- Recurrent unexpected panic attacks characterized by a sudden surge of intense fear or discomfort that reaches a peak within minutes and involves at least 4 of 13 physical or cognitive symptoms. - At least one attack must be followed by 1 month or more of persistent concern about additional attacks or a significant change in behavior related to the attacks. - Panic attacks are not better explained by another mental disorder and are not due to a medical condition or substance.

1. TBL (ANXIETY)
Group 1

2. 02
Separation Anxiety Disorder /
01
03
04
05
07
0
6
08
09
10
Selective Mutism
Specific Phobia
Social Anxiety /
Panic Disorder
Panic Attack Specifier
Agoraphobia
Generalised Anxiety
Disorder
Substance / Medication -
Induced Anxiety
Due to Other Medical
Condition
Contents

3. Anxiety Disorders
- include disorders that share features of excessive fear and anxiety and related behavioral
disturbances.
Fear Anxiety
The emotional response to real or
perceived imminent threat.
Anticipation of future threat.
more often associated with surges of
autonomic arousal necessary for fight or
flight, thoughts of immediate danger, and
escape behaviors.
more often associated with muscle
tension and vigilance in preparation for
future danger and cautious or avoidant
behaviors.
Fear & anxiety overlap, but they also differ.
● Many of the anxiety disorders develop in childhood & tend to persist if not treated.
● Most occur more frequently in females than in males (approximately 2:1 ratio).
Pathologic anxiety occurs when the symptoms are excessive, irrational, out of
proportion to the trigger or are without an identifiable trigger.

4. Separation Anxiety Disorder
01
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to
whom the individual is attached, as evidenced by at least three of the following:
1. Recurrent excessive distress when anticipating or experiencing separation
2. Persistent & excessive worry about losing major attachment figures or about possible harm to them
3. Persistent & excessive worry about experiencing an untoward event that causes separation
4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because
of fear of separation.
5. Persistent and excessive fear of or reluctance about being alone or without
major attachment figures
6. Persistent reluctance or refusal to sleep away from home or to go to sleep
without being near a major attachment figure.
7. Repeated nightmares involving the theme of separation.
8. Repeated complaints of physical symptoms when separation from major
attachment figures occurs or is anticipated.

5. B. Lasting at least 4 weeks in children and adolescents and typically 6 months or more in
adults.
C. Causes clinically significant distress or impairment in important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as:
- refusing to leave home because of excessive resistance to change in autism
spectrum disorder;
- delusions or hallucinations concerning separation in psychotic disorders;
- refusal to go outside without a trusted companion in agoraphobia;
- worries about ill health or other harm befalling significant others in generalized
anxiety disorder;
- or concerns about having an illness in illness anxiety disorder

6. What are the symptoms of separation anxiety in children?
Separation anxiety disorder in children often starts in preschool, daycare or playdate
settings. Your child may refuse to go or have a temper tantrum when you leave.
Other signs of separation anxiety disorder can include:
● Fear that something bad will happen to a family member during separation.
● Fear of being abducted or getting lost.
● Following caregiver around the house.
● Fear of being left alone.
● Nightmares.
● Bedwetting (nocturnal enuresis).

7. What are the symptoms of separation anxiety in adults?
Some symptoms of separation anxiety in adults are the same as separation
anxiety in children. These symptoms include:
● Fear that something bad will happen to a family member during separation.
● Fear of being abducted.
● Following loved ones around the house.
● Fear of being left alone.
Other symptoms in adults include:
● Panic attacks when you can’t reach loved ones.
● Fear that you or a loved one will get injured during separation.
● Social withdrawal.
● Difficulty concentrating

8. Physical symptoms of separation anxiety disorder in children
and adults can include:
● Stomach aches.
● Headaches.
● Dizziness.
● Nausea and vomiting.
● Diarrhea.
● Chest pain.
● Trouble breathing.

9. Management
How can I ease my child’s separation anxiety at home?
● Keep transitions short and sweet.
● Have a good-bye routine and be consistent.
● Build trust by returning when you say you will.
● Practice being apart by letting a trusted caregiver babysit.
How is separation anxiety disorder in children treated?
● Separation anxiety disorder can be treated with cognitive behavioral therapy (CBT).
Cognitive behavioral therapy teaches children how to understand and manage their
fears. CBT is used during separations to help children learn coping skills. These
skills can be used when a child is feeling anxious.
● If separation anxiety disorder in your child is severe, medication may be prescribed.
Antidepressants called selective serotonin reuptake inhibitors (SSRIs) can help
manage symptoms of separation anxiety disorder.

10. How is separation anxiety order in adults treated?
Separation anxiety disorder in adults also can be treated with cognitive behavioral
therapy (CBT). Your healthcare provider may recommend CBT or another type of therapy.
Other therapy options include:
● Dialectical behavioral therapy (DBT), a type of therapy that helps you deal with
difficult emotions.
● Family therapy.
● Group therapy.
Medications also may be prescribed. Antidepressants such as selective serotonin
reuptake inhibitors (SSRIs) and anti-anxiety medication (benzodiazepines) can help
manage symptoms.

11. Selective Mutism
Diagnostic Criteria
● Consistent failure to speak in specific social situations despite
speaking in other situations
● The duration of disturbance last at least 1 month
● The disturbance cause impairment in academic, occupational or social
functioning
● Mutism is not due to language difficulty or communication disorder
02

12. Signs of selective mutism
The main warning sign is the marked contrast in the child's ability to engage with
different people, characterised by a sudden stillness and frozen facial expression
when they're expected to talk to someone who's outside their comfort zone.
They may avoid eye contact and appear:
● nervous, uneasy or socially awkward
● rude, disinterested or sulky
● clingy
● shy and withdrawn
● stiff, tense or poorly coordinated
● stubborn or aggressive, having temper tantrums when they get home from
school, or getting angry when questioned by parents

13. More confident children with selective mutism can use gestures to communicate – for
example, they may nod for "yes" or shake their head for "no".
But more severely affected children tend to avoid any form of communication – spoken,
written or gestured.
Some children may manage to respond with a few words, or they may speak in an altered
voice, such as a whisper.
Treatment
● Psychotherapy: Cognitive behavioural therapy (CBT), family therapy
● Pharmacotherapy: Selective serotonin reuptake inhibitors (SSRI)

14. Specific Phobia
Specific Phobia is an anxiety disorder
characterized by intense fear or anxiety in the
presence of a particular situation or object
(phobic stimulus).
03

15. A
B
C
Specific Phobia - Diagnostic Criteria
(DSM-5)
Fear and Anxiety
About a specific object or
situation.
Actively avoided or endured
To the phobic object or situation
Out of Proportion
(Fear & Anxiety)
Than the danger posed by phobic object/situation
03
D
Provokes Fear Immediately
By the phobic object or situation.

16. E
F
G
Specific Phobia -
Diagnostic Criteria
Last for 6 months
For the fear, anxiety or
avoidance
Social, Occupational, or
other important area of
functioning ↓
To the phobic object or situation
03
Not due to other mental disorder
Including Agoraphobia, OCD, PTSD, Separation
Anxiety Disorder, Social Anxiety DIsorder

17. Natural
Environment
E.g.
Heights,
storms,
water
2
Blood-
injection-injury
E.g.
Needles,
invasive
medical
procedures
3
Situational
E.g.
Airplanes,
elevators,
enclosed
places.
4
Animal
E.g. spiders,
insects,
dogs
1
Other
E.g.
situations
that may
lead to
choking or
vomiting.
5
Specify based on the phobia…

18. Specific Phobia - Signs & Symptoms
Specific Phobia
Signs & Symptoms
Increase in sympathetic
nervous system arousal
01
Vasovagal fainting /
near fainting response
Situational, natural
environment, animal
specific phobias
02
03
Blood-injection-injury
specific phobia

19. - Pharmacotherapy
- Benzodiazepines
- for acute symptom relief
- limited role
- Psychotherapy
- Cognitive behavioural
therapy
- Treatment of choice
1 B
Specific Phobia - Management
03

20. Social Anxiety Disorder (Social Phobia)
Diagnostic Criteria
A. Marked fear or anxiety about one or more social situations in which the individual has exposed to possible
scrutiny by others. Examples include social interactions, being observed, and performing in front of others.
Note: In children, must occur in peer setting, not just during interaction with adults
A. The individual fears that he/she will act in a way or show anxiety symptoms that will be negatively
evaluated.
B. The social situations almost always provoke fear or anxiety.
Note: In children, fear/anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing
to speak in social situations.
04
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear/anxiety is out of proportion to the actual threat posed by the social
situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

21. Social Anxiety Disorder (Social Phobia)
Diagnostic Criteria
G. The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects
of a substance or another medical condition
I. The fear, anxiety or avoidance is not better explained by the symptoms of
another mental disorder such as panic disorder, body dysmorphic disorder or
autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity,
disfigurement from burn or injury) is present, the fear, anxiety or avoidance is
clearly unrelated or is excessive.
04
Resource: DSM V

22. Specifiers
Performance specifier
Specify if: : if the fear is restricted to speaking or
performing in public
Resource: https://www.psychdb.com/anxiety/social-

23. Signs and Symptoms
● The anticipatory anxiety in social anxiety can occur far in
advance of upcoming situations.
○ Individuals often overestimate the negative
consequences of the social situations, but the
sociocultural context always needs to be taken into
account by the clinician.
● Individuals (e.g., public speakers, musicians, dancers,
performers, athletes) with the performance only type of social
anxiety disorder will have performance fears that are typically
most impairing during their careers or professional lives. They
do not fear or avoid non-performance social events.
● Some may have fear of public restroom and avoid urination
when other individuals are present (paruresis or shy bladder
syndrome). Common in male.
● Blushing is considered a hallmark response for social anxiety
disorder
Resource: https://www.psychdb.com/anxiety/social-anxiety

24. Management
Psychotherapy
a. Cognitive behavioral therapy (CBT)
i. Education
ii. Exposure
iii. Cognitive restructuring
iv. Social skills training
v. Emotion-regulation approaches
Resource: https://www.psychdb.com/anxiety/social-anxiety

25. Management
Pharmacological
1. Pharmacological
a. In performance-type of social anxiety disorder
only, beta-blockers have been used.
Resource: https://www.psychdb.com/anxiety/social-anxiety

26. Panic Disorder
Panic Disorder
characterized by recurrent
spontaneous/unexpected,
panic attacks.
Recurrent
more than one
unexpected panic attack.
01
Unexpected
no obvious cue or trigger
at the time of occurrence
/ out of the blue
02
05

27. Diagnostic Criteria
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort
that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying)
may be seen. Such symptoms should not count as one of the four required symptoms.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from one- self).
12. Fear of losing control or “going crazy.”
13. Fear of dying.

28. B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing
control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid
having panic attacks, such as avoidance of exercise or unfamiliar situations)
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur
only in response to feared social situations, as in social anxiety disorder; in response to circumscribed
phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive
disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response
to separation from attachment figures, as in separation anxiety disorder

29. one of the attacks, followed by 1 month (or more),
of one or both:
- Persistent concern/worry on additional panic
attacks or their consequences
- maladaptive change in behavior related to the
attacks (e.g., avoidance of possible triggers)
- Recurrent unexpected panic attacks.
- abrupt surge of intense fear / discomfort,
reaches a peak within minutes
- 4 (or more) of the 13 symptoms occur.
A B
C D
not attributable to the physiological
effects of a substance or another
medical condition
not better explained by another
mental disorder

30. Symptoms of Panic Attacks
Da PANICS
● Dizziness
● Disconnectedness
● Derealization
(unreality)
● Depersonalization
(detached from self)
● Palpitations
● Paresthesias
● Abdominal
distress
● Numbness
● Nausea
● Intense fear of dying,
losing control or
“going crazy”
● Chills
● Chest pain
● Sweating
● Shaking
● Shortness of breath

31. Management
Pharmacotherapy and CBT— most effective
● First-line: SSRIs (e.g., sertraline, citalopram, escitalopram)
● Can switch to TCAs (clomipramine, imipramine) if SSRIs not effective
● Can use benzodiazepines (clonazepam, lorazepam) as scheduled or PRN
(as needed), especially until the other medications reach full efficacy

32. ● An abrupt surge of intense fear or intense discomfort that
reaches a peak within minutes and during which time 4 (or
more) of 13 physical and cognitive symptoms occur.
● can arise from either a calm state or an anxious state, and
time to peak intensity should be assessed independently of
any preceding anxiety.
● Peaks within only a few minutes and usually resolve within
half an hour.
● Not a mental disorder & cannot be coded.
● Can occur in the context of any mental disorders (e.g.,
anxiety disorders, depressive disorders, PTSD, OCD,
substance use disorders) and some medical conditions
(e.g., cardiac, respiratory, vestibular, gastrointestinal).
Panic Attacks Specifiers
0
6
When the presence of a panic attack is
identified, it should be noted as a specifier
(e.g., “PTSD with panic attacks”).
Panic attack is not used as a specifier for
panic disorder because the presence of
panic attack is contained within the panic
disorder criteria.
Limited-symptom attacks:
Attacks that meet all other criteria but
have < 4 symptoms.

33. Types of Panic Attacks
Expected
● attacks for which there is
an obvious cue or trigger,
such as situations in which
panic attacks have
typically occurred.
Unexpected
● there is no obvious cue or
trigger at the time of
occurrence (e.g., when
relaxing or out of sleep
[nocturnal panic attack]).
0
6

34. Agoraphobia
07
B. Fear or avoid these situations in which escape is perceived as
difficult or help might not be available in the event of panic-like
symptoms or other incapacitating or
embarrassing symptoms.
A. Marked fear or anxiety about 2 or more following 5 situations:
i) Using public transportation
ii) Being in open spaces
iii) Being in enclosed spaces
iv) Standing in line or being in a crowd
v) Being outside of home alone
C. The situations almost always provoke fear/anxiety
D. Actively avoided, require companion, endured intense
fear/anxiety

35. Management:
● CBT
● Pharmacotherapy [SSRIs (for
panic symptoms)]
E. Out of proportion to the actual danger & to the sociocultural context.
F. Persistent, last > 6 months
G. Cause clinically significant distress/impairment in social, occupational or other important
areas
of functioning.
H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is
present, the fear, anxiety, or avoidance is clearly excessive.
I. Not better explained by the symptoms of another mental disorder
Note: Diagnosed irrespective of presence of panic disorder.
If an individual’s presentation meets criteria for panic disorder and agoraphobia, both
diagnoses should be assigned.
DDx:
● Specific phobia, situational type.
● Separation anxiety disorder.
● Social anxiety disorder
● Panic disorder.
● Acute stress disorder and
posttraumatic stress disorder.

36. Generalised Anxiety Disorder
08
A. 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).
B. The individual finds it difficult to control the worry.
C. Associated with three (or more) of the following (with at least some symptoms having been
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).

37. D. Cause clinically significant distress or impairment in functioning.
E. The disturbance is not attributable to the physiological effects of a substance (or
another medical condition.
F. The disturbance is not better explained by another mental disorder.
DDx:
1. Anxiety disorder due to another medical condition
2. Substance/medication-induced anxiety disorder
3. Social anxiety disorder
4. OCD
5. PTSD and adjustment disorder
6. Depressive, bipolar, and psychotic disorders

38. 09
Substance / Medication - Induced Anxiety
Diagnostic Criteria
A. Panic attacks or anxiety is predominant in the clinical picture.
A. There is evidence from history, physical examination, or laboratory findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or
withdrawal or after exposure to a medication.
2. The involved substance/ medication is capable of producing the symptoms in Criterion A
A. The disturbance is not better explained by an anxiety disorder that is not substance/ medication-
induced. Such evidence of an independent anxiety disorder could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of
time (eg, about 1 month) after the cessation of acute withdrawal or severe intoxication or there is other evidence
suggesting the existence of an independent non-substance/medication-induced anxiety disorder
A. The disturbance does not occur exclusively during the course of a delirium.
A. The disturbance causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

39. 10
Anxiety Disorder Due to Another Medical Condition
Diagnostic Criteria
A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

40. 10
Anxiety Disorder Due to Another Medical Condition
Medical disorder similar to panic disorder
1. Endocrine
a. Pheochromocytomas
b. Hypo and hyperthyroid states
c. Hyperparathyroidism
d. Episodic hypoglycemia associated with insulinomas
Atypical features of panic attacks that
indicates underlying medical etiology
1. Ataxia
2. Altercation in consciousness
3. Bladder dyscontrol
4. Onset of panic disorder relatively
late in life
2. CNS
a. Seizure disorders
b. Vestibular dysfunction
c. Neoplasms
d. Prescribed and illicit substances on the CNS
3. Cardio & Pulmonary
a. Arrhythmias
b. Chronic obstructive pulmonary disease
c. Asthma

41. 11
Other Specified Anxiety Disorder
Presentation in which symptoms are characteristics of an anxiety disorder that cause clinically
significant distress or impairment in social, occupational , or other important areas of functioning
predominate but do not meet the full criteria for any disorders in the anxiety disorders diagnostic class.
Examples of presentations :
1. Limited - symptom attacks
2. Generalised anxiety not occuring more days than not
3. Khyâl cap (wind attacks)-characterized by dizziness, shortness of breath, palpitations, and other
symptoms of anxiety and autonomic arousal.
4. Ataque de nervios (attack of nerves)