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DSM-IV

In DSM-IV, this disorder is called Substance-Induced Anxiety Disorder

Diagnostic Criteria

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
  • 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.

Specify if:

  • 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

Specify if:

  • 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

Specifiers

Symptoms

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.

Context

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 the symptoms develop during, or shortly after, a withdrawal syndrome.

Recording Procedures

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 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., 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., Cocaine-Induced Anxiety Disorder, With Generalized Anxiety, With Onset During Intoxication; 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 substance is unknown, the category Unknown Substance-Induced Anxiety Disorder should be used.

Specific Substances

Anxiety Disorders can occur in associated 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.

Differential Diagnosis

Substance Intoxication and Withdrawal

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.

Delirium

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.

Other Substance-Induced Disorders

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.

Primary Anxiety Disorders

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 remit within days to several weeks (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.

Anxiety Disorder Due to a General Medical Condition

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 judgement. 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.

DSM-5

Diagnostic Criteria

A. Panic attacks or anxiety is predominant in the clinical picture.

B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):

  1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
  2. The involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by an anxiety disorder that is not substance/medication-induced. Such evidence of an independent anxiety disorder could include the following:

  • The symptoms precede the onset of the substance/intoxication use.
  • The symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication.
  • There is other evidence suggesting the existence of an independent non-substance/medication-induced anxiety disorder (e.g., a history of recurrent non-substance/medication-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 symptoms in Criterion A predominate in the clinical picture and they are sufficiently severe to warrant clinical attention.

Note: If a mild substance use disorder is comorbid with the substance-induced anxiety disorder, the clinician should record "mild [substance] use disorder" before the substance-induced anxiety disorder (e.g., "mild cocaine use disorder with cocaine-induced anxiety disorder"). If a moderate or severe substance use disorder is comorbid with the substance-induced anxiety disorder, the clinician should record "moderate [substance] use disorder" or "severe [substance] use disorder," depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy use of the substance), then the clinician should record only the substance-induced anxiety disorder.

Specify if:

  • With onset during intoxication: This specifier applies if criteria are met for intoxication with the substance and the symptoms develop during intoxication.
  • With onset during withdrawal: This specifier applies if criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.
  • With onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use.

Recording Procedures

The name of the substance/medication-induced anxiety disorder begins with the specific substance (e.g., cocaine, salbutamol) that is presumed to be causing the anxiety symptoms. In cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category "unknown substance" should be used.

When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word "with," followed by the name of the substance-induced anxiety disorder, followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal, with onset during medication use). For example, in the case of anxiety symptoms occurring during withdrawal in a man with a severe lorazepam use disorder, the diagnosis is severe lorazepam use disorder with lorazepam-induced anxiety disorder, with onset during withdrawal. A separate diagnosis of the comorbid severe lorazepam use disorder is not given. If the substance-induced anxiety disorder occurs without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g., psilocybin-induced anxiety disorder, 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., severe methylphenidate use disorder with methylphenidate-induced anxiety disorder, with onset during intoxication; salbutamol-induced anxiety disorder, with onset after medication use).

Differential Diagnosis

Substance intoxication and substance withdrawal

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/medication-induced anxiety disorder should be made in addition to substance intoxication or substance withdrawal when the panic or anxiety symptoms are predominant in the clinical picture and are sufficiently severe to warrant independent clinical attention. For example, panic or anxiety symptoms are characteristic of alcohol withdrawal.

Anxiety disorder (i.e., not induced by a substance/medication)

Substance/medication-induced anxiety disorder is judged to be etiologically related to the substance/medical. Substance/medication-induced anxiety disorder is distinguished from a primary anxiety disorder based on the onset, course, and other factors with respect to substances/medications. For drugs of abuse, there must be evidence from the history, physical examination, or laboratory findings for use, intoxication, or withdrawal. Substance/medication-induced anxiety disorders arise only in association with intoxication or withdrawal states, whereas primary anxiety disorders may precede the onset of substance/medication use. The presence of features that are atypical of a primary anxiety disorder, such as atypical age at onset (e.g., onset of panic disorder after age 45 years) or symptoms (e.g., atypical panic attack symptoms such as true vertigo, loss of balance, loss of consciousness, loss of bladder control, headaches, slurred speech) may suggest a substance/medication-induced etiology. A primary anxiety disorder diagnosis is warranted if the panic or anxiety symptoms persist for a substantial period of time (about 1 month or longer) after the end of the substance intoxication or acute withdrawal or there is a history of an anxiety disorder.

Delirium

If panic or anxiety symptoms occur exclusively during the course of delirium, they are considered to be an associated feature of the delirium and are not diagnosed separately.

Anxiety disorder due to another medical condition

If the panic or anxiety symptoms are attributed to the physiological consequences of another medical condition (i.e., rather than to the medication taken for the medical condition), anxiety disorder due to another medical condition should be diagnosed. The history often provides the basis for such a judgement. At times, a change in the treatment for the other medical condition (e.g., medication substitution or discontinuation) may be needed to determine whether the medication is the causative agent (in which case the symptoms may be better explained by substance/medication-induced anxiety disorder). If the disturbance is attributable to both another medical condition and substance use, both diagnoses (i.e., anxiety disorder due to another medical condition and substance/medication-induced anxiety disorder) may be given. When there is insufficient evidence to determine whether the panic or anxiety symptoms are attributable to a substance/medication or to another medical condition or are primary (i.e., not attributable to either a substance or another medical condition), a diagnosis of other specified or unspecified anxiety disorder would be indicated.