harmless situations or objects (e.g., spiders in specific phobia, or elevators in agoraphobia), patients with GAD often have a fear of “real” dangers (e.g., traffic accidents or plane crashes), but they overestimate the statistical chance of such casualties. Although these individuals would recognize their fears as exaggerated, they would probably not admit that their anxiety is completely unreasonable.

For agoraphobia, GAD, separation anxiety disorder, specific phobia, and SAD, it is now required that the disorder be persistent, typically lasting for 6 months or more for adults. On the one hand, this may minimize overdiagnosis of transient fears; on the other hand, problems may arise if someone has suffered from anxiety symptoms for only 5 months. Can this patient receive treatment, although she or he does not have a codable disorder? For example, could health insurance companies refuse to pay for cognitive behavioral therapy for these patients? For panic disorder and selective mutism, a duration of only 1 month is required.

Panic Disorder (F41.0) and Agoraphobia (F40.00)

The DSM–IV differentiated between panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without a history of panic disorder. In the DSM–5, panic disorder and agoraphobia are now unlinked and form two diagnoses, each with separate criteria. The main reason for this was that there is a larger group of patients who have agoraphobia without panic attacks. However, in two-thirds of cases, panic disorder co-occurs with agoraphobia. These individuals are now diagnosed as having comorbidity of panic disorder and agoraphobia. From a clinician’s point of view, disentangling panic and agoraphobia does not seem to be very useful, as agoraphobia usually develops on average 6 months after a patient has begun experiencing panic attacks,Reference Bandelow, Amering and Benkert ⁵ as a consequence of the distorted beliefs of the patients that they need emergency help when having a panic attack. The patients then start to avoid situations in which receiving immediate medical support would be difficult. Moreover, most patients suffer more from their panic attacks than from their agoraphobic avoidance behavior, with a few exceptions. Furthermore, patients with agoraphobia do not only have the expected panic attacks, but also attacks that do not occur in typical agoraphobic situations.

A typical patient who first starts having recurrent panic attacks and then, as a consequence, avoids situations in which panic attacks might occur, would have to be classified as having “panic disorder with agoraphobia” by the DSM–IV, as having “panic disorder” plus “agoraphobia” in the DSM–5, and as having “agoraphobia with panic disorder” by the ICD–10. This is somehow confusing, as there is an obvious logical association between having panic attacks and the avoidance of typical agoraphobic situations. Moreover, the ICD–10 distinguishes between “phobic” and “other” anxiety disorders. Therefore, panic disorder is listed among the other anxiety disorders, while agoraphobia with or without panic disorder is listed among the phobic disorders. A patient starting with unexpected panic attacks will have to be switched from the “other” to the “phobic” anxiety disorders when he starts to develop additional agoraphobia. In the ICD–11, the DSM–5 classification that separates panic disorder and agoraphobia will probably be adopted.

It is not clear whether this change will lead to changes in clinical treatment research—that is, some trials will only include patients with panic disorder while others might only study individuals with agoraphobia. In clinical reality, panic disorder seems to have priority, as clinicians diagnose “panic disorder” much more frequently than “agoraphobia.” Moreover, there are hundreds of clinical treatment trials for panic disorder (with or without agoraphobia), while very few studies have been conducted with solely agoraphobic patients. Perhaps controversies about optimal treatment may also have influenced the nomenclature for the disorder, as it can be treated both with medication and/or cognitive behavioral therapy (CBT).Reference Bandelow, Reitt, Rover, Michaelis, Gorlich and Wedekind ⁶ Behavioral therapists may favor agoraphobia as the primary disorder, as it is easier to treat agoraphobic avoidance by means of exposure therapy than to treat spontaneous panic attacks occurring out of the blue, a condition that cannot be trained in in-vivo exposure sessions (although panic disorder can be treated with interoceptive exposure).

The DSM–5 removed the description of different kinds of panic attacks (limited or full panic attacks). Two categories now remain: expected and unexpected.

The DSM–5 also introduced the “panic attack specifier,” as panic attacks may not only occur in panic disorder but also in social anxiety, depressive, bipolar, impulse-control, and substance use disorders, so that panic attacks can now be utilized as a specifier that is applicable to all mental disorders. However, there is one important difference. Patients with panic disorder often do not have an explanation for their bodily symptoms and therefore develop a fear of impending death, while patients with social phobia often know the reason why they are so afraid, perhaps when they are in an exam situation—which makes the situation somehow easier, as they are not afraid to die like patients with panic disorder are.

Another new feature in the DSM–5 is that, in order to distinguish agoraphobia from specific phobias, two of five agoraphobic situations must now be endorsed (formerly one).

Generalized Anxiety Disorder (F41.1)

For GAD, there were only minor changes in wording. In the course of development, it was planned to include additional items for avoidance behavior and procrastination of actions (e.g., travel), which are perceived as potentially dangerous. However, these changes were not implemented.

Social Anxiety Disorder (F40.10)

The “generalized” specifier for SAD has been deleted. The reason was that the requirement “fears include most social situations” was difficult to operationalize. The ICD–10 does not distinguish between generalized and nongeneralized SAD.

There is now a “performance only” specifier, which applies for individuals who have social fears only in performance situations (e.g. musicians, dancers, and athletes) or in work, school, and academic settings.

Specific Phobias (F40.2)

For specific phobias, there were only minor changes in wording in the DSM–5. Specifiers were introduced based on the phobic stimulus: for example, animal phobia (e.g., spiders), natural environment phobia (e.g., heights), blood-injection-injury phobia (e.g., needles), or situational phobia (e.g., airplanes, elevators, enclosed places).

Selective Mutism (F94.0)

Children with selective mutism do not initiate speech or reciprocally respond when spoken to by others. They will sometimes speak in their homes in the presence of immediate family but often not even in front of second-degree relatives or close friends. The disorder is often accompanied by severe social fears. It is a rare disorder that usually occurs before the age of 5 years.

In the DSM–5, selective mutism has been moved from the children/adolescence section to the anxiety disorders. The reason for this was that the large majority of children with selective mutism were found to suffer from anxiety. In older children, it may be difficult to separate the disorder from “performance-only” social anxiety disorder, based on the current description.Reference Keeton and Crosby Budinger ⁷ Selective mutism will probably also be included in the ICD–11.

Mixed Anxiety and Depressive Disorder (F41.2)

The ICD–10 has a category entitled “mixed anxiety and depressive disorder” (MADD), which should be used when symptoms of depression and anxiety are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately. When a patient shows anxiety symptoms severe enough to justify the diagnosis of, for example, GAD, and also fulfills the criteria for a major depressive episode (at least to a mild degree), both diagnoses should be recorded, and MADD should not be used.

It had also been intended to include “mixed anxiety and depressive disorder” in the DSM–5, but these plans were dropped.

Möller et al.Reference Möller, Bandelow, Volz, Barnikol, Seifritz and Kasper ⁸ reviewed the evidence in favor of and against MADD and argue that the diagnosis should be included in future classification systems as a diagnostic category, despite divergent results regarding its prevalence and course, diagnostic stability over time, and nosological inconsistencies between subthreshold and threshold presentations of anxiety and depressive disorders, because it appears to be very common, particularly in primary care. In clinical reality, MADD seems to play a larger role than generally assumed. In a German survey, data from a random sample comprising 13.2% of over 10 million patients registered in the outpatient healthcare system in 2008 were analyzed. Of all psychiatric diagnoses made by mental health specialists, ICD–10 MADD was the most commonly diagnosed anxiety disorder (7.2%), followed by panic disorder (4.4%), and GAD (2.5%).Reference Kruse, Larisch, Hofmann and Herzog ⁹ However, the quality of these diagnoses was not scrutinized in the survey, so that it cannot be excluded that in many cases MADD was diagnosed though the patients fulfilled both the full criteria for depression and an anxiety disorder.