Anxiety Disorders in the DSM 5 TR | Symptoms and Diagnosis

Hey there everybody, and welcome to this presentation on diagnosing anxiety and panic in the DSM 5tr. I'm your host, Dr. Donnellice Snipes. In this presentation, very briefly, we're going to review the diagnostic criteria for anxiety disorders, or at least most of them in the DSM 5TR. So let's talk a little bit about anxiety disorders in general. When we're talking about anxiety disorders, we need to remember that fear and anxiety may be expressed as fighting, agitation, tantrums, fleeing, freezing, fawning, clinging or withdrawal, or what I call the final F, which is politely forget about it because people just don't have any more energy left, so they kind of withdraw. Anxiety disorders differ from each other regarding the types of objects or situations that cause fear, anxiety or avoidance behaviors and the associated beliefs. Anxiety disorders represent a response that is not developmentally, culturally, or I also add contextually normative in terms of intensity or duration. So when we're looking at what somebody is anxious about, we're, we want to examine obviously culture and development. Something that a five year old is afraid of is not necessarily going to be the same thing that a 25 year old is afraid of. We also want to look at context though. Something that you're afraid of in one context you may not be afraid of in another. Like for children, being around strangers may not be stressful for them when they are at home or when they're at school and somebody comes in to do a presentation versus when they are alone and they don't have a caregiver around. Interestingly, from August 2020 through December 2020, the percentage of adults reporting symptoms of an anxiety disorder rose from 31.4% to 36 point. Now, when you go through the DSM and you start adding up the prevalence of these anxiety disorders, it is really hard to get to a number anywhere close to 36.9%. So the numbers in the DSM and the numbers in the National Health Survey don't seem to jibe very well. We also have to remember that during 2020 we were at the beginning of the pandemic, so there was obviously more anxiety. You would expect that. But even the 31% that it was prior to 2020 seems to be higher than what is identified in the dsm. So I think that's interesting. The anxiety chapter in the DSM 5TR, just like in the DSM 5 is arranged in order of diagnoses which appear in so Separation Anxiety Disorder appears first and Generalized Anxiety Disorder is down a little ways, whereas you might expect some of the quote, more common disorders to be first. But that's not how the DSM is arranged. However, in this presentation I did put generalized anxiety first. When we talk about generalized anxiety, we, we're talking about excessive anxiety most days for six or more months. And the anxiety is about a variety of things. It's not just about one particular thing like health or an individual or a phobia. It is about a variety of things. The worry, in addition to being excessive for the person's developmental age, culture and context, the worry is difficult to control. The anxiety or the feeling of anxiety is associated with three or more symptoms in adults or one or more symptoms in children. Feeling restless or feeling keyed up or on edge, easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension or sleep disturbance. Now I want you to think about it. Anxiety is part of the fight or flight response. So we would expect somebody experiencing anxiety, would it be experiencing symptoms of HPA axis activation or activation of the threat response or stress response, whatever you want to call it. So we would expect all of these symptoms or any of these symptoms because when the fight or flight system is engaged, the body is not focused on higher order processing or memory or the concentration. It's focused on self preservation and protection. The person becomes more hyper vigilant because they are trying to protect themselves from threats. They're not able to relax enough to get good quality sleep because guess what, they are keyed up. They're scanning for those threats. Muscle tension. And I've mentioned in other videos when I used to play tennis, my coach always used to say don't stand flat footed on the baseline because it takes more time and it's harder for you to run and spring into action to where that ball is going to be. Now that is not a threat per se, but the same thing is true for people with anxiety disorders. When you are, when you've got that muscle tension, it's kind of like standing on your toes on the baseline in tennis. You are primed and ready to go and it makes it easier to theoretically fight or flee. These symptoms have to cause clinically significant distress. People can have subclinical anxiety disorder where they have a lot of worry about a variety of things, but it is either not excessive for, for what they're worried about or it doesn't cause them clinically significant distress. Overall, they report a decent quality of life. It doesn't interfere with functioning in major areas of their life. And generalized anxiety disorder as well as all of the disorders are not better explained by a medical, mental, or substance use disorder. And we're going to talk in the end about differential diagnosis of the anxiety disorders in general, because there's a lot of overlap between the symptoms as well as the differential diagnosis and comorbidities for anxiety disorders. Remember, the difference is often what the person experiences anxiety and the cognitions associated with that. Diagnostic Features of Generalized Anxiety Disorder well, this section, as with most of the sections in the anxiety chapter, pretty much just recapitulated the diagnostic criteria, and it elaborated a little bit. One interesting feature is that for generalized anxiety disorder, they noted that adults tend to worry about general life things like paying bills and getting a promotion or what's going to happen with this or that or what's going on in the world. Kids tend to worry about their competence, like performing at school or their ability to be competent in relationships. Sometimes they worry about disaster. Now, with coming off of the pandemic, we can probably add that too. But other disasters like hurricanes and fires and floods and those sorts of things can prompt a lot of worry in children. And punctuality, interestingly enough, some children become very concerned about being punctual. And so it's interesting to note that there is a difference in what they worry about, which makes sense because adults have different responsibilities than kids do. And you notice that with the exception of disaster, a lot of these worries revolve around the primary life areas or functions of the person. You know, kids aren't worried about paying bills or maintaining or parenting or some of the things that adults worry about. Associated symptoms well, let me talk about disaster really quick. I'm trying not to go too far off the rails today because we've got a lot to cover. But it's important to recognize that children have a difficult time understanding prevalence and likelihood of things. So when there is a disaster such as, you know, we've had several in middle Tennessee over the past two years. And a child watching the news or hearing about the news may not understand how close or far away that disaster was or the likelihood of it recurring. Adults are better able to understand, you know, it's a 1, 100 year flood or there's the chances of it happening again are, you know, whatever the probability is, depending on what you're talking about. Children don't understand that. They see it on the news. It feels like since it's on the news, it's kind of in their house. So it feels like it's right in their space. And it's hard to know when it's going to end or when it's going to happen again, which can prompt them to have a lot more worries about disasters. Parents can help by explaining some of the things to them and explaining to children the probability of another disaster occurring and you know, how that they're safe right now and the steps that they can take. It won't do everything. But it is important again to recognize children's different cognitive abilities compared to adults associated symptoms with generalized anxiety disorder other somatic symptoms that are not as intense as those seen in panic disorder. So we will also see potentially heart racing, clammy skin, rapid breathing, other things and an upset stomach that aren't specifically indicated in diagnostic criteria but we know happen when that fight or flight response is kicked off the prevalence Remember I said if you add up the prevalence of all these anxiety disorders, you're going to be hard pressed to get anywhere close to 31%. And according to the DSM 5 trip, between 1% of adolescents and 3% of adults in the US experience generalized anxiety disorder. According to the national center on health statistics in 2019 now that was before the pandemic, 15.6% of adults experienced symptoms of generalized anxiety disorder in the priority two weeks. The development in course the mean onset is rarely before adolescence and is. I'm sorry, the mean onset is 35 and rarely before adolescence. So this is one of the disorders that actually has a much later onset than other disorders, which I did find that to be somewhat interesting. Now we'll move on to separation anxiety. Separation anxiety is the first disorder in the chapter because it tends to be the one that presents earliest and it can be diagnosed as early as preschool. Separation anxiety is characterized by developmentally inappropriate, excessive recurrent anxiety about separation from major attachment figures. In order to be diagnosed, the person has to have three or more symptoms. It can be diagnosed in childhood, it can be diagnosed in adulthood. If it's diagnosed in adulthood, you do not have to have a childhood onset of separation anxiety. It actually can have an adult onset. So that is something to remember. Symptoms 3 or more distress due to or in in in anticipation of separation from home or from major attachment figures Anxiety about losing a major attachment figure or about possible harm to them Anxiety about something bad happening to the person the patient which would cause them to be separated from an anxiety from an attachment figure so they have fears about something happening to the attachment figure causing separation and fears about them something bad happening to themselves causing separation a reluctance or refusal to go out or away from home because of fear of separation. Now generally this is leaving home and separating from that attachment figure but in some cases, it can include even being reluctant to leave the house with the attachment figure because they're afraid that when they're out there they may get separated. Now think how this might occur if there was a child who happened to be at a carnival and got separated from their caregiver. That might prompt future fears of separation when in public places, fear of or reluctance to being alone or without major attachment figures, refusal to go to sleep without being near a major attachment figure, nightmares about separation, or physical complaints in reaction to or in anticipation of separation. So they have those physiological symptoms of anxiety. Now note here, they keep talking about major attachment figures because remember, this can be diagnosed in adulthood. We're not talking about the primary attachment from infancy. We're talking about the person's current major attachment figure, whether that be their significant other, their parent, whomever that happens to be. The fear, anxiety or avoidance is persistent, lasting at least four weeks in children and adolescents and typically six months or more in adults. And you'll find that's a common theme where a lot of these situations or conditions have to last six months or more and be causing clinically significant distress for six months or more in order to rank a diagnosis. Although the symptoms often develop in childhood, they can be expressed throughout adulthood. It can be diagnosed in adults in the absence of a history of childhood separation anxiety disorder. And as I said, it causes clinically significant distress or impairment in one or more areas of functioning. The diagnostic features section repeats the diagnostic criteria with some elaboration and examples. It's a pretty straightforward diagnosis in terms of development and course. The onset of separation anxiety can be anytime from preschool through adulthood, but generally before the age of 30. So you can have diagnoses of separation anxiety up in through the 20s. There may be periods of exacerbation and remission, although most child onset cases do not experience ongoing clinically significant impairment. I thought that was kind of interesting. Associated features. Now these are not diagnostic criteria. These are features that are associated with separation anxiety but didn't rank in the diagnostic criteria. Sadness or apathy? Well, if somebody is perpetually anxious, that HPA axis is going to down regulate some which may contribute to apathy. If they are perpetually anxious, they may also start feeling hopeless and helpless, which is associated with feelings of sadness and depression. They may have difficulty concentrating well, the mind is not focused on concentration. If it's in a perpetual state of fight or fleet, there may be social withdrawal, just stepping away from everything because they don't have the energy to engage with others because the anxiety Is so pervasive in older children. You may see homesickness or pining when they are away at camp or something like that. Now, obviously, a lot of children who don't have separation anxiety disorder Experience homesickness when they're away at camp for the first time. However, this is also associated with separation anxiety. The child may ex or the person may exhibit anger or aggression towards separators. So anybody who's causing a separation between the patient and their major attachment figures may provoke anxiety, provoke anger. Perceptual disturbances. Now, these are not hallucinations. These are when a person is alone, for example, at night, and they feel like somebody's watching them, or they think they see something moving in the shadows, it's not really there. And by turning on the light so there's no more shadows, you know, that goes away. It's not a persistent hallucination that the person is experiencing. But perceptual disturbances are more common in children than they are in adults, and we want to make sure we don't mislabel that as something related to a psychotic disorder. Children with separation anxiety tend to be described as demanding, intrusive, and in need of constant attention, according to the dsm. Now, I would argue, when we get down a little further, that this may be true of all people with separation anxiety. Adults may appear dependent and are likely to contact their major attachment figures throughout the day and track their whereabouts. They are also often overprotective as parents and pet owners. Interestingly enough, the DSM did mention pets where the person with separation anxiety may be excessively concerned about knowing where their pet is at all times. The prevalence of separation anxiety in children is approximately 4%, and in adolescents and adults, it ranges from 1 to 2%. In the culture section, the DSM talked about the importance of differentiating separation anxiety disorder from the high value some cultural communities place on strong interdependence among family members. Specific phobias is the next in the line of disorders we're going to talk about. And a specific phobia is pretty straightforward. There's a marked fear or anxiety about an object or a situation. About 75% of people that have one phobia have more than one phobia. And I think if you think about it, even if it doesn't rise to the level of being a diagnosable phobia, you can think about, if you have one, what we'll call irrational fear, you probably have a couple of others. When I started to think about it, I'm like, yeah, I have. I have A couple in there. The stimulus almost always produces an immediate fear response and is actively avoided. The fear is disproportionate to the threat, persists for, guess what, six months or more, and causes clinically significant distress. And I have this bold and italicized because it's important to remember that having a fear. And I've talked in other videos about my fear of bridges. I also have a fear of enclosed spaces. I hate, you know, those little water tubes and tunnels and things that make me feel closed in. Does it cause me clinically significant distress or cause me to have to alter my life to get around it? No. So it doesn't rise to the level of specific phobia. A lot of people have fears that may not have a basis or the fear may be disproportionate to the threat. In reality, we recognize it, but it doesn't cause us clinically significant distress. So it would not be diagnosable as a specific phobia. The specific phobia is not better explained by another mental disorder. And I'm thinking here more obsessive compulsive disorder. But in the differential diagnosis list on the anxiety disorders, there were a lot. So we're just going to go through all of those at the end. The diagnostic features again for specific phobias was pretty much a restatement of the diagnostic criteria. Associated features, interestingly enough, for some people, are arousal. Well, that makes sense. When the HPA axis kicks off, a lot of people have a increased heart rate, sort of a panic sort of feeling about them. Not to the level of a panic attack necessarily, but they have that aroused state in preparation for fight or flee. Other people may have what they call a vasovagal response in which their heart rate decelerates, their blood pressure drops and they may faint. My grandmother used to do this. Oh my gosh. And it wasn't necessarily hers, wasn't phobia related. But when she would get startled or surprised, she would fall out. And for the longest time the doctors couldn't figure out exactly what was going on. But ultimately my guess would be it had something to do with with anxiety or generalized anxiety. The prevalence of phobias is between 8 and 12%. It peaks in adolescents at 16%. So 16% of adolescents have specific phobias. The development in course it usually develops prior to age 10 or after a trauma. And the presence of phobias is a risk factor for neurocognitive disorders in older adults. Why is this again? We've talked in other videos about how hyperactivation of that stress response system keeps levels of glutamate and norepinephrine and stuff high in the brain, which causes neurodegeneration, which can lead to neurocognitive disorders. Additionally, because of social withdrawal and avoidance and restructuring of their daily lives to avoid the phobic stimulus, there tends to be less stimulation for the person with specific phobias, which may also lead to a decline in what they call cognitive reserve and social anxiety disorder. In social anxiety disorder, there's a marked fear of social situations in which one might be judged. So you've got generalized anxiety, which is anxiety about a lot of things over the course of at least six months. We have specific phobia, which is obviously something specific like enclosed spaces or spiders or snakes. Separation anxiety, which is anxiety or fear of being separated from an attachment figure. And then social anxiety, which is fear from being in situations in which one might be judged. With children, the symptoms have to be present not only in relationships with adults, but in relationships with their peers. It's natural for children to be somewhat anxious if they're interacting with adults. If they're having the same anxiety when they're interacting with their peers, then that's really what we're going to look for for a trigger. The person has a excessive fear of being embarrassed, rejected, or offensive. And the offensive seems to be increasing in popularity or not popularity in commonality very quickly with Twitter and Facebook and TikTok and all these other things and trying to be politically correct. A lot of people have developed a level of social anxiety. Maybe not to the level of being a disorder, but definitely a level of social anxiety because they fear not saying the right thing, because they fear being canceled. Social situations almost always trigger the anxiety and social anxiety disorder. Social situations are actively avoided, endured with intense fear, and the level of fear is disproportionate to the potential consequences. People may have a high level of fear and anxiety before going out and giving a performance in front of 10,000 people. The level of anxiety for that would probably be different than giving a speech in front of six classmates. You see the difference here? But a person with social anxiety disorder, they would have that same level of fear in front of six people they knew, as opposed to 10,000, that they didn't. Persistence again for six months or more causes clinically significant distress and is not due to another medical, mental health or substance related condition. There is a note that social anxiety disorder can be performance only. And you do want to specify that if it only has to do with giving speeches Performing sports, music, anything like that. The diagnostic features section gave further examples of the symptoms that were identified in the diagnostic criteria. Associated features with social anxiety, the person may be passive or shy. They may want to kind of blend into the wall. They may be somewhat withdrawn because they don't want to be out there in the limelight. They don't want want to be in this position where they fear being judged. On the other end of the spectrum though, there's a proportion of people with social anxiety disorder who are highly controlling of situations and they may try to control the conversation and control other people in the situation in order to avoid feeling out of control. Use of substances, substance use, misuse or abuse is often associated with people with social anxiety disorder. And I have parenthetically here, liquid courage. That's what we used to call it back in the day. I don't know if it's what they still call it. But using substances to help temporarily allay anxiety. Interestingly, as alcohol leaves the body, people tend to have an enhanced anxiety response. So using alcohol prior to a social situation may actually end up causing more problems for some people. But that's, that's up to them. Additionally, you may see a worsening of physical illness symptoms such as tachycardia or increased tremor. And in people with social anxiety disorder. So if they already have something that causes a tremor or a tic, that may get worse. If they already have something that causes tachycardia, that may get worse in situations in which they fear being judged. Now I have here increased pain that's not identified in the DSM 5tr. However, we know that hyperactivation of the HPA axis contributes to ultimately development of systemic inflammation and worsening of autoimmune disorders. So I would be interested to see what the actual numbers are for that. And no, I could not find any research that actually compared the rates of increased pain with social anxiety. Specifically prevalence. 7% of people in the United States experience social anxiety disorder. Now brace yourself, this is not a typo. 2.3% of people in Europe can be diagnosed with social anxiety disorder. So what is that? A third what's different in the United States that is contributing to significantly higher rates of social anxiety and fear of being judged and fear of offending people. Just saying. Additionally, social anxiety disorder does tend to be highest in non Hispanic white whites. So what is unique about non Hispanic whites in the US I'll leave you to talk about that and panic disorder. People with panic disorder experience recurrent unexpected surges of intense fear or discomfort that peaks within minutes and has the accompanying four plus plus symptoms. Now I have bolded and italicized unexpected here. There are expected panic attacks when you're in a situation in which you've had a panic attack before. When there is a known trigger for the panic attack, that's a expected panic attack. That doesn't count towards our diagnosis here, which I don't know, seems a little strange. But okay. The panic attacks have to be unexpected, that is they come from out of the clear blue and the panic attacks need to be characterized by four or more of the following symptoms. Palpitations, which is when it feels like your heart is like fluttering pounding heart or tachycardia, which is racing heart, sweating, trembling or shaking a feeling of shortness of breath or smothering. You just can't don't feel like you can breathe feeling like you're choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, lightheaded or faint chills or heat sensations, numbness or tingling Derealization, which things just don't feel real. You feel like you're kind of in a in a dream or depersonalization, you don't feel like you're part of your own body anymore. Fear of losing control or going crazy and fear of dying. Now I'll mention even though it's pretty obvious many of these symptoms are also symptoms of a heart attack, it is important if you are a clinician not to assume that somebody who is experiencing a panic attack it's just a panic attack and to dismiss it. It's important to take every panic attack seriously when somebody's experiencing it and work with their medical provider to help them differentiate between what's a panic attack, how do I know when I'm having another panic attack versus versus how do I know when I need to go to the ER and their doctor will work with them on that. Culture specific symptoms for panic may include tinnitus or ringing in the ear, neck soreness, headache, uncontrollable screaming or crying. Interestingly, even though these are culture specific symptoms, the DSM said those don't count toward the required four plus symptoms. So additionally, at least one of the attacks, unexpected attacks, has been followed by one month or more of both of the persistent concern or worry about additional panic attacks or their consequences and a significant maladaptive change in behavior related to the attacks, avoidance of situations where you think they might happen again, or ritualized or superstitious behavior or extreme behavior like changing your diet completely or doing something extreme in order to try to prevent the attack so the unexpected attack happens and then for the next month or more, both of those persistent concern about it happening again and significant maladaptive changes in behavior are occurring. It has to cause clinically significant distress and it's not due to another mental, medical or substance use disorder. Interestingly, for panic attack there were no specifiers but in the diagnostic features it did note that panic attacks can be full means four or more symptoms or limited symptom. So it doesn't meet all, it doesn't meet four symptoms or more, but the person's clearly having a panic response. If the person has never had a full blown panic attack, four or more symptoms, then you would not diagnose panic disorder. Frequency can be relatively regular, like one per week. Or it can come in bursts where they have multiple really close together. Then they go weeks, months or even years without having them. And then they have another burst of panic attacks. And there could also be instances where they just have a panic attack and then they may go for a couple of years or more before they have another one. It still qualifies as panic disorder. There is no code for remission of panic disorder. And the expectation is unfortunately that if somebody has had a panic disorder at some point, they probably will have another panic attack at another point. Remember that expected panic attacks and occur with known triggers and there are many culture related diagnostic issues due to expected triggers. So if you read through the culture related diagnostic issues section of the DSM 5TR, you will find that they talk about a lot of culture bound triggers that can cause a panic attack in people. Associated features. People who have panic attacks panic disorder may also have intermittent anxiety about health or mental health. They tend to be more somatically sensitive. That means they're more aware of what's going on in their body. Well, that makes sense if you've already had your body kind of go haywire on you once. Makes sense that you would be a little bit more hypersensitive to it happening again. They may have increased anxiety about ability to tolerate daily stress there. A lot of times this may stem from the fear of if they experience too much stress, it'll trigger another panic attack and they may have more extreme behaviors to control panic. The prevalence of panic disorder is about the same 2% to 3% in both the US and Europe. The only disorder that had a marked difference between the US and other countries, interestingly enough, was social anxiety disorder. The development of panic disorder, the median age is 20 to 24 in the US and 32 worldwide. So that is a little bit divergent you know, the prevalence that the number of people that experience it worldwide is pretty comparable. But the median age for panic disorder is much younger in the US than other countries. Additionally, they speculate that older adults may attribute symptoms to medical conditions. So they may be underrepresented in the prevalence rates because when they're having these panic symptoms, they're attributing them to medication, side effects or other health conditions that they already have. So let's talk about some of the risk and prognostic factors for anxiety disorders in general. Anxiety disorders often develop after a life stress. This could be a death, a severe illness, a disaster, a big move, becoming a parent, or adverse childhood experiences or ACEs. That's just to name a few. Obviously that those aren't all of the causes. But I think it's interesting that becoming a parent was in there as a life stress that often triggers the development of anxiety disorders. I mean, I'm a parent myself, I can see how that could happen, but it's not something that I had really considered in the past as a risk factor for the development of anxiety disorders. People who've been bullied have an increased risk of developing anxiety disorders. Heritability of anxiety disorders ranges between 30 and 75%. I found that interesting, but they didn't explain in any of the diagnoses whether they were looking at twins that were raised in the same household or twins that were raised in different households. If they're raised in different households, it gives more credence to a genetic component. If they're raised in the same household, they then they're exposed to the same psychosocial environmental stressors. Both of them are. So I don't know what the actual data is on that. People with negative affectivity, they tend to be more brooding, more depressed, more irritable, people who are more self conscious, people who ruminate more. Also all of these kind of are combined, often referred to as neuroticism, they are at higher risk for the development of anxiety disorders. Attentional bias to threat was noted in generalized anxiety disorder as being an associated feature. But research actually shows that people with any anxiety disorder tend to have a stronger attentional bias to threat, which means they tend to be more hyper vigilant, they tend to be more aware when there's threats in the environment. Anxiety disorders by and large tend to be much more frequent in women than in men. Interesting. Not sure why. Again, my assumption is this is people who are biologically female and it seems to be consistent across cultures. Therefore, I am wondering what the genetic predisposition might be that may cause this. It seems like it's less about environment and shaping and behavioral training and more about a physiological response. But additionally and these last two were not in the DSM but I did a PubMed search for risk factors for anxiety disorders and those who have a more external locus of control that means they believe that things happen in the world by fate, by chance. There's not a they don't have a whole lot of control or ability to change what's going on, destiny is preordained, etc. People with that outlook who have a more external locus of control tend to have much higher rates of anxiety and depressive disorders. And again not in the DSM but in the in PubMed in the literature. People who have a lack of emotional support also tend to be at greater risk for development anxiety disorders seems pretty self explanatory in terms of suicidal thoughts. Anxiety itself increases risk of suicidal thoughts. All of your anxiety disorders carry with them an increased risk of suicidal thoughts. People with separation anxiety have that generalized anxiety related increased risk. But people with specific phobias, interestingly enough have an increased transition from ideation to attempt. In a study that was cited in the DS well mentioned in the dsm but they didn't say what the study was. They looked at adults and they found that up to 30% of people, people who had their first suicide attempt, it was related, they also had a specific phobia or it was related to that specific phobia. So that's 30% is a big number when we're, especially when we're talking about suicide attempts and suicidal ideation. If you have somebody with specific phobia we often downplay that because we think it's just a fear of this or a fear of that. But that fear can feel very limiting and oppressive to a lot of people. And again 30% of them, 30% of people who have attempted suicide also had specific phobia. Functional Consequences Now I could go on a diatribe about the functional consequences of anxiety disorders. The DSM didn't have much to say about it. So let's talk about some of these limited independent activities. This is especially true in agoraphobia and separation anxiety. People who are afraid of leaving the house for fear of being separated from their significant other or for fear of being separated from their safe place. And people who have social anxiety, who fear being in social situations may have a lot of restrictions on their life activities and limited activities that they feel safe or comfortable doing by themselves. Not in the DSM.5tr. But in the literature also the functional consequences of impaired relationships. People with anxiety disorders, maybe because of their restrictions on life activities and their potential need to know where people are and their separation anxiety, etc. A lot of times people with anxiety disorders struggle in their relationships because it can feel overwhelming to the partners. As I mentioned earlier, people with anxiety disorders have higher rates of autoimmune issues. Continuous or excessive levels of stress hormones contributes to systemic inflammation which will trigger depression or is associated with triggering depression and associated with worsening of autoimmune conditions and obesity. I thought this one was interesting, but it makes sense when you look at it. People with anxiety disorders, who often are restricted in their life activities, may feel worn down and exhausted from being stressed out all the time, may not have a lot of energy to do other stuff, tend to be more prone to develop obesity. So that's an interesting functional consequence. Now, differential diagnosis. I told you there was a laundry list of them. Generalized anxiety disorder in gad, excessive anxiety is about a variety of things for at least six months. Separation anxiety, the worry or the anxiety is about separation from the attachment figure. Okay, that's pretty clear. Agoraphobia, the fear is about being trapped or helpless in situations in which escape is difficult. The fear surrounds being away from their safe place, not being away from a person. They want to be in a place where they feel feel safe. And it needs to be not specific to one setting. So being trapped or helpless in a situation, I give the example of an MRI, those closed MRIs, oh my gosh, I can't stand them, I'm terrified of them. But that is specific to one setting. And I'm not afraid to leave the house for fear of being trapped or helpless in a situation. Social anxiety, the anxiety is about being judged negatively and illness anxiety. And this illness anxiety actually falls under the somatic disorders. But illness anxiety, the worry is about the illness, not separation, judgment or being away from your safe place place. So that's differential diagnosis of your basic anxiety disorders in terms of other disorders, because there's that criteria not better explained by another mental health or medical disorder. Psychotic disorders. People who have hallucinations and delusions may also have anxiety, but their worry or fear surrounds hallucinations or delusions and is not not reversed by context or the presence of an attachment figure. So a person with psychotic disorders, if their major attachment figure shows up, that doesn't help them feel more comfortable. If they turn on the light to eliminate the shadows, that doesn't make them feel more comfortable. And the hallucinations Are not due to or the with psychotic disorders, the hallucinations are not due to something that are actually present. Eating disorders Avoidance behavior is only related to food and food related cues. According to the dsm, however, one of the main criteria for your eating disorders is a excessive fear about weight, shape and size. And it's important to recognize that because people with eating disorders may avoid mirrors and scales and food, obviously certain foods and that could all be related to their eating disorder. Body dysmorphia Dysmorphic disorder the fears are only related to people being offended by a particular perceived flaw. In obsessive compulsive disorder, the fear is an object or situation as a result of obsessions. So if they start thinking about germs on their hands and they keep thinking about it, then they start developing a fear of getting germs on their hands. So the fear becomes the object of their obsessions or their obsessions turn cause what they're thinking about to become a fear. In autism spectrum, the person lacks sufficient age appropriate relationships and social communication capacity. In anxiety disorders, the person often has has sufficient age appropriate relationships and can communicate socially socially understand others just fine. What we're looking at in anxiety is fear of being judged. Conduct disorder. School avoidance is a very common symptom of conduct disorder. But school avoidance is not due to worry or fear. In conduct disorder, school avoidance and conduct disorder is due to not wanting to be told what to do. Thank you very much. In oppositional defiant disorder, the oppositional behaviors occur in response to multiple situations, not just separation or situational anxiety, not just in response to an anxiety provoking threat. So if somebody has separation anxiety, they may become oppositional about leaving their major attachment figure. If somebody has social phobia, they may become oppositional about engaging in situations that would prompt that anxiety. Or if they have a specific phobia, maybe they're afraid of snakes. They may become oppositional about doing something like going hiking because they are actively avoiding that phobic stimulus. If they are actively avoiding a phobic stimulus or an anxiety provoking stimulus, it's probably not oppositional defiant. Now you can have both. You can have them co occur, but you do want to differentiate what is the cause of the behavior. Prolonged grief is characterized by intense longing and yearning for the deceased, not fear of separation from them. Now you can have prolonged grief and separation anxiety co occur. You can have somebody who develops a fear of separation from others after a particularly particularly traumatic loss. That can happen. But you do want to differentiate and diagnose appropriately. And in depression and bipolar. A lot of people who are in a major depressive episode may have reluctance to leave home, but this is due to lack of motivation and energy to engage and apathy. It's not due to fear of something out there. They just they don't care or they don't have the energy. Dependent personality. The person with dependent personality relies too much on others. It's not that they fear their safety or loss of attachment figures. An avoidant personality disorder, broader avoidance patterns and a pervasive negative self concept differentiate avoidant personality disorder from anxiety related disorders. Not in the DSM I'm bringing up for differential diagnosis. Anxiety is related to apprehension and vigilance of physiological sensations and may have an onset after a concussion. POTS is postural orthostatic tachycardia and when people have it, when they stand up, their heart rate will jump 30 or more beats just from when they move from sitting to standing and that can feel very scary. They can also get lightheaded, they can faint. Hypoglycemia can also produce symptoms of anxiety and sweating and agitation in people. So we want to differentiate diagnosed. I believe I read a study that more than 25% of Americans are pre diabetic and don't know it. Comorbidity Anxiety disorders are comorbid with each other, so if you have one you probably have some of its buddies. It's also comorbid with depression, bipolar, ptsd, prolonged grief, obsessive compulsive disorder, obsessive compulsive personality disorder, somatic symptom related disorders. So any of your physical symptom disorders, antisocial personality, specifically social anxiety, commonly may co occur with antisocial oppositional defiant disorder and substance use disorder. Physically autoimmune diseases may increase the risk of psychiatric disorders partially due to thyroid dysfunction. When that HPA axis goes offline, it also affects the functioning of the thyroid. Cardiovascular issues like supraventricular tachycardia can also be misdiagnosed and is often misdiagnosed for panic disorder. Hormone level fluctuations, especially extreme hormone fluctuations, can contribute to anxiety related symptoms. High levels of estrogen or testosterone, nutrient deficiencies or toxicities. So too much or too little of certain vitamins and minerals can also cause anxiety like symptoms. Environmentally, poverty is a high risk factor for the development of anxiety disorders for obvious reasons and socially adverse childhood experiences that include abuse, neglect, abandonment or mental illness in the household are all risk factors for the development of anxiety disorders later in life. Anxiety disorders represent an anxiety response that is developmentally, culturally and contextually excessive. It's persistent or recurrent and causes clinically significant distress. So that differentiates it from people's run of the mill anxiety, if you will. Multiple anxiety disorders are common. This presentation covered some of the more common anxiety disorders, but did not cover selective mutism, substance induced anxiety, or other specified and unspecified anxiety disorders. Finally, it is important to rule out or diagnose comorbidly any physiological causes of anxiety symptoms, including cardiovascular issues, pots, or diabetes.