The essential features of Substance-Induced Anxiety Disorder are prominent anxiety symptoms (Criterion A) that are judged to be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure) (Criterion B). Depending on the nature of the substance and the context in which the symptoms occur (i.e., during intoxication or withdrawal), the disturbance may involve prominent anxiety, Panic Attacks, phobias, or obsessions or compulsions. Although the clinical presentation of the Substance-Induced Anxiety Disorder may resemble that of Panic Disorder, Generalized Anxiety Disorder, Social Phobia, or Obsessive-Compulsive Disorder, the full criteria for one of these disorders need not be met. The disturbance must not be better accounted for by a mental disorder (e.g., another Anxiety Disorder) that is not substance induced (Criterion C). The diagnosis is not made if the anxiety symptoms occur only during the course of a delirium (Criterion D). The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E). This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the anxiety symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the anxiety symptoms are sufficiently severe to warrant independent clinical attention.
A Substance-Induced Anxiety Disorder is distinguished from a primary Anxiety Disorder by considering the onset, course, and other factors. For drugs of abuse, there must be evidence from the history, physical examination, or laboratory findings of Dependence, Abuse, intoxication, or withdrawal.
Substance-Induced Anxiety Disorders arise only in association with intoxication or withdrawal states, whereas primary Anxiety Disorders may precede the onset of substance use or occur during times of sustained abstinence. Because the withdrawal state for some substances (e.g., some benzodiazepines) can be relatively protracted, the onset of the anxiety symptoms can occur up to 4 weeks after cessation of substance use but is usually earlier.
Another consideration is the presence of features that are atypical of a primary Anxiety Disorder (e.g., atypical age at onset or course). For example, the onset of Panic Disorder after age 45 years (which is rare) or the presence of atypical symptoms during a Panic Attack (e.g., true vertigo; loss of balance, consciousness, or bladder or bowel control; headaches; slurred speech; or amnesia) may suggest a substance-induced etiology. In contrast, factors suggesting that the anxiety symptoms are better accounted for by a primary Anxiety Disorder include persistence of anxiety symptoms for a substantial period of time (i.e., a month or longer) after the end of Substance Intoxication or acute Withdrawal; the development of symptoms that are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or a history of prior recurrent primary Anxiety Disorders.
The following specifiers can be used to indicate which symptom presentation predominates:
With Generalized Anxiety. This specifier may be used if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation.
With Panic Attacks. This specifier may be used if Panic Attacks predominate in the clinical presentation.
With Obsessive-Compulsive Symptoms. This specifier may be used if obsessions or compulsions predominate in the clinical presentation.
With Phobic Symptoms. This specifier may be used if phobic symptoms predominate in the clinical presentation.
The context of the development of the anxiety symptoms may be indicated by using one of the following specifiers:
With Onset During Intoxication. This specifier should be used if criteria for intoxication with the substance are met and the symptoms develop during the intoxication syndrome.
With Onset During Withdrawal. This specifier should be used if criteria for withdrawal from the substance are met and the symptoms develop during, or shortly after, a withdrawal syndrome.
The name of the diagnosis of Substance-Induced Anxiety Disorder begins with the specific substance (e.g., alcohol, methylphenidate, thyroxine) that is presumed to be causing the anxiety symptoms. The diagnostic code is selected from the listing of classes of substances provided in the criteria set. For substances that do not fit into any of the classes (e.g., thyroxine), the code for “Other Substance” should be used. In addition, for medications prescribed at therapeutic doses, the specific medication can be indicated by listing the appropriate E-code on Axis I (see Appendix G). The name of the disorder (e.g., Caffeine-Induced Anxiety Disorder) is followed by the specification of the predominant symptom presentation and the context in which the symptoms developed (e.g., 292.89 Caffeine-Induced Anxiety Disorder, With Panic Attacks, With Onset During Intoxication). When more than one substance is judged to play a significant role in the development of anxiety symptoms, each should be listed separately (e.g., 292.89 Cocaine-Induced Anxiety Disorder, With Generalized Anxiety, With Onset During Intoxication; 291.89 Alcohol-Induced Anxiety Disorder, With Generalized Anxiety, With Onset During Withdrawal). If a substance is judged to be the etiological factor, but the specific substance or class of substances is unknown, the category 292.89 Unknown Substance-Induced Anxiety Disorder should be used.
Anxiety Disorders can occur in association with intoxication with the following classes of substances: alcohol; amphetamine and related substances; caffeine; cannabis; cocaine; hallucinogens; inhalants; phencyclidine and related substances; and other or unknown substances. Anxiety Disorders can occur in association with withdrawal from the following classes of substances: alcohol; cocaine; sedatives, hypnotics, and anxiolytics; and other or unknown substances.
Some of the medications reported to evoke anxiety symptoms include anesthetics and analgesics, sympathomimetics or other bronchodilators, anticholinergics, insulin, thyroid preparations, oral contraceptives, antihistamines, antiparkinsonian medications, corticosteroids, antihypertensive and cardiovascular medications, anticonvulsants, lithium carbonate, antipsychotic medications, and antidepressant medications. Heavy metals and toxins (e.g., volatile substances such as gasoline and paint, organophosphate insecticides, nerve gases, carbon monoxide, carbon dioxide) may also cause anxiety symptoms.
Anxiety symptoms commonly occur in Substance Intoxication and Substance Withdrawal. The diagnosis of the substance-specific intoxication or substance-specific withdrawal will usually suffice to categorize the symptom presentation. A diagnosis of Substance-Induced Anxiety Disorder should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the anxiety symptoms are judged to be in excess of those usually associated with the intoxication or withdrawal syndrome and when the anxiety symptoms are sufficiently severe to warrant independent clinical attention. For example, anxiety symptoms are a characteristic feature of Alcohol Withdrawal. Alcohol-Induced Anxiety Disorder should be diagnosed instead of Alcohol Withdrawal only if the anxiety symptoms are more severe than those usually encountered with Alcohol Withdrawal and are sufficiently severe to be a separate focus of attention and treatment. If substance-induced anxiety symptoms occur exclusively during the course of a delirium, the anxiety symptoms are considered to be an associated feature of the delirium and are not diagnosed separately. In substance-induced presentations that contain a mix of different types of symptoms (e.g., mood, psychotic, and anxiety), the specific type of Substance-Induced Disorder to be diagnosed depends on which type of symptoms predominates in the clinical presentation.
A Substance-Induced Anxiety Disorder is distinguished from a primary Anxiety Disorder by the fact that a substance is judged to be etiologically related to the symptoms.
A Substance-Induced Anxiety Disorder due to a prescribed treatment for a mental disorder or general medical condition must have its onset while the person is receiving the medication (or during withdrawal, if a withdrawal syndrome is associated with the medication). Once the treatment is discontinued, the anxiety symptoms will usually improve markedly or remit within days to several weeks to a month (depending on the half-life of the substance and the presence of a withdrawal syndrome). If symptoms persist beyond 4 weeks, other causes for the anxiety symptoms should be considered.
Because individuals with general medical conditions often take medications for those conditions, the clinician must consider the possibility that the anxiety symptoms are caused by the physiological consequences of the general medical condition rather than the medication, in which case Anxiety Disorder Due to a General Medical Condition is diagnosed. The history often provides the primary basis for such a judgment. At times, a change in the treatment for the general medical condition (e.g., medication substitution or discontinuation) may be needed to determine empirically for that person whether or not the medication is the causative agent. If the clinician has ascertained that the disturbance is due to both a general medical condition and substance use, both diagnoses (i.e., Anxiety Disorder Due to a General Medical Condition and Substance-Induced Anxiety Disorder) may be given. When there is insufficient evidence to determine whether the anxiety symptoms are due to a substance (including a medication) or to a general medical condition or are primary (i.e., not due to either a substance or a general medical condition), Anxiety Disorder Not Otherwise Specified would be indicated.
Diagnostic criteria for Substance-Induced Anxiety Disorder
A. Prominent anxiety, Panic Attacks, or obsessions or compulsions predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
(1) the symptoms in Criterion A developed during, or within 1 month of, Substance Intoxication or Withdrawal
(2) medication use is etiologically related to the disturbance
C. The disturbance is not better accounted for by an Anxiety Disorder that is not substance induced. Evidence that the symptoms are better accounted for by an Anxiety Disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence suggesting the existence of an independent non-substance-induced Anxiety Disorder (e.g., a history of recurrent non-substance-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the anxiety symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the anxiety symptoms are sufficiently severe to warrant independent clinical attention.
Code [Specific Substance]-Induced Anxiety Disorder
(291.89 Alcohol; 292.89 Amphetamine (or Amphetamine-Like Substance); 292.89 Caffeine; 292.89 Cannabis; 292.89 Cocaine; 292.89 Hallucinogen; 292.89 Inhalant; 292.89 Phencyclidine (or Phencyclidine-Like Substance); 292.89 Sedative, Hypnotic, or Anxiolytic; 292.89 Other [or Unknown] Substance)
With Generalized Anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation
With Panic Attacks: if Panic Attacks predominate in the clinical presentation
With Obsessive-Compulsive Symptoms: if obsessions or compulsions predominate in the clinical presentation
With Phobic Symptoms: if phobic symptoms predominate in the clinical presentation
With Onset During Intoxication: if the criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome
With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome