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     What’s New in the Classification of Anxiety Disorders?
      Fast Forward to Changes within the Diagnostic and Statistical Manual of Mental Disorders – 5 (DSM-5)
      by Colleen Cummings, Ph.D.,   Clinical Psychology Associates of North Central Florida
The diagnosis of Anxiety Disorder, Posttraumatic Stress Disorder, Childhood Anxiety Disorder, Separation Anxiety Disorder, Fears or Phobias, and Obsessive Compulsive Disorders has undergone change in the transition from DSM-IV and DSM-IV TR to DSM-5 published in May 2013.  This article provides an overview of the changes in the classification and diagnostic criteria.
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We may often question “What is in a Name?”   The American Psychiatric Association periodically updates what various mental disorders are called, what larger categories they are subdivided into, adds or proposes new disorders and committees fuss about how many and what symptoms qualify for a diagnosis.  While people do not change as fast at the latest revisions of tests or classification symptoms, revisions in have important implications for insurance determinations, qualifications for benefits, and research concerning effective treatment and outcomes.
Changes in the diagnostic criteria for the anxiety disorders from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; American Psychiatric Association, 2000) to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association, 2013) may seem relatively minor. Still, even small changes can impact diagnostic decision-making of a psychologist or psychiatrist, so we detail these changes below.
First, slight changes have been made to Separation Anxiety Disorder (SAD; 309.21). In DSM-IV-TR, this disorder was classified under “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.”  DSM-5 now classifies Separation Anxiety Disorder under the “Anxiety Disorders” category.   Further, while DSM-IV-TR specified an onset before age 18, DSM-5 now does not specify any age of onset requirement, nor does it specify an “early onset” form of Separation Anxiety Disorder. DSM-5 does note that in order to meet criteria, fear, anxiety, or avoidance must last at least 4 weeks in children and adolescents and typically 6 months or more in adults. Thus, in DSM-5 Separation Anxiety Disorder is no longer conceptualized as a disorder that must onset in childhood, although a much longer duration is expected for a diagnosis in adulthood. Within the differential diagnosis section, distinctions are now drawn between Separation Anxiety Disorder and some personality disorders (dependent personality disorder and borderline personality disorder).
Selective Mutism (312.23) was also classified in DSM-IV-TR under “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,” and is now classified under the general category of DSM-5 Anxiety Disorders. Otherwise, no differences in diagnostic criteria are noted. This is a disorder, in which a child, adolescent, or adult will only speak to select few people.
DSM-V Specific Phobia (300.29) criteria now no longer require that individuals over age 18 years recognize that their anxiety is excessive or unreasonable, although DSM-5 specifies that the fear is out of proportion to the actual danger posed by the feared object. The duration criterion has changed from “the duration is at least 6 months” to “the fear, anxiety or avoidance is persistent, typically lasting 6 or more months.” Therefore, the duration of symptoms for 6 months seems to be no longer a stringent requirement, but rather a guideline. Further, while DSM-IV-TR only applied the duration criterion to individuals under age 18, now it applies to everyone.
In DSM-5, DSM-IV-TR Social Phobia is referred to as Social Anxiety Disorder (300.23). As with the criteria for Specific Phobia, the duration criterion now reflects a less stringent guideline of “the fear, anxiety, or avoidance is persistent, typically lasting for six months or more. Although DSM-5 still specifies that children must demonstrate social anxiety with peers (rather than just adults), it is no longer stated that “in children, there must be evidence a capacity for age-appropriate social relationships with familiar people.” As with specific phobia, DSM-IV-TR requires that “the person recognizes that the fear is excessive or unreasonable,” whereas DSM-5 requires that “the fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.” Also, the subtypes of Social Anxiety Disorder have changed: where DSM-IV-TR specified “generalized” social anxiety disorder (when fears include most social situations), DSM-5 specifies “performance only” social anxiety (when fear is restricted to speaking or performing in public).
Prior DSM-IV TR diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two separate diagnoses: Panic Disorder (300.01) and Agoraphobia (300.22). Panic Disorder specifies “recurrent unexpected panic attacks,” which have the same criteria as a DSM-IV-TR Panic Attack. Interestingly, DSM-5 describes the use of a Panic Attack Specifier when panic attacks occur within the context of another anxiety disorder.  This should be noted within the diagnosis (e.g., Social Anxiety Disorder with panic attacks). It is also clarified that culture-specific symptoms are not considered symptoms of a panic attack.
Agoraphobia has new criteria; mainly, marked fear or anxiety regarding two or more of the following situations: (a) using public transportation; (b) being in open spaces; (c) being in enclosed places; (d) standing in line or being in a crowd; (e) being outside of the home alone. The individual fears or avoids these situations due to thoughts that escape might be difficult or help might not be available in the event or developing panic-like symptoms or other incapacitating or embarrassing symptoms. Further, the agoraphobic situations almost always provoke fear or anxiety. The situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety, and the fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. The fear, anxiety, or avoidance is persistent, typically lasting for six months or more, is not better explained by the symptoms of another mental disorder, and causes significant distress or impairment in social, occupational, or other important areas of functioning. Agoraphobia no longer requires individuals over age 18 to recognize that their anxiety is excessive or unreasonable. DSM-5 states that agoraphobia is diagnosed regardless of the present of panic disorder, and when both disorders are present, both agoraphobia and panic disorder are diagnosed.
Otherwise, Generalized Anxiety Disorder (300.02), Substance/Medication-Induced Anxiety Disorder, and Anxiety Disorder Due to Another Medical Condition (293.84) have not changed.
For those situations when individuals present with symptoms characteristic of an anxiety disorder with distress/impairment but do not meet full criteria of any disorder, clinicians no longer diagnose DSM-IV-TR Anxiety Disorder Not Otherwise Specified (300.00). Instead, they must code either DSM-5 Other Specified Anxiety Disorder (300.09) or Unspecified Anxiety Disorder (300.00). For other specified anxiety disorder, the clinician communicates the specific reason criteria are not met for any anxiety disorder within the diagnosis. Examples include “limited-symptom attacks, generalized anxiety not occurring more days than not, and "atauq de nervious.” Unspecified anxiety disorder can be used when the clinician chooses not to specify why criteria are not met for an anxiety disorder, for instance, when sufficient information is not available to make a diagnosis.  
Obsessive Compulsive Disorder (OCD, 300.3) is no longer classified under the Anxiety Disorder section, and now is classified within a new separate category, “Obsessive Compulsive and Related Disorders.” DSM-5 OCD diagnosis now includes specifiers regarding level of insight. These include: (1) with good or fair insight; (2) with poor insight; (3) with absent insight/delusional beliefs. Further, DSM-5 no longer requires that the person recognize that the obsessions or compulsions are excessive or unreasonable. DSM-5 does note that young children may not be able to articulate the aims of their compulsions.
Changes in DSM-V criteria for Posttraumatic stress disorders have generated some controversy.  Posttraumatic Stress Disorder (PTSD, 309.81) is now classified within the new “Trauma- and Stressor-Related Disorders” category. PTSD has undergone some changes. First, DSM-5 describes the trauma as “exposure to actual or threatened death, serious injury, or sexual violence.” This can include (1) directly experiencing; (2) witnessing the event as it occurred to others; (3) learning that the traumatic event occurred to a close family member or friend; or (4) experiencing repeated or extreme exposure to aversive details of the event (but not applied in the case of media, television, movies, or pictures). The DSM-5 intrusion symptoms line up well with the DSM-IV-TR re-experiencing symptoms. The DSM-5 diagnosis of PTSD now only has two avoidance symptoms: (1) avoidance of distressing memories and (2) avoidance of external reminders compared with the 7 symptoms outlined in DSM-IV-TR. Some of the DSM-IV-TR symptoms of avoidance are moved to a category that describes negative alterations in cognitions and mood associated with the traumatic event. New symptoms in this category include (1) persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; (2) persistent, distorted cognitions about the cause or consequences of the traumatic event that lead the individual to blame himself/herself or others; (3) persistent negative emotional state. The symptoms of increased arousal are relatively similar between the DSM-5 and DSM-IV-TR PTSD criteria. DSM-5 does not appear to specify if the disorder is acute versus chronic, but it does now specify if dissociative symptoms are present. Importantly, DSM-5 now describes PTSD for children 6 years and younger within a separate section (page 272-274).
Overall, DSM-5 we see some changes in duration and onset criterion of the anxiety disorders.  Further, the criterion that individuals must recognize that their symptoms are excessive has been removed from all anxiety disorders. Some restructuring of categories (e.g., OCD and PTSD to their own separate sections) has occurred. The disorders that have had the most significant changes in terms of diagnostic criteria are Panic Disorder, Agoraphobia, and PTSD. We hope that these changes will improve the identification and diagnosis of psychological disorders in the population, as well as inform appropriate prevention and treatment strategies.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th edition, text revision). Washington, DC: American Psychiatric Association.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th edition). Arlington, VA: American Psychiatric Publishing.
About the Author:
Dr. Colleen Cummings completed her doctorate in clinical psychology with a specialty in child psychology from The Ohio State University.  She completed her American Psychological Association-accredited internship training in clinical child psychology at the Children's National Medical Center in Washington, D.C. and postdoctoral research and clinical work at the Temple University Child and Adolescent Anxiety Disorders Clinic in Philadelphia, Pennsylvania.  She is an expert in evidence-based treatment for childhood and adolescent anxiety disorders, incorporating cognitive-behavioral techniques in her therapy.
Update 11/24/14: Colleen Cummings, Ph.D. now practices as a licensed psychologist in Rockville, Maryland. Her practice website link is:
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