Diagnostic Features
The essential feature of Anxiety Disorder Due to a General Medical Condition is clinically significant anxiety that is judged to be due to the direct physiological effects of a general medical condition. Symptoms can include prominent, generalized anxiety symptoms, Panic Attacks, or obsessions or compulsions (Criterion A). There must be evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition (Criterion B). The disturbance is not better accounted for by another mental disorder, such as Adjustment Disorder With Anxiety, in which the stressor is the general medical condition (Criterion C). The diagnosis is not made if the anxiety symptoms occur only during the course of a delirium (Criterion D). The anxiety symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E).

In determining whether the anxiety symptoms are due to a general medical condition, the clinician must first establish the presence of a general medical condition. Further, the clinician must establish that the anxiety symptoms are etiologically related to the general medical condition through a physiological mechanism.

A careful and comprehensive assessment of multiple factors is necessary to make this judgment. Although there are no infallible guidelines for determining whether the relationship between the anxiety symptoms and the general medical condition is etiological, several considerations provide some guidance in this area. One consideration is the presence of a temporal association between the onset, exacerbation, or remission of the general medical condition and the anxiety symptoms. A second consideration is the presence of features that are atypical of a primary Anxiety Disorder (e.g., atypical age at onset or course, or absence of family history). Evidence from the literature that suggests that there can be a direct association between the general medical condition in question and the development of anxiety symptoms may provide a useful context in the assessment of a particular situation. In addition, the clinician must also judge that the disturbance is not better accounted for by a primary Anxiety Disorder, a Substance-Induced Anxiety Disorder, or other primary mental disorders (e.g., Adjustment Disorder).

Specifiers

The following specifiers can be used to indicate which symptom presentation predominates in Anxiety Disorder Due to a General Medical Condition:

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.

Recording Procedures
In recording the diagnosis of Anxiety Disorder Due to a General Medical Condition, the clinician should first note the presence of the Anxiety Disorder, then the identified general medical condition judged to be causing the disturbance, and finally the appropriate specifier indicating the predominant symptom presentation on Axis I (e.g., Anxiety Disorder Due to Thyrotoxicosis, With Generalized Anxiety). The ICD-9-CM code for the general medical condition should also be noted on Axis III (e.g.,  thyrotoxicosis).

Associated General Medical Conditions
A variety of general medical conditions may cause anxiety symptoms, including endocrine conditions (e.g., hyper- and hypothyroidism, pheochromocytoma, hypoglycemia, hyperadrenocorticism), cardiovascular conditions (e.g., congestive heart failure, Pulmonary embolism, arrhythmia), respiratory conditions (e.g., chronic obstructive pulmonary disease, pneumonia, hyperventilation), metabolic conditions (e.g., vitamin B12 deficiency, porphyria), and neurological conditions (e.g., neoplasms, vestibular dysfunction, encephalitis). The associated physical examination findings, laboratory findings, and patterns of prevalence or onset reflect the etiological general medical condition.

Differential Diagnosis

A separate diagnosis of Anxiety Disorder Due to a General Medical Condition is not given if the anxiety disturbance occurs exclusively during the course of a delirium. However, a diagnosis of Anxiety Disorder Due to a General Medical Condition may be given in addition to a diagnosis of dementia if the anxiety is a direct etiological consequence of the pathological process causing the dementia and is a prominent part of the clinical presentation. If the presentation includes a mix of different types of symptoms (e.g., mood and anxiety), the specific Mental Disorder Due to a General Medical Condition depends on which symptoms predominate in the clinical picture.

If there is evidence of recent or prolonged substance use (including medications with psychoactive effects), withdrawal from a substance, or exposure to a toxin, a Substance-Induced Anxiety Disorder should be considered. It may be useful to obtain a urine or blood drug screen or other appropriate laboratory evaluation. Symptoms that occur during or shortly after (i.e., within 4 weeks of) Substance Intoxication or Withdrawal or after medication use may be especially indicative of a Substance-Induced Anxiety Disorder, depending on the type, duration, or amount of the substance used. 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) can be given.

Anxiety Disorder Due to a General Medical Condition should be distinguished from a primary Anxiety Disorder (especially Panic Disorder, Generalized Anxiety Disorder, and Obsessive-Compulsive Disorder) and from Adjustment Disorder With Anxiety or With Mixed Anxiety and Depressed Mood (e.g., a maladaptive response to the stress of having a general medical condition). In primary mental disorders, no specific and direct causative physiological mechanisms associated with a general medical condition can be demonstrated. Late age at onset and the absence of a personal or family history of Anxiety Disorders suggest the need for a thorough assessment to rule out the diagnosis of Anxiety Disorder Due to a General Medical Condition. In addition, anxiety symptoms may be an associated feature of another mental disorder (e.g., Schizophrenia, Anorexia Nervosa).

Anxiety Disorder Not Otherwise Specified is diagnosed if the clinician cannot determine whether the anxiety disturbance is primary, substance induced, or due to a general medical condition.

Diagnostic criteria for Anxiety Disorder Due to . . . [Indicate the General Medical Condition]

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 that the disturbance is the direct physiological consequence of a general medical condition.
C. The disturbance is not better accounted for by another mental disorder (e.g., Adjustment Disorder With Anxiety in which the stressor is a serious general medical condition).
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.

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

Coding note: Include the name of the general medical condition on Axis I, e.g., Anxiety Disorder Due to Pheochromocytoma, With Generalized Anxiety; also code the general medical condition on Axis III.