The Diagnostic and Statistical Manual of Mental Disorders (DSM)

• Anxiety disorder DSM-IV classifications
  • Acute Stress Disorder
  • Social Phobia
  • Generalised Anxiety Disorder
  • Panic Attack
  • Specific phobias
  • Obsessive Compulsive Disorder
  • Post Traumatic Stress Disorder
  • Anxiety Disorder due to general medical condition
  • Agoraphobia
  • Agoraphobia without history of Panic Disorder
  • Panic Disorder without Agoraphobia and Panic Disorder with Agoraphobia
  • Anxiety Disorder not otherwise specified

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The Diagnostic and Statistical Manual of Mental Disorders (DSM) was first published in 1952 and lists the different categories of mental disorder and the criteria used for diagnosing them. It is published by the American Psychiatric Association who have decided on this criterion. There have been four revisions since it was first published the most recent being DSM-IV in 1994, and there was also a text revision in 2000.It is also useful to note that the mental disorders section of the International Statistical Classification of Diseases and Related Health Problems (ICD), is another commonly used guide and it uses the same diagnostic codes as the DSM. Clinicians, researchers and also insurance companies and policy makers use the DSM worldwide. DSM-III (1980), DSM-III-R (1987), and DSM-IV (1994) introduced and refined new classifications of some types of anxiety taking into account recent findings about the bio chemical and post traumatic origins of these anxiety disorders. Before this psychiatrists would diagnose patients on the basis of theory that saw anxiety as being the outcome of unconscious conflict within the patients mind. The definitions that are used at present are therefore based on the external and reported symptoms rather than on theories about the cause. Twelve separate anxiety disorders are defined in the DSM-IV as affecting adults. They can be put under seven different headings. These are:

1. Panic disorder with or without agoraphobia. The main characteristic of panic disorder is the occurrence of a panic attack linked with the fear of another attack. Agoraphobia is not, within a clinical setting, categorised as a disorder but is usually associated in some way with panic disorder. Agoraphobics are afraid of places or situations in which they may have another attack and be unable to leave or find someone to help them.
2. Phobias: Specific phobias and social phobia are both included under this heading. A phobia is described as an intense and irrational fear of a specific object or situation that is so intense it can cause the individual to be compelled to go to great lengths to avoid it. Phobias can be about harmful things or situations that present a risk but they can also be of harmless situations, objects or sometimes animals. Social phobia can include a fear of being judged, scrutinised or humiliated in some way. It can show itself with a fear doing certain things in front of others such as public speaking or using the toilet.
3. Obsessive Compulsive Disorder: is characterised by unwanted, intrusive, persistent or repetitive behaviours, these will reflect a persons attempts to control them and the anxiety caused by them. OCD effects around 2-3% of the population making it far more common than it was previously considered to be.
4. Stress disorders: This includes posttraumatic stress disorder (PTSD) and acute stress disorders. These are categorised as being a symptomatic response to a traumatic experience that the individual has had.
5. Generalised Anxiety Disorder (GAD): Is the most commonly diagnosed anxiety disorder and usually affects young adults.
6. Anxiety disorders due to known physical cause. This includes medical conditions and symptoms caused by drug misuse.
7. Anxiety disorder not otherwise specified. This is not a separate type of disorder but included in order to cover symptoms that do not meet the criteria for any of the other anxiety disorders.

All of the disorders also have a criterion of severity. The anxiety disorder has to be severe enough to be classed as interfering in an individual’s life. This includes work commitments, social activities, educational commitments and any other activities they take part in.

Anxiety disorder DSM-IV classifications

Each of the anxiety disorders are classified within DSM-IV as follows:

DSM-IV diagnostic criteria for 308.3 Acute Stress Disorder

1. The person has been exposed to a traumatic event in which both of the following were present:
   1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
   2. the person’s response involved intense fear, helplessness or horror
2. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
   1. a subjective sense of numbing, detachment, or absence of emotional responsiveness
   2. a reduction in awareness of his or her surroundings (e.g., “being in a daze”)
   3. derealization
   4. depersonalisation
   5. dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
3. The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
4. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
5. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
6. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
7. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
8. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder.

DSM-IV diagnostic criteria for 300.23 Social Phobia

1. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
3. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
4. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
5. The avoidance, anxious anticipation, or distress in the feared social or performance situations(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
6. In individuals under age 18 years, the duration is at least 6 months.
7. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
8. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behaviour in Anorexia Nervosa or Bulimia Nervosa.

Specify if:

Generalized: if the fears include most social situations, also consider the additional diagnosis of Avoidant Personality Disorder.

DSM-IV diagnostic criteria for 300.02 Generalised Anxiety Disorder

1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
2. The person finds it difficult to control the worry.
3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.
   1. restlessness or feeling keyed up or on edge.
   2. Being easily fatigued
   3. Difficulty concentrating or mind going blank
   4. Irritability
   5. Muscle tension
   6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
4. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder) being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.
5. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
6. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

DSM-IV criteria for Panic Attack

A discrete period of intense fear or discomfort, in which 4 (or more) of the following symptoms developed abruptly and reached a peak within ten minutes.

1. Palpitations, pounding heart or accelerated heart rate.
2. Sweating
3. trembling or shaking
4. Sensations of shortness of breath or smothering.
5. feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light headed or faint.
9. derealisation(feelings of unreality) or depersonalisation (being detached from oneself)
10. Fear of losing control or going crazy.
11. Fear of dying
12. Paresthesias (numbness or tingling sensations)
13. Chills or hot flushes.

DSM-IV criteria for 300.29 Specific phobias

1. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g. flying, heights, animals, receiving an injection, seeing blood)
2. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally pre disposed panic attack. Note: in children, the anxiety may be expressed by crying, tantrums, freezing or clinging.
3. The person recognises that the fear is excessive and unreasonable. Note: in children this feature may be absent.
4. The phobic situation is avoided or is endured with intense anxiety or distress.
5. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with a persons routine, occupational (or academic) functioning, or social activities or relationships or there is a marked distress about having the phobia.
6. In individuals under the age of 18 years the duration is at least 6 months.
7. The anxiety panic attacks or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder such as OCD (e.g. fear of dirt in someone with an obsession about contamination), post traumatic stress disorder (e.g. avoidance of school), social phobia, panic disorder with agoraphobia or agoraphobia without history of panic disorder).

DSM diagnostic criteria for 300.3 Obsessive Compulsive Disorder

1. Either obsessions or compulsions: Obsessions as defined by 1,2, 3 and 4;
   1. Recurrent and persistent thoughts, impulses or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.
   2. The thoughts, impulses or images are not simply excessive worries about real life problems.
   3. The person attempts to ignore or suppress such thoughts, impulses or images or to neutralise them with some other thought or action.
   4. The person recognises that the obsessional thoughts, impulses or images are a product of his or her own mind (not imposed from without as with thought insertion).
   Compulsions are defined as 1 and 2
   1. Repetitive behaviours (e.g. hand washing, ordering checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to the rules that must be applied rigidly.
   2. The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralise or prevent or are clearly excessive.
2. At some points during the course of the disorder, the person has recognised that the obsessions or compulsions are excessive or unreasonable. Note: this does not apply to children.
3. The obsessions and compulsions cause marked distress, are time consuming (take more than one hour a day), or significantly interfere with the persons normal routine, occupational (or academic) functioning, or usual social activities or relationships.
4. If another axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g. preoccupation with food in the presence of an eating disorder, hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder: preoccupation with drugs in the presence of a Substance use disorder : preoccupation with having a serious illness in the presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia: or guilty ruminations in the presence or major depressive Disorder.
5. The disturbance is not due to the direct physiological effects of a substance (e.g. drug of abuse, a medication) or a general medical condition.

Specify if with poor insight: If, for most of the time during the current episode, the person does not recognise that the obsessions and compulsions are excessive or unreasonable.

Although people have very different abilities to endure stress, it seems likely that everyone has a breaking point if exposed for long enough to an extreme enough stressor. Once Posttraumatic Stress Disorder occurs, its symptom pattern is remarkably uniform regardless of the individuals’ previous psychological history or cultural background. However different a people are before developing Posttraumatic Stress Disorder, there is a very characteristic human pattern of response to an extreme stressor that includes avoidance of stimuli that remind the person of the stressor, re experiencing the stressor in a number of ways, and increased physiological arousal, particularly on exposure to memory jogging triggers.

DSM diagnostic criteria for 309.81 Post Traumatic Stress Disorder

1. The person has been exposed to a traumatic event in which both of the following were present:
   1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
   2. The person’s response involved intense fear, helplessness, or horror. NOTE: in children, this may be expressed instead by disorganised or agitated behaviour.
2. The traumatic event is persistently re experienced in one (or more) of the following ways.
   1. Recurrent and intrusive distressing recollections of the event including images thoughts or perceptions. Note: In young children repetitive play may occur in which themes or aspects of the trauma are expressed.
   2. Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognisable content.
   3. Acting or feeling as if the traumatic event were recurring (includes a sense of relieving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: in children, trauma specific re-enactment may occur.
   4. Intense psychological distress at exposure to the internal or external cues that symbolise or resemble an aspect of the traumatic event.
3. Persistant avoidance of stimuli associated with the trauma and the numbing of general responsiveness. (Not present before trauma), as indicated by three or more of the following:
   1. Efforts to avoid thoughts, feelings or conversations associated with the trauma.
   2. Efforts to avoid the activities, places or people that arouse recollections of the trauma.
   3. Inability to recall important aspect of the trauma
   4. Markedly diminished interest or participation in significant activities.
   5. Feelings of detachment or estrangement from others.
   6. Restricted range of affect ( e.g. unable to have loving feelings)
   7. Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span).
4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
   1. Difficulty falling or staying asleep
   2. Irritability or outbursts of anger
   3. Difficulty concentrating
   4. Hyper vigilance
   5. Exaggerated startle response
5. Duration of the disturbance (symptoms in criteria B, C and D) is more than one month.
6. The disturbance causes clinically significant distress or impairment in social occupational, or other important areas of functioning.

Specify if: Acute: if duration of symptoms is less than three months. Chronic: if duration of symptoms is three months or more.

Specify if: with delayed onset: If onset of symptoms is at least 6 months after the stressor.

DSM-IV diagnostic criteria for 293.89 Anxiety Disorder due to general medical condition

1. Prominent anxiety, panic attacks, or obsessions or compulsions predominate in the clinical picture.
2. There is evidence from the history, physical examination or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
3. The disturbance is not better accounted for by another mental disorder (e.g. Adjustment Disorder with anxiety in which the stressor is a serious general medical condition).
4. The disturbance does not occur exclusively during the course of the delirium.
5. The disturbance causes clinically significant distress or impairment in social occupational, or other important areas of functioning.

Specify if:

• With generalized anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation.
• With panic attacks: if the panic attacks predominate in the clinical presentation.
• With Obsessive Compulsive symptoms: If obsessions or compulsions predominate in the clinical presentation.

DSM-IV criteria for Agoraphobia

Agoraphobia is not a codable disorder. Code the specific disorder in which the Agoraphobia occurs (e.g. 300.21 Panic Disorder with Agoraphobia or 300.22 Agoraphobia without history of panic disorder.

1. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic attack or panic like symptoms. Agoraphobia fears typically involve characteristic clusters of situations that include being outside the home alone: being in a crowd or standing in a line; being on a bridge: and traveling in a bus, train, or automobile. Note: consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations or Social Phobia if the avoidance is limited to social situations.
2. The situations are avoided (e.g. travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic like symptoms, or require the presence of a companion.
3. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social phobia (e.g. avoidance limited to social situations because of fear of embarrassment), Specific phobia (avoidance limited to a single situation like elevators), Obsessive Compulsive Disorder (e.g. avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g. Avoidance of stimuli associated with a severe stressor) or Separation Anxiety Disorder (e.g.avoidance of leaving home or relatives).

DSM-IV diagnostic criteria for 300.22 Agoraphobia without history of Panic Disorder

1. The presence of Agoraphobia related to fear of developing panic- like symptoms (e.g. dizziness or diarrhea).
2. Criteria have never been met for Panic Disorder.
3. The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or general medical condition.
4. If an associated general medical condition is present, the fear described in criterion A is clearly in excess of that usually associated with the condition.

Summary of DSM-IV diagnostic criteria for 300.01 Panic Disorder without Agoraphobia and 300.21 Panic Disorder with Agoraphobia

1. Both (1) and (2)
   1. Recurrent unexpected Panic Attacks
   2. At least one of the attacks has been followed by at least a month of the following:
      1. Persistent concern about having additional attacks
      2. Worry about the implications of the attack or its consequences (e.g losing control, having a heart attack, “going crazy”)
      3. A significant change in behavior related to the attacks
2. This criterion differs for Panic Disorder with and without Agoraphobia as follows: For 300.21 Panic Disorder with agoraphobia: the presence of Agoraphobia. For 300.01 Panic Disorder without Agoraphobia: absence of Agoraphobia.
3. The Panic Attacks are not due to the direct physiological effects of a substance (e.g. a drug of abuse, medication) or a general medical condition (e.g. hyperthyroidism).
4. The Panic Attacks are not better accounted for by another mental disorder, such as Social phobia (e.g. occurring on exposure to feared social situations), Specific Phobia, (e.g. on exposure to phobic situation), Obsessive Compulsive Disorder (e.g. on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder, (e.g. in response to stimuli associated with a severe stressor), or separation Anxiety Disorder (e.g. in response to being away from home and close relatives).

DSM-IV text for 300.00 Anxiety Disorder not otherwise specified

This category includes disorders with prominent anxiety or phobic avoidance that do not meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with mixed Anxiety and depressed mood. Examples include:

1. Mixed anxiety-depressive disorder: clinically significant symptoms of anxiety and depression, but the criteria are not met for either a specific Mood Disorder or a specific Anxiety Disorder.
2. Clinically significant social phobic symptoms that are related to the social impact of having a general medical condition or mental disorder (e.g. Parkinson’s disease, dermatological conditions, Stuttering, Anorexia Nervosa, Body Dysmorphic Disorder).
3. Situations in which the clinician has concluded that an Anxiety Disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.