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Classification of Anxiety Disorders in Children and Adolescents
Cecilia A. Essau1, Beatriz Olaya2, and Thomas H. Ollendick3
1University of Roehampton, UK
2CIBER en Salud Mental (CIBERSAM), Spain
3Virginia Polytechnic Institute and State University, USA
Anxiety is a mood state characterized by strong negative emotion in response to threatening events or situations â either real or imagined (Barlow, 1988). It is part of the human condition and is observed in infancy and early childhood. Anxiety is a complex phenomenon which is expressed through three interrelated response systems: physical, cognitive, and behavioral systems. At the cognitive level, the situation is perceived as either threatening or dangerous. Cognitive components of anxiety include anxiety thoughts in response to negative distortions in attention and interpretation, such as worry, fear of being unable to cope with the situation, and uncertainty about the future (Beck, 1976). At the physical level, the perception or anticipation of danger involves the activation of the sympathetic nervous system, which produces both chemical and physical effects that help to mobilize the body for action (Rapee, Craske, & Barlow, 1995). At the behavioral level, the urge that accompanies the fight/flight response is a desire to escape the situation. Behavioral responses include nail-biting and foot-tapping. The most common behavioral symptom, however, is avoidance of the fearful stimuli (e.g., tunnel) or situations (e.g., speaking in a group). Although avoidance results in temporary relief of the anxiety symptoms, it keeps anxiety going and may cause impairment in various life domains.
All children experience anxieties and fears as a normal part of growing up (Table 1.1). However, fears and anxieties change throughout childhood and adolescence and correspond to the childâs cognitive development in recognizing and interpreting situations as dangerous. Anxiety serves as a biological warning system and readies the child for action. As such, anxiety can have adaptive value when a child is actually confronted by dangerous stimuli. In fact, moderate levels of anxiety enhance performance and facilitate important developmental transitions. Although normal anxiety can be acutely distressing, in most children it is usually transient. However, because all children show anxiety in some situations and because anxiety is normative at certain developmental periods, it is often difficult to differentiate ânormalâ from âabnormalâ anxiety (or an anxiety disorder). An anxiety is classified as a disorder that should be treated when: (1) the duration and intensity does not correspond to the real danger of the situation; (2) it occurs in âharmlessâ situations; (3) it is chronic (i.e., lasts over a long period of time); and (4) causes impairment and interferes with psychological, academic, and social functioning (Essau, 2007).
Table 1.1 Common fears in infancy, childhood and adolescence.
Our current classification systems â the Diagnostic and Statistical Manual (DSM) currently in its fourth edition (DSM-IV) (APA, 2000) and the International Classification of Diseases (ICD) currently in its 10th revision (ICD-10) (WHO, 1992) â make an explicit distinction between ânormalâ and âabnormalâ anxiety based on the number, severity, persistence, and impairment of symptoms. Additionally, the symptoms cannot be better accounted for by other mental disorders, a general medical condition, or as a result of substance use.
Categorical Classification Systems: DSM-IV and ICD-10
Both DSM-IV and ICD-10 classification systems use categorical approaches to classification. The basic assumption of this approach is that emotional, behavioral, cognitive, and physiological symptoms of psychopathology cluster together to form discrete disorders that are distinct from each other (APA, 2000). The DSM-IV criteria were established, for the most part, by empirical studies via systematic field trials and then balanced by expert opinion. In contrast, the diagnostic criteria in the ICD-10 are based primarily on expert consensus that was later tested with field trials in various countries (WHO, 1992). Although the most recent versions of these systems have increasingly resulted in greater convergence between them, some differences remain (Table 1.2).
Table 1.2 Classification of anxiety disorders according to ICD-10 and DSM-IV.
F40 Phobic anxiety disorders
F40.0 Agoraphobia
.00 Without panic disorder
.01 With panic disorder
F40.1 Social phobias
F40.2 Specific (isolated) phobias
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified |
300.22 Agoraphobia without history of panic disorder
300.23 Social phobia
300.29 Specific phobia |
F41 Other anxiety disorders
F41.0 Panic disorder [episodic paroxysmal anxiety]
F41.1 Generalized anxiety disorder
F41.2 Mixed anxiety and depressive disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified |
300.21 Panic disorder with agoraphobia
300.01 Panic disorder without agoraphobia
300.02 Generalized anxiety disorder
300.00 Anxiety disorder NOS |
F42 Obsessive-compulsive disorder
F42.0 Predominantly obsessional thoughts or ruminations
F42.1 Predominantly compulsive acts [obsessional rituals]
F42.2 Mixed obsessional thoughts and acts
F42.8 Other obsessive-compulsive disorders
F42.9 Obsessive-compulsive disorder, unspecified |
300.3 Obsessive- compulsive disorder |
F43 Reaction to severe stress, and adjustment disorders
F43.0 Acute stress reaction
F43.1 Post-traumatic stress disorder
F43.2 Adjustment disorders
F43.8 Other reactions to severe stress
F43.9 Reaction to severe stress, unspecified |
308.3 Acute stress disorder
309.81 Posttraumatic stress disorder |
Several changes have taken place in the categorization of anxiety disorders in childhood in DSM-IV (APA, 1994). Except for separation anxiety disorder (SAD), all the other anxiety disorders are classified in one category regardless of the age in which the disorder first manifests. Two anxiety disorders that are specific to childhood in DSM-III-R â avoidant disorder and overanxious disorder â were subsumed under social phobia and generalized anxiety disorder (GAD), respectively, in DSM-IV. The decision was to increase consistency with the ICD; furthermore, the decision was based on the lack of evidence that avoidant disorder and overanxious disorder are sufficiently different from their adult counterparts (Kendall & Warman, 1996). Children and adolescents with avoidant disorder do not differ significantly in sociodemographic features (e.g., race, socioeconomic status) from those with social phobia, and there was considerable overlap between these two disorders (Francis, Last, & Strauss, 1992).
In DSM-IV, anxiety disorders can be categorized into eight separate major diagnostic syndromes, which are applicable to children, adolescents, and adults. These include: social phobia, specific phobia, GAD, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD), and agoraphobia. The common characteristics of all these anxiety disorders are extensive anxiety, physiological anxiety symptoms, and behavioral disturbances (e.g., extreme avoidance of feared objects or situations) which cause significant impairment in functioning. They differ in relation to the nature of the feared stimulus and the anxiety response produced by it. The content of anxious thoughts or worries, and the anticipated harm also varies across anxiety disorders. For example, the main content of worry or anxious thoughts experienced by children with OCD may be contamination, and the anticipated fear is contracting a disease (Keeley & Storch, 2009). Among children with SAD, the content of worry is related to being separated from the caregiver, and the anticipated fear is harm to self or the caregiver (Seligman & Ollendick, 2011).
For almost all anxiety disorders, any differences in diagnostic criteria for children, adolescents, and adults are provided within the criteria set. These differences are usually related to duration, symptom types, or the extent to which children possess enough insight into the excessiveness or inadequacy of fear (APA, 2000). Specifically, for example, in order to minimize overdiagnosis of normal developmental fears, the symptoms must be present for at least 6 months in specific and social phobias (APA, 2000). Children may also express their anxiety through crying, tantrums, and clinging. For OCD, specific and social phobias, children do not have to acknowledge their fears as being unreasonable or excessive.
In ICD-10, childhood anxiety disorders are classified in a single category, with subcategories that comprise separation anxiety disorder, phobic anxiety disorder, social anxiety disorder, and sibling rivalry disorder; these disorders differ from anxiety disorders in adults by being exaggerations of normal developmental fears (WHO, 1992). ICD also has a category called âotherâ which includes identity disorder and overanxious disorder.
In this chapter, we will review the major characteristics of anxiety disorders as listed in DSM-IV and their differences from ICD-10.
Separation Anxiety Disorder (SAD)
SAD is defined as a developmentally inappropriate and excessive anxiety regarding separation from those to whom the individual is attached (APA, 2000). In order to meet the DSM-IV criteria for SAD at least three of the following eight criteria must be met: (i) recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated; (ii) persistent and excessive worry about losing, or about possible harm befalling, major attachment figures; (iii) persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or kidnapped); (iv) reluctance or refusal to go to school or elsewhere because of fear of separation; (v) persistently and excessively fearful or reluctance to be alone or without major attachment figures at home or without significant adults in other settings; (vi) persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home; (vii) repeated nightmares involving the theme of separation; and (viii) repeated complaints of physical symptoms (e.g., headaches, stomach aches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated (APA, 2000). Furthermore, the symptoms must last at least 4 weeks and the onset of the symptoms must be before 18 years of age.
Both DSM-IV and ICD-10 are similar in terms of the specific indicator for SAD; however, they differ in criteria related to impairment, age of onset, and symptoms duration. Specifically, DSM-IV requires that the symptoms result in impairment in the academic, familial, social, and other domains. ICD-10, on the other hand, requires impairment only in the social domain. In terms of age of onset, DSM-IV specifies an onset anytime before the age of 18 years whereas ICD-10 states that separation concerns need to be present during the preschool years and should these concerns persist, SAD is diagnosed during later childhood and adolescence. The symptoms must have been present for at least 4 weeks in DSM-IV. ICD-10 does not specify any criteria for minimum duration.
Specific Phobia
The main feature of a specific phobia (formerly called simple phobia in DSM-III and DSM-III-R) is a marked and persistent fear of a specific object or situation that poses little or no danger (APA, 2000). The presence or anticipation of a specific object/situation almost always leads to an immediate anxiety response which might reach the severity threshold of situational bound panic attack. The situations or objects are avoided whenever possible or endured with intense anxiety. The fear and the avoidance behavior have to interfere significantly with the childâs normal life or to be associated with clinically significant suffering (Ollendick, King, & Muris, 2004).
DSM-IV modified three criteria that are used for children, namely that (i) panic-like features might be manifested with different emotional responses and may take the form of crying, tantrums, freezing or clinging; (ii) children are not required to consider their fear as irrational or excessive; and (iii) the duration in children must be at least of 6-month duration to warrant a diagnosis.
The DSM-IV differentiates between four subtypes of specific phobia: animal type (fear cued by animals or insects), natural-environment type (fear cued by natural environment such as water, heights, storm), blood-injection-injury type (fear cued by seeing blood, or receiving an injection), situational type (fear cued by specific situations such as flying in an airplane, going through a tunnel), and a residual category (fear cued by other stimuli such as choking, vomiting, loud sounds, and costumed characters). The main feature of each subtype of specific phobia is that fear is circumscribed to a specific object. Thus, when confronted with a feared object, the child with specific phobia will become immediately frightened. The fear is related to concern about dreadful things happening or fear of consequences related to being exposed to the feared object. The decision to differentiate between various types of phobia arises from research suggesting that each type has distinct features, including different gender distribution, age of onset, physiological response, and comorbidity patterns (Antony, Brown, & Barlow, 1997; Lipsitz, Barlow, Mannuzza, et al., 2002; Ollendick, Raishevich, Davis, Sirbu, & Ost, 2010).
The diagnostic criteria of ICD-10 are similar to that of DSM-IV, except that ICD-10 does not classify specific phobic into specific types. Furthermore, ICD-10 does not specify a duration criterion whereas DSM-IV indicates duration of at least 6 months.
Social Phobia
Social phobia (or social anxiety disorder) is characterized by a persistent fear of social (e.g., social gatherings, oral presentation) or performance (e.g., oral presentation) situations that involve possible scrutiny of others (APA, 2000). The individuals fear they will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. As a result, the feared situations are avoided or are endured with distress. Exposure to the feared social situations generally produces high levels of anxiety and is associated with a wide range of symptoms such as stammering, trembling, and blushing. DSM-IV provides a specifier for social phobia: the specific and the generalized type (APA, 2000). Individuals with the specific type of social phobia have a fear of specific, circumscribed social situations, while those with generalized social phobia fear being in most soc...
