DSM-5 Changes: Anxiety Disorders & Phobias

By JOHN M. GROHOL, PSY.D.

The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has a number of changes to anxiety and anxiety disorders, including phobias. This article outlines some of the major changes to these conditions. According to the American Psychiatric Association (APA), the publisher of the DSM-5, the DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder or PTSD (posttraumatic stress disorder). Instead, these disorders have been relocated to their own respective chapters.

Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia)

The largest change for these three disorders is that a person no longer has to recognize that their anxiety is excessive or unreasonable in order to receive one of these diagnoses. According to the APA, This change is based on evidence that individuals with such disorders often overestimate the danger in phobic situations and that older individuals often misattribute phobic fears to aging. The anxiety now must be out of proportion to the actual threat or danger the situation poses, after taking into account all the factors of the environment and situation.

The symptoms must also last at least 6 months for all ages now, a change intended to help minimize over-diagnosis of occasional fears.

Panic Attack
There are no significant changes to the criteria for panic attacks. However, the DSM-5 removes the description of different kinds of panic attacks and lumps them into one of two categories expected and unexpected. Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders, including but not limited to anxiety disorders, notes the APA. Hence, panic attack can be listed as a specifier that is applicable to al l DSM5 disorders.

Panic Disorder and Agoraphobia

The biggest change with these two disorders in the new DSM-5 is that panic disorder and agoraphobia are no longer linked together. They are now recognized as two separate disorders. The APA justifies this unlinking because they found that a significant number of people with agoraphobia do not experience panic symptoms. Agoraphobia symptom criteria remain unchanged from DSM-IV, although endorsement of fears from two or more agoraphobia situations is now required, because this is a robust means for distinguishing agoraphobia from specific phobias, says the APA. Also, the criteria for agoraphobia are extended to be consistent with criteria sets for other anxiety disorders (e.g., clinician judgment of the fears as being out of proportion to the actual danger in the situation, with a typical duration of 6 months or more).

Specific Phobia (also known as Simple Phobia)

Specific phobia symptom criteria remain unchanged from the DSM-IV, except (as previously noted) adults no longer must recognize that their anxiety or fear is excessive or unreasonable. Symptoms must also now have been present for at least 6 months for all ages in order for a diagnosis to be made of specific phobia.

Social Anxiety Disorder (also known as Social Phobia)

Specific symptoms of social anxiety disorder (social phobia) remain unchanged from the DSM-IV, except (as previously noted) adults no longer must recognize that their anxiety or fear is excessive or unreasonable. Symptoms must also now have been present for at least 6 months for all ages in order for a diagnosis to be made of social anxiety disorder. The only other significant change was made in the specifiers of social phobia: the generalized specifier has been deleted and replaced with a performance only specifier, according to the APA. Why? The DSM-IV generalized specifier was problematic in that fears include most social situations was difficult to operationalize. Individuals who fear only performance situations (i.e., speaking or performing in front of an audience) appear to represent a distinct subset of social anxiety disorder in terms of etiology, age at onset, physiological response, and treatment response.

Separation Anxiety Disorder

Specific symptoms of separation anxiety disorder remain unchanged, although the wording of the criteria has been slightly modified and updated. For example, attachment figures may include the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school, notes the APA. In contrast to DSM-IV, the diagnostic criteria no longer specify that age at onset must be before 18 years, according to the APA, because a substantial number of adults report onset of separation anxiety after age 18. Also, a duration criterion typically lasting for 6 months or more has been added for adults to minimize overdiagnosis of transient fears. Separation anxiety disorder was moved from the DSM-IV section Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence and is now considered an anxiety disorder.

Selective Mutism
Selective mutism was previously classified in the section Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence in the DSM-IV. It is now classified as an anxiety disorder. Why was this change made? The APA justifies it because a large majority of chi ldren with selective mutism are anxious. The diagnostic criteria are largely unchanged from DSM-IV.