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293.84 Anxiety Disorder Due to Another Medical Condition Symptoms and Related DSM–5 Diagnosis




Anxiety Disorder Due to Another Medical Condition

Information related to Anxiety Disorder Due to Another Medical Condition as well as the specific symptoms follow below. While some of these Anxiety Disorder Due to Another Medical Condition symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis. A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.




Anxiety Disorder Due to Another Medical Condition diagnostic criteria 293.84 (F06.4):

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 delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Coding note: Include the name of the other medical condition within the name of the mental disorder (e.g., 293. 84[F06.4] anxiety disorder due to pheochromocytoma). The other medical condition should be coded and listed separately immediately before the anxiety disorder due to the medical condition (e.g. 227.0 [D35. 00] pheochromocytoma; 293. 84 [F06.4] anxiety disorder due to pheochromocytoma.

Diagnostic Information and Criterion for Anxiety Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist



Librium medication: Your choice for anxiety disorders?





Brand Name: Librium

Generic Name: Chlordiazepoxide

Why is Librium prescribed?

Librium is most frequently prescribed for anxiety disorders. It is often prescribed for short-term relief of anxiety symptoms, withdrawal from acute alcoholism as well as for anxiety and apprehension prior to surgery. This medication belongs to the family of anxiety medications commonly referred to as benzodiazepines.

Important facts related to this drug:

This medication is habit-forming and you can become dependent upon it. You should make sure not to quit taking Librium abruptly as you may experience withdrawal symptoms. You should always be careful not to discontinue this medication or change your dosage without the approval of your physician.

When should Librium not be prescribed?

This drug should not be prescribed if you are sensitive to or have ever had an allergic reaction to this medication or similar tranquilizers. If you’re experiencing everyday stress or anxiety you should probably not take these types of medications. You should always discuss your symptoms with your doctor.

If I am pregnant or breast-feeding what do I need to know?

You should not take Librium if you’re pregnant or planning to become pregnant as there may be an increased risk of birth defects. This drug may appear in breast milk and could affect a nursing infant. If the medication is essential to your health, your physician may advise you to discontinue breast-feeding until your treatment with Librium and has finished.




Librium Dosage:

Librium dosage: How do you take this anti-anxiety medication?

You should take Librium exactly as prescribed.

What if I miss my Librium dosage?

You should take your dosage of Librium as soon as you remember. If it is within an hour or so of when you’re scheduled to take your next dose, you should skip the missed dose and get back to your normal schedule as soon as possible. You should never double up on your dosage of Librium.

Storage instructions:

You should always store your medications away from heat, moisture and light.

Recommended Librium dosages:

Librium Dosages : Adults

Mild or moderate anxiety- The usual dosage of Librium is 5 – 10 mg, three to four times per day.

Severe anxiety– The usual dose is 20 – 25 mg three or four times per day.

Anxiety and apprehension before surgery- On days before surgery, the usual dosage is 5 – 10 mg three or four times per day.

Acute symptoms of alcohol withdrawal- The usual starting Librium dosage is 50 – 100 mg. The physician will usually repeat this dose up to 300 mg per day, until the level of agitation has been adequately controlled.
The doctor may then reduce the dosage as much as possible.

Children- Librium dosage :

The usual Librium dosage for children six years of age or older is 5 mg, anywhere from two to four times per day. Some children may need to take as much as 10 mg two or three times per day. Librium is not usually recommended for children under the age of six.

Dosage for older adults

Your doctor will usually limit or minimize your Librium dosage in order to avoid sedating elderly individuals too much, or otherwise negatively effecting their level of coordination. For senior adults, the usual Librium dosage is 5 mg two to four times per day

Librium overdosage:

Any medication taken in excess of the prescribed dosage may have serious negative effects. If you suspect an overdosage of this medication you should seek medical attention immediately. Some of the symptoms of overdosage include coma, confusion, sleepiness and slow reflexes.

What Librium side effects may possibly be expected?

Specific Librium side effects cannot realistically be anticipated, but if any develop or change in intensity you should contact your doctor immediately. Only your physician can determine if you need to continue taking this medication in spite of your side effects.

Additional Librium side effects may include:

Confusion, constipation, drowsiness, fainting, increased or decreased sex drive, liver problems, lack of muscle coordination, minor menstrual irregularities, nausea, skin rash or eruptions, swelling due to fluid retention, yellow eyes and skin

Side effects of Librium that may be due to rapid decrease or abrupt withdrawal include:
Abdominal muscle cramps, convulsions, exaggerated feeling of depression, sleeplessness, sweating, tremors and vomiting

Special warnings and concerns:

Librium can possibly make you drowsy or less alert, therefore you should not drive or operate heavy machinery until you are well aware of how you are effected by the side effects of Librium. If you are depressed or have a history of depression, you should contact your doctor prior to taking this anxiety medication. Also, this drug may cause children to be less alert as well. If you have a hyperactive or aggressive child taking this medication, you should talk to your physician immediately if you notice negative reactions such as excitement, stimulation or acute rage. Also, you should contact your physician immediately before taking Librium if you’re being treated for porphyria, (a rare metabolic disorder), or liver or kidney disease.


Food and drug interactions possible in addition to Librium side effects:

This medication will intensify or cause an additive effect when taken while drinking alcohol as it is a central nervous system depressant. You should never drink alcohol when taking this drug. If Librium is taken with other medications, the effects of the medications can be increased, decreased or in other ways possibly altered. You should always talk with your physician prior to taking or combining Librium with the following:

• Antacids such as Maalox and Mylanta
• Antidepressant drugs known as MAO inhibitors including Nardil and Parnate
• Antipsychotic medications such as chlorpromazine and trifluoperazine
• Barbiturates such as Phenobarbital
• Blood thinning drugs such as Coumadin
• Cimetidine (Tagamet)
• Disulfiram (Antabuse)
• Levodopa (Larodopa)
• Narcotic pain medicines such as Demerol and Percocet
• Oral contraceptives

Librium side effects should always be noted and reported to your doctor immediately. Never disregard the negative interactions with other medications or any specific Librium side effects.

Some information adapted from The PDR Pocket Guide to Prescription Drugs – Sixth Edition

Additional Information and webpage by Paul Susic Ph.D. Licensed Psychologist (Health and Geriatric Psychologist)




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Ativan Medication: Everything You Need to Know





Generic Name: Lorazepam.

What is Ativan prescribed for?

Ativan is an anxiety medication which is used for the treatment of anxiety disorders for the short-term relief of anxiety symptoms. This anxiety medication belongs to the class of drugs known as benzodiazepines.
What do I need to know about this anxiety medication?
When using Ativan you should always be aware of the fact that tolerance and dependence can develop with its use. You should also be very concerned about withdrawal symptoms which you may experience if you stop using this medicine abruptly. You should follow your doctor’s recommendations if you decide to discontinue or change your dosage.

How should you take this anxiety medication?

You should always take Ativan exactly as it is prescribed by your physician.

What if you miss a dose of this anxiety medication?

If it is within an hour or so of your usual scheduled time you should take the missed dose as soon as you remember. If not, you should skip the dose and go back your regular schedule. You should never take two doses at once.

How is it stored?

You should store this and similar anxiety medications at room temperature in a tightly closed container away from the light.

When should Ativan not be prescribed?

This anxiety medication should not be prescribed if you are sensitive to or have ever had an allergic reaction to this or similar antianxiety medications such as Valium. You should also avoid Ativan if you have had the eye disease acute narrow-angle glaucoma. Do not take Ativan to relieve the symptoms of normal everyday tension or anxiety. Everyday stress and worry does not require treatment with Ativan. You should discuss your anxiety symptoms thoroughly with your physician before trying Ativan or similar anxiety medications.

Ativan side effects:

What Ativan side effects may be expected?

Ativan side effects cannot really be anticipated, but if any develop or a change in intensity you should notify your doctor immediately. Only your physician can determine if it is safe to continue taking this anxiety medication.




If you experience any side effects to Ativan, they will usually appear at the beginning of your medication treatment. They will usually disappear as you continue to take this drug or if you reduce the dosage.

Ativan side effects may also include:

Dizziness, memory problems, sedation, transient amnesia, unsteadiness, weakness
Side effects of Ativan due to a rapid decrease in dosage or abrupt withdrawal:
Abdominal muscle cramps, convulsions, depressed mood, inability to fall or stay asleep, sweating, tremors, vomiting

What are some of the other special concerns related to Ativan?

Ativan and similar medications may cause you to become drowsy or less alert. You should never drive or operate dangerous machinery or participate in hazardous activities which require full mental attention when taking this medication. Also, if you suffer from depression you should consult your doctor before taking Ativan. If you have decreased kidney or liver function the use of this antianxiety drug should be discussed with your physician. If you’re an elderly individual, or if you have been using Ativan for a prolonged period of time, your physician may want to monitor you closely for stomach and upper intestinal problems.

What are some the possible food and drug interactions when taking this drug?

This and other similar anxiety medications are known to increase the effects of alcohol. You should always avoid alcohol when taking these anti-anxiety medications. When taken along with some other drugs, the effects of either could be increased, decreased or otherwise altered. It is very important to consult your doctor before combining Ativan with barbiturates (Phenobarbital, Seconal, and Amytal) or sedative-type medications such as Valium and Halcion.

Can you take this medication if you’re pregnant or breast-feeding?

You should not take Ativan if you’re pregnant or planning to become pregnant. Clinical experience and research has identified an increased risk of birth effects. Also, is not known if Ativan shows up in breast milk. If this medication is essential to your health, your doctor may advise you to discontinue breast-feeding until your medication treatment is finished.

Ativan dosages recommended for adults and children:

Ativan dosage for adults:

The common Ativan dosage recommended for adults is a total of 2mg to 6 mg per day divided into smaller doses. Usually, the largest dose is taken around bedtime. The total daily Ativan dosage may vary from 1mg to 10 mg per day.

Dosage for Insomnia due to anxiety:

Ativan is usually taken at bedtime in doses of 2mg to 4 mg.

For anxiety:

The usual starting Ativan dosage is a total to 3 mg per day taken in two or three smaller doses.

Ativan dosage for children:

The safety and effectiveness has not been established for using Ativan for children under the age of 12 years of age.

For older adults:

The usual starting Ativan dosage for the elderly and for those in a weakened condition should not exceed a total of 1mg to 2 mg per day, evenly divided into smaller doses to avoid oversedation. This dose can be adjusted by your doctor as necessary.

Ativan overdosage:

All medications taken in excess of the recommended amounts may have very serious consequences. An overdose of Ativan can be fatal, although this is relatively rare. If you suspect an overdose, you should seek medical attention immediately.

Symptoms of an overdose may include:

Coma, confusion, drowsiness, hypnotic state, lack of coordination, low blood pressure, sluggishness.

Information adapted from The PDR Pocket Guide to Prescription Drugs – Sixth Edition

Additional Information and webpage by Paul Susic  Ph.D. Licensed Psychologist  (Health and Geriatric Psychologist)




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300.22 Agoraphobia Symptoms and Related DSM–5 Diagnosis




300. 22 Agoraphobia Diagnosis (F40.00):

Agoraphobia is a diagnosis recently codable according to the new DSM-5 (Diagnostic And Statistical Manual Fifth Edition) published by the American Psychiatric Association. The agoraphobia diagnosis is given when you experience a high level of fear from either real or imagined exposure to specific circumstances or situations. It is most frequently experienced by teens and middle-aged adults in the U.S. with a prevalence rate of 1.7%. It is rarely initially experienced among seniors and young children. If you receive a diagnosis of agoraphobia, you may have anywhere from a moderate to severe level of impairment in your activities of daily living. It has been noted that approximately 33% of people diagnosed with this anxiety disorder feel restricted to their homes.

Agoraphobia Diagnosis: Key Features

Some of the primary aspects of agoraphobia are that you feel fear in situations in which you believe you cannot escape or in which you believe that bad things can happen to you beyond your control. The fear can vary according to your experience with the actual situation or even may occur in anticipation of the circumstance. This response must occur every time you have experience with the situation. An agoraphobia diagnosis cannot be given if you only experience the fear and potential avoidance occasionally. Agoraphobia usually results in avoidance of that situation and may affect both your thinking and behaviors.

An agoraphobia diagnosis can be given whether you meet the criteria or not for a . If the criteria is met for both disorders, you may be given a diagnosis for both. This is a very intense, disabling diagnosis frequently resulting in an individual becoming homebound. An initial agoraphobia diagnosis is rare among children and seniors with a mean age of onset of 17 years old. It usually shows its first signs in the teen and middle-aged years. There are some gender-related differences in that females are about twice as likely to have agoraphobia as males. In most cases if you have a agoraphobia diagnosis you most often experience comorbid mental health disorders such as anxiety and depression. In most cases if you meet the criteria of both agoraphobia and another diagnosis, both diagnoses are given.

Agoraphobia is typically treated within the context of panic disorder. Additional information related to agoraphobia symptoms and treatments may be found on additional pages of this website.

Coding for a Agoraphobia Diagnosis:

Coding for Agoraphobia diagnosis is 300.22 (F40.00). Also, a specifier with panic attacks is often given in conjunction with a diagnosis of agoraphobia.
More specific agoraphobia diagnostic criteria follow below.


Agoraphobia diagnostic criteria 300.22 (F40.00):

A. Marked fear or anxiety about two (or more) of the following five situations:

1. Using public transportation such as automobiles, buses, trains, ships or planes.
2. Being in open spaces such as parking lots, marketplaces or bridges.
3. Being in enclosed places such as shops, theaters, or cinemas.
4. Standing in line or being in a crowd.
5. Being outside of the home alone.




B. The individual fears or avoids these situations because of the thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms such as fear of falling in the elderly or fear of incontinence.

C. The Agoura phobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for six months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. If another medical condition such as inflammatory bowel disease or Parkinson’s disease is present, the fear, anxiety, or avoidance is clearly excessive

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations as in social anxiety disorder; and are not related exclusively to obsessions as in obsessive-compulsive disorder, perceived effects of flaws in physical appearance as in body dysmorphic disorder, reminders of traumatic events as in posttraumatic stress disorder, or fear of separation as in separation anxiety disorder.

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and Agoraphobia, both diagnosis should be assigned.

Diagnostic Information and Criterion adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist



Panic Attack Specifier and Related DSM- 5 Diagnostic Information




Panic Attack Specifier:

Panic attacks can be referred to as a specifier and do not have their own diagnostic code. They are abrupt and intense fears which can occur with other mental disorders such as anxiety and depressive disorders along with physical or medical conditions. The panic attack specifier can be used for both physical and mental disorders. The actual symptoms are detailed below but also are contained within the criteria of panic disorder.

Main Features of the Panic Attack Specifier:

Panic attacks are defined as very intense fears or severe discomfort that occurs and peaks rapidly. The predominating symptoms are physical and must include at least four of the 13 symptoms identified below. These intense symptoms occur and reach their peak usually within several minutes. Panic attacks are very common and have a prevalence rate in the United States of about 11.2%.

A feature that distinguishes panic attacks from normal everyday anxiety is that they reach a high level of intensity within a very short period of time. They are also associated with higher risks for suicidal thoughts and attempts. They are very rare among children and are more frequently experienced by women than men. Panic attacks are not usually treated specifically but are treated within the context of a panic disorder with medications and psychosocial and psychotherapeutic interventions.See below for more specific criteria for the panic attack specifier.




Panic Attack Specifier:

Note: Symptoms are presented for the purpose of identifying a panic attack; however, panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of an anxiety disorder as well as other mental disorders such as depressive disorders, posttraumatic stress disorder, substance use disorders and some medical conditions such as cardiac, respiratory, vestibular, and gastrointestinal. When the presence of a panic attack is identified, it should be noted as a specifier such as in posttraumatic stress disorder with panic attacks. For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, 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.

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, lightheaded, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from one’s self).
12. Fear of losing control or “going crazy.”
13. Fear of dying.

Note: Culture specific symptoms such as tinnitus, neck soreness, headache, or uncontrollable screaming or crying may be seen. Such symptoms should not count as one of the four required symptoms.

Diagnostic Information and Criterion adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist



300. 01 Panic Disorder Symptoms and Related DSM- 5 Diagnosis




Panic Disorder Diagnosis: Introduction

A panic disorder diagnosis can be given when you experience an unexpected series of panic attacks over a period of time. It was first classified by DSM-3 in 1980. Panic disorder is a very common mental health disorder with an annual prevalence rate in the United States of 2.1% to 2.8%, which is the highest rate in the world. Although a small percentage of patients may be diagnosed in early childhood it is most often diagnosed in the teens and early twenties. The median age of onset is 20 to 24 years old, and not many people are identified as having the initial symptoms after the age of 45 years old.

Panic Disorder Diagnosis: The Most Essential Features

The primary features that define a panic disorder are having persistent, inappropriate fears or worries about and recurring and unexpected panic attacks. These usually include changes to your body including dizziness, trembling, increased heart rate and sweating. Both cognitive and physical symptoms accompany the panic attacks and it is also necessary to recognize that the panic attacks that define a panic disorder diagnosis may also be of an expected nature. Usually, people persistently worry about having these recurrent physical symptoms with an intense fear of losing control.

Panic Disorder Diagnosis: Social and Cultural Considerations

It is estimated that approximately 50% of individuals with a panic disorder diagnosis report waking up panic stricken with what has been defined as “nocturnal panic attacks.” It has been proposed that there may be some evidence of genetic predisposition with more women than men having panic disorder. There are also social and cultural considerations involved at times. For example, it is believed that childhood sexual and physical abuse can be a risk factor as well as various other cultural considerations.

It is believed that individuals with a panic disorder diagnosis may display it in different ways within the context of their specific culture. It has been found that African-American and individuals from Afro-Caribbean countries have lower rates of panic disorder than Caucasians. Interestingly however, although Caucasians have a higher rate of panic disorder, they seem to have less functional impairment associated with the panic disorder than among African-Americans.

Panic Disorder and Panic Attacks:

Panic attacks on their own is not a diagnosable condition. Panic attacks do not become panic disorder until an individual has persistent worry and behavioral changes in relation to the unexpected panic attacks over a period of time. Also, panic disorder is not diagnosed if the panic attack is a result of a medical condition or due to the use or abuse of a medication or other substance.

Coding and Treatment for a Panic Disorder:

The only DSM-5 diagnostic code for panic disorder is 300.01 (F41.0). Although panic attack is referred to as a specifier it is not considered to be a mental health disorder and does not have a diagnostic code associated with it. Fortunately, both psychological treatment and medications are available for patients with panic disorder. Also, additional information related to panic disorder symptoms and treatment follows on another page of this website.

The specific symptoms necessary for a panic disorder diagnosis follow below:





Panic Disorder Diagnostic Criteria: 300.01 (F41.0):

A. Unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, 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.

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 oneself).
12. Fear of losing control or “going crazy”.
13. Fear dying.

Note: Culture-specific symptoms such as tinnitus, neck soreness, headache, uncontrollable screaming or crying may be seen. Such symptoms should not count as one of the four required symptoms.

B. At least one of the attacks has been followed by one month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences such as losing control, having a heart attack or “going crazy”.

2. A significant maladaptive change in behavior related to the attacks such as 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 such as a drug of abuse, a medication or another medical condition such as hyperthyroidism or cardiopulmonary disorders.

D. The disturbance is not better explained by another mental disorder such as panic attacks, do not occur only in response to fear and 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.

Diagnostic Information and Criterion adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist



Specific Phobia Symptoms and Related DSM-5 Diagnosis




Specific phobia 300. 29 (F 40. __)

Specific phobia is when an individual has a very high level of fear or anxiety in the presence of a specific circumstance or object. The target object or situation is referred to as the “phobic stimulus”. This fear or anxiety must be significantly disproportionate to the actual threat involved. Specific phobia was first identified as a mental health disorder in the DSM-III published by the American Psychiatric Association in 1987. Some studies have concluded that this phobic disorder carries a lifetime prevalence rate of 9.4% to 12.5%.

Specific Phobia: Main Features

The primary feature of a specific phobia is a very significant fear or anxiety of a specific object or situation which is very disproportionate to the actual threat. A specific phobia can result from experiencing or even witnessing a traumatic experience. Subsequently, the individual will then avoid any exposure or memory of the situation or object. The anxiety and fear will occur at every exposure and may even include panic attacks. The median age of onset is approximately 13 years old.

Significant physiological change occurs resulting in symptoms of accelerated heart rate and blood pressure, hyperarousal, and feeling faint. An individual’s quality of life and daily functioning can be significantly impaired. It is very important to have early intervention as the rate of recovery among children has been found to be about 60% after being treated with cognitive behavioral therapy.

It is important to consider ethnicity and culture when diagnosing specific phobia. In the context of some cultures, fear and anxiety from certain situations and objects may be very real, An example may be a fear of spiders in some geographic locations. African-Americans may have the highest prevalence of specific phobias followed by Caucasians in the United States. Latinos and Asians seem to possess lower rates of specific phobia among the main ethnic groups in the United States. The diagnosis should not be given if a fear is either relevant or proportional when considering the cultural context.

In addition to cultural considerations, it is also important to consider the developmental level involved. Childhood fears and anxieties may be more easily resolved or grown out of then the phobic responses of adults.
It is important to understand the degree of impairment and distress associated with a specific phobia. It is also very important to differentiate it from other phobic reactions. Agoraphobia is known to have many fears that seem to overlap with specific phobias. It would be necessary for the mental health clinician to diagnose agoraphobia when there is more than one object or circumstance that is feared. Social anxiety disorder (social phobia) may be diagnosed when social situations are the source of the fear and anxiety rather than specific phobia. Panic attacks may also occur in relation to feared objects. However, the diagnosis of panic disorder should always supersede the diagnosis of specific phobia if the panic attacks occur unexpectedly.

Specific Phobia Coding:

The ICD-9-CM coding system only included one diagnostic code for specific phobia (300.29). Under the newer ICD-10-CM system assignment is given in relation to the specific phobia involved. Under this newer system, psychologists and counselors should utilize all the codes involved. It has been noted that approximately 75% of individuals diagnosed with a specific phobia fear more than one object or situation. In cases where the individual also experiences panic attacks, the mental health clinician should also add with panic attacks to their specific diagnosis. A complete list of specifiers for specific phobia are listed on the Anxiety Disorders page. An overview of specific phobia information and treatment can also be found on this website.

Diagnostic criteria for specific phobia follow.




Specific Phobia diagnostic criteria:

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or cleaning.

B. The phobic object or situation almost always provokes immediate fear or anxiety.

C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.

D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.

E. The fear, anxiety, or avoidance is persistent, typically lasting for six months or more.

F. The fear, anxiety, or avoidance cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

G. The disturbance is not better explained by the symptoms of another mental disorder including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

Specify if:
Code based on the phobic stimulus:

300. 29 (F40.218) Animal (e.g., spiders, insects, dogs).

300.29 (F40. 228) Natural environment (e.g., heights, storms, water).

300.29 (F40.23x) blood-injection-injury (E. G., Needles, invasive medical procedures).
Coding note:
ICD-10-CM code as follows:
F40.230 fear blood
F40.231 fear of injections and transfusions
F40.232 fear of other medical care
F40.233 fear of injury.

300. 29 (F40. 248) Situational (e.g., airplanes, elevators, enclosed places).

300. 29 (F40. 298) Other (e.g., situations that may lead to choking or vomiting; in children, e.g. loud sounds or costumed characters).
Coding note: When more than one phobic stimulus is present, code all ICD-10-CM codes that apply (e.g., for fear of snakes and flying, F40.218 specific phobia, animal, and F40.248 specific phobia, situational).

Diagnostic Information and Criterion adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist



300.23 Social Anxiety Disorder (Social Phobia) Symptoms and Related Diagnosis




Social Anxiety Disorder and the DSM-5

Social phobia was first classified as a mental disorder in the DSM-III. More recently it has been reclassified in the DSM-5 (Diagnostic And Statistical Manual of Mental Disorders-Fifth edition) as social anxiety disorder. It is one of the most common anxiety disorders with some researchers believing that it has a lifetime prevalence rate of a little more than 10%. Most people are diagnosed with social anxiety disorder in childhood or in the earlier adolescent years. This anxiety disorder is frequently comorbid with other mental health disorders such as major depressive disorder, substance use disorders and other anxiety disorders.

Main Characteristics of Social Anxiety Disorder:

Some of the key features of social anxiety disorder include an ongoing fear and worry of social situations. If you have social anxiety disorder, you may have a fear of negative evaluation by others, performance anxieties or fear of being observed in various social circumstances. The DSM-5 also included a performance only specifier which needs to be experienced for a minimum of six months. Children and adolescents also share the same minimum duration as adults.

While both genders seem to share the same intense fears and worries, women tend to be diagnosed with social anxiety disorder more often than men. An interesting anecdote is that people with social anxiety disorder tend to never marry or have children. This anxiety disorder is highest among Caucasian and Native Americans, and studies have found it to also be high among Latino and Caucasian youth.




Some people may believe shyness to be a social anxiety disorder, but it is not. Shyness is not pathological and does not result in the severe impairment that you would see in someone who has social anxiety disorder. Also, when comparing social anxiety disorder to specific phobias, phobic individuals typically do not worry about being judged in social situations. Individuals with social anxiety disorder seem to have a capacity for age-appropriate interactions as well as social relationships, although they sometimes avoid them and may experience significant personal distress at times. Individuals diagnosed with social anxiety disorder often have significant insight into the disproportionate fear and anxiety they experience in social situations.

Social Anxiety and Public Speaking:

The most common and most easily recognizable social anxiety disorder is fear of public speaking. This disorder is experienced by approximately three out of four or about 75% of the overall population. Most people have some anxiety about speaking in public, while individuals with this performance related social anxiety disorder may have very intense almost disabling ability to speak in front of other people.

Social Anxiety Disorder Treatments:

Some of the treatments available for social anxiety disorder include both psychological treatments and medication. Psychological treatments include cognitive behavioral therapy, relaxation therapy and the use of exposure treatment. Medications treatments include the use of depression medications such as the SSRIs, and anxiety medication such as Xanax and Klonopin.

Social Anxiety Disorder Coding and Specifiers:

Social anxiety disorder has only one diagnostic code: 300.23 (F40.10). However, a performance only specifier may also be included with this disorder if it is specifically related to speaking or performing in public. In most cases these individuals do not avoid social situations and fear evaluation or scrutiny except for when public speaking or performing in front of others. If people experience panic attacks in conjunction with social anxiety disorder, they may also be given the specifier with panic attacks, which should be added to the actual diagnosis.

The specific symptoms of social anxiety disorder follow below.

Social Anxiety Disorder (Social Phobia) diagnostic criteria 300.23 (F40.10):

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions such as having a conversation, meeting unfamiliar people, being observed eating or drinking, and performing in front of others such as giving a speech.

B. Individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated such as feeling humiliated or embarrassed or will lead to rejection or offend others.

C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or 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 six months or more.

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 such as drug of abuse, a medication 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 such as Parkinson’s disease, obesity, disfigurement from burns or injury is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if:

Performance only: If the fear is restricted to speaking or performing in public.

Diagnostic Information and Criterion adaptedfrom the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist



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312.23 Selective Mutism Symptoms and Related DSM-V Diagnosis





Selective Mutism 313.23 (F94.0):

Selective mutism is a voluntary refusal to speak. Elective mutism was first described as a mental disorder in the DSM-III and then was changed to selective mutism in the DSM-IV-TR. It was then moved to the anxiety disorders chapter in the DSM-V due to a restructuring of the categories of mental disorders in the new diagnostic manual.

The primary features of selective mutism are a refusal to speak outside of the home or with other people who are not immediate family members due to choice rather than physical inability to speak. Children may sometimes use nonverbals such as nodding or may choose to speak only to immediate family members although they have the physical capability of speech. The most common age of onset is before five years old and may occur initially at school. It may be seen among adolescents and adults also but not as frequently as among children. A very high level of shyness is also seen among these children along with significant diagnostic comorbidity with other anxiety disorders such as social anxiety disorder. Obviously, children with selective mutism suffer severely in school and social settings and experience significant impairment and withdrawal in these environments.

When diagnosing a child with selective mutism, mental health clinicians need to consider the child’s developmental level and the context within which the symptoms are demonstrated. It is very important not to pathologize normal developmental transitions. With selective mutism the lack of communication is not specific to social environments and is much more widespread. It should be diagnosed only when the child has demonstrated the ability to speak in other situations such as in the home. It is common for children to also experience social anxiety disorder. In this case, both social anxiety disorder and selective mutism should be diagnosed. It is also important to differentially diagnose selective mutism from neurodevelopmental disorders, schizophrenia and other psychotic disorders.

Selective mutism coding:

The only diagnostic code for selective mutism is 313.23 (F94.0) with no specifiers.




Selective Mutism diagnostic criteria 312. 23 (F94.0):

A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g. at school) despite speaking in other situations.

B. The disturbance interferes with educational or occupational achievement or with social communication.

C. The duration of the disturbance is at least one month (not limited to the first month of school).

D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

E. The disturbance is not better explained by a communication disorder (e.g., childhood onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or in another psychiatric disorder.

Diagnostic Information and Criterion adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association By Paul Susic Ph.D. Licensed Psychologist



309. 21 Separation Anxiety Disorder Symptoms and Related Diagnosis





Separation Anxiety Disorder Symptoms and Diagnosis 309.21 (F 93.0):

Separation anxiety disorder was first included as a diagnosable condition in the DSM-3 in 1980. In the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders Fifth Edition) which was published in 2013, it was then moved from the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter of the previous DSM-4-TR to the Anxiety Disorders chapter. Additionally, the age of onset requirement was no longer an expectation allowing the diagnosis of separation anxiety disorder to also be allowed for adults.

Separation Anxiety Disorder Symptoms:

The most important features of separation anxiety disorder include developmentally inappropriate nervousness and fear of separation from a primary caregiver. The physical symptoms include stomachaches, headaches and cardiovascular symptoms in adolescents and adults which are experienced in addition to the fear and anxiety. Usually the fear or worry experienced is associated with a concern for possible harm to figures of attachment. In most cases this leads to a desire to not be away from these attachment figures or of being alone.

For children to experience separation anxiety disorder, symptoms must stand out and be experienced for no less than a minimum of one month. Adults can experience separation anxiety disorder symptoms for their entire lifetime but must be significant for a period of at least six months or longer. Lifetime prevalence rates for separation anxiety disorder are highest among children with the rate of about 4%. Adolescents seem to experience separation anxiety disorder at a rate of approximately 1.6%, with a rate of 0.9% to 1.9% for adults. However, the National Comorbidity Survey Replication found an overall lifetime prevalence rate of separation anxiety disorder in adulthood of approximately 6.6%. Girls tend to experience separation anxiety disorder more often than boys with both experiencing impairment in school, work and social settings.

Although the symptoms of separation anxiety disorder are greater among children, the symptoms for both children and adults are similar in that the individual develops an inordinate fear of separation from loved ones or a fear of harm to them. However, symptoms among children are more overt such as crying and open displays of fear. Adults seem to display the symptoms in a more covert form such as wanting to stay close by, staying home from work or activities or may want to “check-in” often.

An additional concern when diagnosing separation anxiety disorder is that there are some cultural considerations in that individuals from more collectivist cultures may easily be pathologized because the children and adults may be less often separated. These cultures may also result in fewer people seeking treatment for separation anxiety disorder because the closeness may be relatively more of a social expectation.

In addition to the cultural considerations, mental health clinicians need to distinguish between developmentally inappropriate reactions to separation and abnormal reactions. Other mental health conditions such as panic disorder, generalized anxiety disorder, conduct disorder, agoraphobia, PTSD, bereavement, depressive and bipolar disorder, personality disorders, and oppositional defiant disorder are some of the mental health conditions which need to be distinguished from and differentially diagnosed from separation anxiety disorder. Once again, with separation anxiety disorder, the concern is an inordinate fear and worry of being separated from attachment figures.

Separation Anxiety Disorder Treatment:

Treatment for separation anxiety disorder is like treatment for most other anxiety disorders. Psychotherapy including cognitive behavioral therapy, family counseling and medications for anxiety are most often used to remediate the symptoms in children and adults.

Separation Anxiety Disorder Coding:
The coding for separation anxiety disorder is 309.21 (F93.0). There are no specifiers for this anxiety disorder.
Specific separation anxiety disorder symptoms and diagnostic information follow below.

Separation Anxiety Disorder Diagnostic Criteria: 309.21 (F93.0)

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 from home or from major attachment figures.

2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.

3. Persistent and excessive worry about experiencing an untoward event (e.g. Getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.

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 a reluctance about being alone or without major attachment figures at home or in other settings.

6. Persistent reluctance or refusal to sleep away from home or go to sleep without being near a major attachment figure.

7. Repeated nightmares involving the theme of separation.

8. Repeated complaints of physical symptoms (e.g. headaches, stomach aches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.

B. The fear, anxiety, or avoidance is persistent, lasting at least four weeks in children and adolescents and typically six months or more in adults.

C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other 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.

Diagnostic Information and Criterion for Anxiety Disorders from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychiatric Association