Epidemiology
Etiology
Classifications
| Disorder | Defining Feature | Key Differentiator | Dx & Tx |
|---|---|---|---|
| Social Anxiety | Fear of scrutiny/embarrassment in social or performance situations. | Fear is specific to social contexts; performance-only subtype exists. | ≥6 mo; Tx: SSRI/SNRI, CBT. Propranolol for performance type. |
| Panic Disorder | Recurrent, discrete, unexpected panic attacks. | ”Fear of the fear”—persistent worry about having more attacks. | ≥1 mo of worry/avoidance after attack; Tx: SSRI/SNRI, CBT. BZDs for acute attacks. |
| Specific Phobia | Marked, irrational fear of a specific object or situation (e.g., spiders, heights). | Fear is immediate & predictable upon exposure to the trigger. | ≥6 mo; Tx: CBT with exposure is first-line. |
| Acute Stress Disorder | PTSD-like sx (intrusion, avoidance, arousal) after a traumatic event. | Duration is key: symptoms last from 3 days to 1 month post-trauma. | Dx based on timing; Tx: Trauma-focused CBT. |
| GAD | Excessive, chronic, constant worry about multiple life domains (work, money, health). | Worry is “free-floating,” not focused on one trigger; physical sx like muscle tension, fatigue. | ≥6 mo; Tx: SSRI/SNRI, Buspirone, CBT. |
| Agoraphobia | Fear of ≥2 situations where escape is difficult (e.g., crowds, open spaces, public transport). | Fear is about being trapped or unable to get help if anxiety occurs; leads to avoidance. | ≥6 mo; Tx: SSRI/SNRI, CBT. |
Clinical features
GAD
- Core Feature: Excessive, uncontrollable, disproportionate anxiety and worry about multiple everyday domains (e.g., work, finances, family, health) occurring more days than not for ≥ 6 months.
- Associated Somatic Symptoms (requires ≥ 3 of 6 in adults; only ≥ 1 in children) — Mnemonic: MR FICS:
- Functional Impairment: Clinically significant distress or impairment in social, occupational, or other functional areas.
Diagnostics
Treatment
Psychotherapy
- CBT (preferred)
Pharmacotherapy
- First-line agents
- SSRIs
- SNRIs
- Alternative agents
- Buspirone
- Benzodiazepines for short-term use only
- TCAs, e.g., imipramine
Warning
Long-term use of benzodiazepines is associated with significant adverse effects (e.g., motor and cognitive impairment) and risk of dependence.
Separation anxiety disorder
- Etiology & Demographics:
- Most common childhood anxiety disorder; peak onset 7–9 yo (normal developmental milestone at 8–14 mos; pathologic if persistent).
- Triggers: Major life stressor (e.g., illness, parental conflict, relocation, loss of pet).
- Clinical Presentation:
- Excessive distress when separated from primary attachment figures.
- Persistent worry regarding harm, illness, or death befalling caregivers.
- School refusal and reluctance to sleep alone or attend sleepovers. c
- Somatic complaints (e.g., recurrent abdominal pain, headaches, nausea) present on school mornings; resolve on weekends/holidays.
- Diagnosis (DSM-5):
- ≥3 symptoms present for ≥4 weeks in children/adolescents (≥6 months in adults).
- Causes clinically significant academic or social impairment.
- Clinical diagnosis; avoid unnecessary invasive workup for somatic complaints if routine PE is normal.
- Key Differentials:
- Normal separation anxiety: Resolves by age 2–3; developmentally appropriate.
- Social anxiety disorder: Fear of negative peer evaluation/scrutiny, not separation.
- Specific/School phobia: Fear of school-specific triggers (e.g., bullies, tests), not leaving parents.
- Conduct disorder / Truancy: Skips school covertly for antisocial/pleasurable activities; no anxiety or desire to remain home.
- Management:
- First-line: CBT (gradual exposure) + parental guidance (firm limit setting).
- Immediate priority: Prompt return to school (prolonged absence worsens prognosis).
- Pharmacotherapy (moderate-to-severe / refractory): SSRIs (e.g., fluoxetine, sertraline); avoid benzodiazepines.
Panic disorder
- Management:
- Acute attack: Benzodiazepines (e.g., Lorazepam, Alprazolam) for rapid abortive relief (avoid long-term). c
- First-line maintenance: SSRI / SNRI (start at low dose to prevent paradoxical activation) + CBT (superior to either alone).
- Second-line maintenance: Switch to an alternate SSRI/SNRI or use a TCA (e.g., Imipramine).
- Complications:
- Agoraphobia (avoidance of settings where escape is difficult).
- Secondary depression, increased suicide risk, and alcohol/sedative self-medication.
Selective mutism
- Definition: Consistent failure to speak in specific social situations (e.g., school) despite speaking normally in familiar settings (e.g., home with family). c
- Epidemiology: Typical onset < 5 yo, but usually diagnosed at school entry (ages 5–6); highly comorbid with Social Anxiety Disorder (SAD).
- Diagnostic Criteria (DSM-5-TR):
- Duration: ≥ 1 month (crucial: must persist beyond the first month of school).
- Impairs educational, occupational, or social functioning.
- Not due to a lack of language fluency or a primary communication disorder.
- Initial workup: Audiometry (rule out hearing loss) and speech/language evaluation.
- Key Differentials:
- Normal developmental shyness: Resolves within the first month of school; no significant functional impairment. c
- Social Anxiety Disorder (SAD): High overlap, but pts with isolated SAD speak when forced (tremulous/soft), whereas selective mutism features complete mutism.
- Autism Spectrum Disorder (ASD): Impairments are pervasive across all settings (present at home too); includes repetitive behaviors/restricted interests.
- Management:
- First-line: Cognitive Behavioral Therapy (CBT) utilizing behavioral exposure techniques (graded exposure, stimulus fading, positive reinforcement).
- School-based support: Educate teachers, facilitate nonverbal communication, avoid pressuring or punishing the child to speak.
- Pharmacotherapy (Second-line / Refractory / Severe): SSRIs (e.g., fluoxetine, sertraline).
Specific phobia
- Epidemiology & Core Features:
- Most common anxiety disorder (F > M, onset in childhood/adolescence).
- Marked, persistent, out-of-proportion fear of a specific trigger lasting 6 months.
- Active avoidance of stimulus; causes significant functional impairment.
- Subtypes & Key Buzzwords:
- Animal (dogs, spiders), Natural environment (heights), Situational (flying, elevators).
- Blood-injection-injury (BII): Causes a unique biphasic autonomic response (sympathetic surge followed by parasympathetic crash) bradycardia, hypotension, and vasovagal syncope.
- Diagnosis:
- Clinical (DSM-5 criteria); no labs or imaging needed.
- High-Yield Differential Diagnosis:
- Agoraphobia: Fear of 2 situations (e.g., crowds, public transit) due to concern that escape/help is impossible if panic occurs.
- Social Anxiety Disorder: Fear strictly focused on negative evaluation/scrutiny by others.
- Panic Disorder: Recurrent, unexpected attacks without an external cue.
- Management:
- First-line (Treatment of Choice): CBT with graded exposure therapy (systematic desensitization). c
- BII Subtype: Applied muscle tension (isometric contraction of large muscles to prevent syncope).
- Infrequent, acute exposure (e.g., rare flight): Short-acting benzodiazepine PRN (e.g., lorazepam).
- Ineffective: SSRIs/SNRIs are not effective for specific phobia.