anxiety disorders ICD11.docx

 Anxiety and fear-related disorders involve excessive fear, anxiety, and behavioral disturbances. **Fear** is a reaction to imminent, present threats; **anxiety** is future-oriented, relating to anticipated threats. Disorders are differentiated based on the **focus of apprehension**, i.e., stimul...

 Anxiety and fear-related disorders involve excessive fear, anxiety, and behavioral disturbances. **Fear** is a reaction to imminent, present threats; **anxiety** is future-oriented, relating to anticipated threats. Disorders are differentiated based on the **focus of apprehension**, i.e., stimuli or situations that trigger fear or anxiety. - **Specific phobia**: Focus on highly specific stimuli. - **Generalized anxiety disorder**: Focus on a broader class of situations.  **Associated cognitions** help distinguish disorders by clarifying what causes the fear or anxiety.  **Cultural considerations**: - Somatic complaints (physical symptoms) may be more prevalent than cognitive symptoms in some cultural groups. - In certain cultures, fear and anxiety may be attributed to external factors (e.g., witchcraft, sorcery) rather than internal psychological states **Generalized Anxiety Disorder (GAD)** - **Essential Symptoms:** - Persistent anxiety or worry not linked to specific environmental factors (free-floating anxiety). - Excessive worry about multiple aspects of daily life (e.g., work, health, finances). - Associated symptoms include: - Muscle tension or restlessness. - Sympathetic overactivity (e.g., nausea, heart palpitations, sweating, trembling). - Nervousness, restlessness, or feeling "on edge." - Difficulty concentrating. - Irritability. - Sleep disturbances (trouble falling or staying asleep, restless sleep). - **Duration & Impact:** - Symptoms persist for several months, more days than not. - Not explained by another mental disorder, medical condition, or substance use. - Causes significant distress or impairment in daily functioning; any maintained functioning requires significant effort. - **Additional Clinical Features:** - Some may experience general apprehensiveness and somatic symptoms without specific worry. - Behaviors like avoidance, need for reassurance, and procrastination may be attempts to reduce anxiety. - **Distinction from Normal Anxiety:** - Normal anxiety is adaptive and helps focus on problem-solving and alertness. - GAD anxiety is excessive, persistent, and negatively impacts functioning. - Anxiety is considered GAD when it is disproportionate to the situation and not appropriate to extreme stress (e.g., warzone circumstances) **Course and Developmental Features of Generalized Anxiety Disorder :** - **Age of Onset:** - Can begin at any age; most commonly in early to mid-30s. - Earlier onset linked to greater impairment and co-occurring disorders. - **Symptom Patterns:** - Symptom severity fluctuates between full and subthreshold levels. - Full remission is uncommon. - Worry content varies by age (e.g., academic/sports for youth, personal well-being for adults). - **Developmental Presentations:** - GAD is prevalent among childhood and adolescent anxiety disorders, becoming more common as cognitive abilities develop. - Rare in children under 5 due to limited capacity for worry. - **Manifestations in Children & Adolescents:** - May be overly concerned with rules and pleasing others; can act as \"rule enforcers,\" affecting peer relationships. - Engage in excessive reassurance-seeking, repetitive questioning, and may display distress over uncertainty. - Perfectionistic behaviors, prolonged task completion, and sensitivity to criticism. - **Somatic Symptoms in Youth:** - Prominent somatic complaints (e.g., headaches, abdominal pain, gastrointestinal distress). - Sleep disturbances, such as difficulty falling asleep and night-time wakefulness. - **Worry Content Across Development:** - Younger children worry about safety and health; adolescents focus on performance, perfectionism, and meeting others\' expectations. - Adolescents may exhibit increased irritability and are at higher risk for depressive symptoms. **Culture-Related Features of GAD:** - Somatic complaints (e.g., dizziness, heat sensations) may be prominent in some cultures. - Realistic worries may be misjudged without cultural context (e.g., migrant workers fearing deportation). - Worry content varies by culture (e.g., spiritual concerns in some societies vs. personal achievement in individualistic cultures). **Sex/Gender-Related Features:** - GAD prevalence is about twice as high in women. - Girls with GAD typically experience symptoms earlier than boys. - Co-occurring substance use disorders are more common in men. **Differential Diagnosis Boundaries:** - **Panic Disorder:** - Panic disorder involves sudden, intense fear or anxiety episodes. - GAD is characterized by persistent, generalized worry about various life events. - If panic attacks occur only in the context of GAD-related worries, an additional diagnosis of panic disorder is not necessary unless attacks are unexpected. - **Social Anxiety Disorder:** - Social anxiety disorder is focused on fear of negative evaluation in social situations. - GAD involves general worry about performing poorly without a primary concern about others\' evaluation. - **Depressive Disorders:** - Depressive disorders are characterized by persistent low mood, loss of pleasure, and other symptoms (e.g., appetite changes). - GAD can co-occur with depression but is diagnosed separately if symptoms were present before or after a depressive episode. - **Adjustment Disorder:** - Related to specific psychosocial stressors with excessive worry focused on the stressor. - GAD involves worry about multiple areas of life, not centered around a specific stressor. - Symptoms of adjustment disorder generally resolve within 6 months. - **Obsessive-Compulsive Disorder (OCD):** - OCD is marked by intrusive, unwanted thoughts or urges (obsessions). - GAD worry is about everyday events and may be seen as helpful in preventing negative outcomes. - **Hypochondriasis and Bodily Distress Disorder:** - Involve worry about physical symptoms and health. - GAD includes health concerns but extends to worry about various life aspects. - **Post-Traumatic Stress Disorder (PTSD):** - PTSD anxiety is triggered by trauma reminders and focused on perceived threats linked to the trauma. - GAD worry is broader, encompassing multiple life domains (e.g., health, finances). **Panic Disorder** **Essential Features:** - **Recurrent Panic Attacks:** Intense fear or apprehension with rapid onset of symptoms. - Symptoms: palpitations, sweating, trembling, shortness of breath, choking sensations, chest pain, nausea, dizziness, chills/hot flushes, paraesthesias, depersonalization, fear of losing control or death. - **Unexpected Attacks:** Some panic attacks are unprovoked and occur \"out of the blue.\" - **Worry and Behavioral Changes:** Persistent concern about attacks and changes in behavior (e.g., avoidance). - **Not Due to Other Causes:** Symptoms aren\'t due to other medical conditions, substances, or another mental disorder. - **Impaired Functioning:** Significant impairment in personal, social, educational, or occupational life. **Additional Clinical Features:** - **Duration and Frequency:** Attacks usually last minutes; frequency varies (multiple per day to few per month). - **Association with Triggers:** Panic attacks can become expected over time if linked to specific stimuli or situations. - **Limited-Symptom Attacks:** Similar to panic attacks but with fewer symptoms; common in panic disorder. - **Nocturnal Attacks:** Waking up in a state of panic is possible. - **High Impairment:** Panic disorder is highly impairing and often leads to emergency care visits. **Differentiation from Normal Fear:** - **Distinction from Normal Reactions:** Frequent, unexpected panic attacks and related worry or avoidance differentiate it from normal anxiety reactions. - **Intensity and Onset:** Sudden onset, unexpected nature, and intense symptoms distinguish panic attacks from typical situational anxiety. **Course and Developmental Features:** - **Typical Onset:** Early 20s. - **Symptom Patterns:** Vary from episodic outbreaks with remission to persistent symptoms. - **Comorbidity Impact:** Co-occurring disorders (e.g., anxiety, depression) worsen prognosis. - **Agoraphobia Link:** Presence of agoraphobia is associated with greater severity and poorer prognosis. - **Adolescent Risk:** Increased prevalence in adolescence with risk for depression, suicidality, and substance use disorders. **Culture-Related Features:** - **Symptom Presentation Varies by Culture:** Attributions about causes differ (e.g., \"khyâl\" in Cambodians, \"ataque de nervios\" in Latin Americans). - **Cultural Concepts of Distress:** Specific cultural interpretations link panic attacks to social and environmental factors (e.g., wind, interpersonal conflict). - **Clarifying Cultural Context:** Understand cultural meanings to determine if panic attacks are considered unexpected or culturally expected responses. **Sex- and Gender-Related Features:** - **Higher Prevalence in Females:** Panic disorder is twice as prevalent in females, starting from puberty. - **No Gender Differences in Symptoms:** Symptom presentation is similar across genders. **Boundaries and Differential Diagnosis:** - **Generalized Anxiety Disorder (GAD):** If anxiety is confined to panic attacks or their implications, GAD is not diagnosed. An additional diagnosis is made only if anxiety extends to broader life concerns. - **Agoraphobia:** Over time, panic attacks may become linked to specific situations, leading to avoidance or fear. A diagnosis of agoraphobia is considered if fears about panic are extensive across multiple situations. - **Depressive Disorders:** Panic attacks can occur with depressive disorders, especially those with anxiety symptoms. A diagnosis of panic disorder may be added if the primary concern is panic recurrence. - **Hypochondriasis (Health Anxiety):** Concerns about life-threatening illness can overlap with panic symptoms. Panic disorder is not diagnosed if attacks are solely due to health fears; \"with panic attacks\" specifier may be used for hypochondriasis. - **Oppositional Defiant Disorder (ODD):** Children may show defiance when anxious. A diagnosis of ODD is not made if defiance is limited to anxiety-triggered situations. - **Other Mental Disorders:** Panic attacks can co-occur with other disorders (e.g., phobias, OCD, PTSD). A diagnosis of panic disorder is only made if some attacks are unexpected and not tied to the focus of another disorder. **Agoraphobia :** **Essential Features:** - **Marked and excessive fear/anxiety** in situations where escape might be difficult or help unavailable (e.g., public transport, crowds, being outside alone). - **Consistent fear of specific outcomes** like panic attacks or incapacitating symptoms; these situations are either actively avoided, endured with distress, or require a companion. - **Persistent symptoms**, lasting at least several months. - **Not explained by another disorder** (e.g., paranoia, social withdrawal). - **Significant distress or impairment** in social, occupational, or other key areas of functioning. **Additional Clinical Features:** - Fear may involve panic attack symptoms (e.g., palpitations, dizziness) or other incapacitating symptoms. - History of panic attacks is common but not required for diagnosis. - Individuals often use **safety behaviors** (e.g., needing a companion, carrying items for security). - Can be highly impairing, with some becoming **housebound**. **Boundary with Normality:** - Transient or situational avoidance due to normal stress or disability does not qualify as agoraphobia. - Diagnosis requires **functional impairment beyond what is expected** for any medical or physical condition. **Course Features:** - Onset typically in **late adolescence** or early adulthood; rare in childhood. - Chronic condition with risk for depression, substance use disorders, and poor prognosis if severe. - **Severity and co-occurring disorders** (e.g., depression, anxiety) are linked to worse outcomes. **Developmental Presentations:** - Symptoms vary by age: children fear being alone or lost, adults fear crowds/open spaces, older adults fear falling. - Children often **avoid leaving home without a caregiver**; fear centers around being lost or not finding help. **Culture-Related Features:** - Consider cultural norms when assessing agoraphobia. Fears that align with the cultural context (e.g., fear of violence, common homebound behavior) should not be diagnosed as agoraphobia unless they exceed cultural norms. **Gender-Related Features:** - **Prevalence**: Twice as high in women; symptoms in children are more common and occur earlier in girls. - **Men\'s Co-occurrence**: More likely to have substance use disorders alongside agoraphobia. **Differential Diagnosis:** - **Panic Disorder**: Panic attacks in panic disorder are **unexpected** and not tied to specific situations. Agoraphobia may have panic attacks tied to agoraphobic contexts only. - **Specific Phobia**: Fear is **circumscribed** to specific stimuli (e.g., animals, heights) rather than multiple situations related to escape or help-seeking difficulty. - **Social Anxiety Disorder**: Fear is focused on **social situations** and potential negative evaluation by others, unlike agoraphobia, which is about escape/help-seeking. - **Separation Anxiety Disorder**: Avoidance is due to fear of **separation** from an attachment figure, rather than fear of agoraphobic situations. - **Schizophrenia/Psychotic Disorders**: Avoidance is due to **delusions/paranoia**, not fear of physical symptoms or help/escape difficulty. - **Depressive Disorders**: Avoidance is related to **loss of interest** or energy, not fear or anxiety about escape/help-seeking in multiple situations. - **PTSD**: Avoidance is tied to **trauma reminders**, not fear of perceived dangerous outcomes in general situations. - **Oppositional Defiant Disorder (ODD)**: Defiance occurs **specifically due to anxiety-provoking situations** in agoraphobia; in ODD, defiance is more pervasive. ### Specific Phobia: #### Essential Features - **Excessive Fear/Anxiety**: Consistently triggered by exposure or anticipation of specific objects/situations (e.g., animals, heights). - **Avoidance/Endurance**: Actively avoided or endured with intense fear. - **Persistent Symptoms**: Lasts several months; not transient. - **Differentiation**: Symptoms aren't better explained by another disorder. - **Impairment/Distress**: Causes significant distress or impairment in functioning. #### Additional Clinical Features - **Common Phobias**: Animals, heights, enclosed spaces, blood/injury, flying, storms, etc. - **Multiple Phobias**: Most individuals fear multiple stimuli. - **Reactions**: Range from disgust to physical symptoms (e.g., fainting in blood phobias). - **Learning**: Can develop through vicarious experiences or direct negative events. - **Cultural Context**: Fear should be disproportionate considering cultural norms. #### Boundary with Normality - **Children/Adolescents**: Fears are normal in development; diagnosis only if fear is excessive compared to peers. #### Course Features - **Onset Age**: Common in early childhood (7-10 years); may result from fear-provoking events. - **Onset Variations**: Younger onset for animal/natural fears; older for heights, flying. - **Comorbidity**: High rates with depressive and anxiety disorders; phobia often precedes other disorders. - **Persistence**: Phobias persisting into adulthood rarely remit spontaneously. #### Developmental Presentations - **Prevalence in Youth**: Common in children/adolescents; early signs by age 3. - **Responses in Children**: Freezing, tantrums, crying; distinguish from typical fears by duration/intensity. - **Age Differences**: Tangible object phobias more in children; harm-based fears in teens/adults. - **Avoidance**: Excessive avoidance behaviors seen across all ages. #### Culture-Related Features - **Cultural Influence**: Fear response can be culture-specific; diagnosis must consider cultural norms. - **Environmental Context**: Fear of stimuli influenced by local environment (e.g., poisonous animals). #### Sex/Gender Features - **Prevalence**: Twice as high in females. - **Type Differences**: Blood/injection phobias equal in both sexes; situational/animal/environment phobias more common in females. ### Differential Diagnosis of Specific Phobia: #### Panic Disorder - **Contextual Panic Attacks**: If panic attacks occur only in the context of phobic stimuli, no additional diagnosis of panic disorder is needed. - **Unexpected Panic Attacks**: If panic attacks occur unexpectedly outside phobic contexts, panic disorder may be diagnosed separately. #### Agoraphobia - **Specific vs. Multiple Situations**: Specific phobia involves fear of particular objects/situations (e.g., heights, animals), while agoraphobia is fear of situations where escape/help might be difficult. #### Social Anxiety Disorder - **Trigger and Focus**: Social anxiety is fear of social situations due to potential negative evaluation by others. Specific phobia is fear of specific objects or situations not related to social judgment. #### Obsessive-Compulsive Disorder (OCD) - **Avoidance Reasons**: OCD involves avoidance due to obsessions/compulsions (e.g., contamination). Specific phobia avoidance is due to fear of the object/situation itself, not obsessional thoughts. #### Hypochondriasis (Health Anxiety Disorder) - **Focus of Avoidance**: In health anxiety disorder, avoidance is due to fear of exacerbating disease-related worries. In specific phobia, avoidance is related directly to the phobic object/situation. #### Post-Traumatic Stress Disorder (PTSD) & Complex PTSD - **Symptom Differences**: PTSD includes re-experiencing trauma and heightened current threat perception, differentiating it from specific phobia where trauma is experienced as a past event. #### Feeding and Eating Disorders - **Reason for Avoidance**: In eating disorders, food is avoided due to weight/shape concerns or sensory qualities. In specific phobia, food avoidance is due to fear of direct effects (e.g., choking). #### Oppositional Defiant Disorder (ODD) - **Context of Defiance**: If defiance (anger, noncompliance) occurs only in situations eliciting anxiety, fear, or panic (e.g., being near a feared object), ODD diagnosis is usually not appropriate. ### Social Anxiety Disorder: #### Essential Features - **Excessive Fear/Anxiety**: Consistent fear in social situations (e.g., conversations, eating in public, public speaking). - **Fear of Negative Evaluation**: Concern over acting in a way that will be humiliating, embarrassing, or lead to rejection. - **Avoidance/Endurance**: Avoidance of social situations or enduring them with intense anxiety. - **Persistent Symptoms**: Symptoms persist for months and aren't transient. - **Distress/Impairment**: Symptoms cause significant distress or impairment in daily functioning. #### Additional Clinical Features - **Physical Concerns**: Individuals often worry about symptoms like blushing or trembling. - **Comorbidity**: Often co-occurs with anxiety, depressive, and substance use disorders. - **Cultural Considerations**: Fear may not be viewed as excessive; clinical judgment is required to determine if fear is disproportionate. #### Boundary with Normality - **Developmental Norms**: Differentiate from normal shyness or fears based on severity, interference with functioning, and duration. - **Cultural Context**: Excessive fear and avoidance should be above normal for cultural standards. #### Course Features - **Onset Age**: Most common onset between 8-15 years old; can develop gradually or after stressful events. - **Chronic Condition**: Often chronic but may remit spontaneously, especially with later onset and less severity. - **Prognosis Factors**: Severity, substance use, and comorbid disorders can worsen prognosis. #### Developmental Presentations - **Age-Specific Trends**: Less common under age 10, increases significantly during adolescence. - **Behavioral Inhibition**: Trait linked to social anxiety; children may be \"slow to warm up.\" - **Subtle Avoidance**: Children and teens might avoid eye contact or limit speech. - **Symptom Manifestation by Age**: Younger children show anxiety with adults; adolescents may show increased anxiety with peers and social demands. - **School Impact**: Symptoms often become evident with increased social demands in school settings, potentially leading to social withdrawal, school refusal, and difficulties in social situations. #### Summary Points - Diagnosis requires persistent, excessive fear of social situations leading to avoidance or distress. - Symptoms are often context-specific and develop during childhood or adolescence. - Associated with avoidance behaviors, impairment in social functioning, and may vary in presentation across age groups. #### Culture-Related Features - **Cultural Norms Assessment**: Evaluate anxiety within relevant cultural contexts (e.g., public dancing expectations). - **Normative vs. Disorder**: Avoidance of social situations may be normal in some cultures unless the anxiety is disproportionate. - **Cultural Concepts**: Conditions like *taijin kyofusho* (fear of offending others) in Japan/Korea may represent a form of social anxiety or other disorders (e.g., delusional disorder). - **Collectivist Societies**: High social anxiety but lower disorder prevalence due to tolerance for social withdrawal. #### Sex/Gender-Related Features - **Higher Prevalence in Women**: More women diagnosed in community settings, but no gender difference in clinical settings. - **Symptoms & Co-Occurrence**: Women have greater symptom severity and more social fears; men more likely to experience anxiety in dating and public urination. - **Co-Occurring Disorders**: Women: depressive, bipolar, anxiety. Men: substance use, oppositional defiant disorder, conduct disorder. - **Substance Use**: Men more likely to use alcohol/drugs to manage anxiety. #### Differential Diagnosis - **Generalized Anxiety Disorder (GAD)**: Worry extends to multiple everyday situations, not just social evaluation. - **Panic Disorder**: Panic attacks only in social situations do not warrant a panic disorder diagnosis; unexpected panic attacks do. - **Agoraphobia**: Fear of inability to escape/help in various situations; embarrassment secondary to practical concerns (e.g., diarrhea in public). - **Specific Phobia**: Fear tied to specific stimuli (e.g., heights), not social evaluation. - **Selective Mutism**: Failure to speak in certain situations; broader social avoidance seen in social anxiety disorder. - **Autism Spectrum Disorder (ASD)**: Social withdrawal linked to communication deficits and lack of social interest in ASD. - **Depressive Disorders**: Social avoidance occurs almost exclusively during depressive episodes. - **Body Dysmorphic Disorder (BDD)**: Concern restricted to perceived physical defect; social anxiety is broader across contexts. - **Olfactory Reference Disorder**: Avoidance due to belief of emitting a foul odor, unlike fear of negative social evaluation in social anxiety. - **Oppositional Defiant Disorder (ODD)**: Defiance linked to anxiety-provoking situations does not warrant an ODD diagnosis. - **Medical Conditions**: Concerns about symptom perception in conditions like Parkinson's do not indicate social anxiety unless excessive and persistent fear is present. ### Separation Anxiety Disorder: #### Essential Features - **Excessive Fear of Separation**: Intense anxiety about separation from key attachment figures (parents, caregivers, spouse, children). - **Manifestations by Development Level**: - **Children/Adolescents**: Thoughts of harm to attachment figures, refusal to go to school, nightmares, physical symptoms (nausea, headache). - **Adults**: Similar anxiety regarding spouses, partners, children. - **Persistent Symptoms**: Symptoms last for months and are not transient. - **Impairment/Distress**: Causes significant distress or functional impairment. #### Additional Clinical Features - **Comorbidity**: High rates with other disorders (e.g., generalized anxiety, mood disorders, PTSD). - **Parenting Style**: In childhood, may be linked to overprotective parenting, limiting autonomy. #### Boundary with Normality - **Attachment vs. Disorder**: Separation anxiety becomes a disorder when excessive, persistent, and causing distress beyond normal levels for age or culture. - **School Refusal**: Anxiety about school may relate to other issues (e.g., bullying) and not necessarily indicate separation anxiety. #### Course Features - **Typical Onset**: Begins in childhood but can persist into adulthood. - **Risk for Other Disorders**: Elevated risk for internalizing disorders (e.g., depression), behavior disorders, and ADHD. #### Developmental Presentations - **Age-Specific Focus**: - **Younger Children**: Less credible fears (e.g., kidnapping), tantrums, crying. - **Older Children/Adolescents**: More realistic fears (e.g., accidents), social withdrawal. - **Separation Distress**: Younger children follow caregivers closely; older children may avoid socializing outside family. #### Culture-Related Features - **Cultural Norms**: Consider cultural attitudes toward separation; some cultures have more restrictive norms on spending time apart from family. - **Prolonged Living with Family**: Children staying in parental homes longer is increasingly common globally, affecting disorder assignment. #### Sex/Gender-Related Features - **Slightly Higher in Females**: Lifetime prevalence is higher in females (5.6%) than males (4%), but childhood school refusal rates are similar for both. #### Differential Diagnosis - **Generalized Anxiety Disorder (GAD)**: GAD involves excessive worry about many aspects of life, including attachment figures, but is not limited to separation concerns. - **Panic Disorder**: Panic attacks specific to separation anxiety don\'t warrant a panic disorder diagnosis; unexpected panic attacks might. - **Agoraphobia**: Avoidance in agoraphobia is due to fear of not getting help during panic/incapacitating symptoms, not due to separation anxiety. - **Social Anxiety Disorder (SAD)**: Avoidance in SAD is driven by fear of negative evaluation by others, not separation. - **Depressive Disorders**: Avoidance of leaving home in depressive disorders is linked to depression episodes, not separation concerns. - **Post-Traumatic Stress Disorder (PTSD)**: PTSD involves re-experiencing a traumatic event; focus is not on separation but on traumatic memories. Separation anxiety can develop after trauma if all criteria are met. - **Disruptive Behavior and Dissocial Disorders**: - **Oppositional Defiant Disorder (ODD)**: Similar behaviors (e.g., refusal to go to school) are due to defiance in ODD, not separation. - **Conduct-Dissocial Disorder**: School refusal/truancy in this disorder is not due to attachment concerns. - **Personality Disorder**: Fear of abandonment and dependence in personality disorders are part of broader patterns of maladaptive behavior, with possible co-occurrence with separation anxiety. In all cases, consider if the anxiety is specifically due to separation from key attachment figures to determine separation anxiety disorder diagnosis. ### Selective Mutism: #### Essential Features - **Selective Speaking**: Adequate speech in some settings (e.g., home) but fails to speak in others (e.g., school). - **Duration**: At least 1 month (not just the first month of school). - **Language Proficiency**: Not due to lack of language skills. - **Impairment**: Significantly interferes with academic, social, or other functioning. #### Additional Clinical Features - **Assessment**: Receptive language assessment often feasible; informants\' reports may be needed. - **Overlap with Social Anxiety**: Similarities to social anxiety disorder, but typically an earlier onset (before age 5), language difficulties, and oppositional behavior. - **Impairment**: Significant social/academic challenges, such as not asking for help, avoiding social interactions, and risk of bullying. - **Temperament Factors**: Linked to behavioral inhibition and negative affectivity. #### Boundary with Normality - **Transient Mutism**: Common when first starting school; diagnosis only if persistent beyond one month. - **Language Barriers in Immigrants**: Reluctance to speak due to unfamiliar language should not be diagnosed as selective mutism. #### Course Features - **Early Onset**: Before age 5, but impairment often seen at school entry. - **Comorbidity**: High with other anxiety disorders (e.g., social anxiety). - **Oppositionality**: Seen in situations requiring speech; no ODD diagnosis if explained by selective mutism. - **Course**: Average duration is 8 years; may lead to remission or development of social anxiety. - **Residual Difficulties**: Social communication and anxiety issues often persist after core symptoms resolve. - **Prognosis**: Poorer outcomes associated with a family history of selective mutism. #### Cultural Features - **Cultural Norms**: Avoidance of speaking in certain contexts may be culturally normative and not indicate selective mutism. #### Differential Diagnosis - **Developmental Speech/Language Disorders**: Mutism limited to certain situations, not pervasive across all social settings. - **Autism Spectrum Disorder (ASD)**: Impairments in language/social communication in ASD are seen across all environments. - **Schizophrenia/Psychotic Disorders**: Disrupted speech across all situations, unlike selective mutism. - **Social Anxiety Disorder**: Selective mutism involves failure to speak in specific settings, while social anxiety disorder is fear/anxiety in multiple social situations. ### ### Other Specified Anxiety or Fear-Related Disorder #### Essential Features - **Symptoms Similar to Anxiety Disorders**: Symptoms resemble those of other anxiety/fear disorders (e.g., arousal, avoidance) but do not fully meet any specific disorder criteria. - **Not Explained by Another Condition**: Symptoms are not better accounted for by other mental, developmental, or medical conditions. - **Distress/Impairment**: Symptoms cause significant distress or impairment in key life areas; maintained functioning requires extra effort. #### **Unspecified Anxiety or Fear-Related Disorder** - **General Descriptor**: Used when anxiety symptoms are present but don\'t clearly match any specific disorder in this group. #### Specifier: With Panic Attacks - **Panic Attacks Contextualized**: Can indicate panic attacks occurring in the context of anxiety or other disorders, not solely as a panic disorder. - **Greater Severity and Poorer Outcomes**: Panic attacks in the context of other disorders may indicate more severe psychopathology, poorer treatment response, and higher suicide risk. - **Situational Panic Attacks**: Occur specifically in response to the feared situation (e.g., social anxiety triggers panic in social settings). - **Unexpected Panic Attacks**: If panic attacks are also unexpected and not tied to specific triggers, a separate diagnosis of panic disorder is warranted. #### Specifier Application - Applicable to disorders such as generalized anxiety disorder, agoraphobia, specific phobia, social anxiety disorder, and separation anxiety disorder, each with the \"with panic attacks\" specifier. - Not typically used for selective mutism. Examples of combinations: - **6B00/MB23.H**: Generalized anxiety disorder with panic attacks - **6B02/MB23.H**: Agoraphobia with panic attacks - **6B03/MB23.H**: Specific phobia with panic attacks - **6B04/MB23.H**: Social anxiety disorder with panic attacks - **6B05/MB23.H**: Separation anxiety disorder with panic attacks - **6B0Y/MB23.H**: Other specified anxiety/fear disorder with panic attacks - **6B0Z/MB23.H**: Unspecified anxiety/fear disorder with panic attacks