Anxiety & Panic

The essential feature of separation anxiety disorder is excessive anxiety concerning separation by a child from the home or from those (in adolescents and adults) to whom the person is attached. This anxiety is beyond that which is expected for the individual’s developmental level. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

Children with separation anxiety disorder tend to come from families that are close-knit. When separated from home or major attachment figures, they may recurrently exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work or play.

Depending on their age, individuals may have fears of animals, monsters, the dark, muggers, burglars, kidnappers, car accidents, plane travel, and other situations that are perceived as presenting danger to the integrity of the family or themselves. Concerns about death and dying are common. School refusal may lead to academic difficulties and social avoidance. Children may complain that no one loves them or cares about them and that they wish they were dead. When extremely upset at the prospect of separation, they may show anger or occasionally hit or lash out at someone who is forcing separation.

When alone, especially in the evening, young children may report unusual perceptual experiences (e.g., seeing people peering into their room, scary creatures reaching for them, feeling eyes staring at them).

Children with this disorder are often described as demanding, intrusive, and in need of constant attention. The child’s excessive demands often become a source of parental frustration, leading to resentment and conflict in the family. Sometimes, children with the disorder are described as unusually conscientious, compliant, and eager to please. The children may have somatic complaints that result in physical examinations and medical procedures.

Depressed mood is frequently present and may become more persistent over time, justifying an additional diagnosis of dysthymic disorder or major depressive disorder. The disorder may precede the development of panic disorder with agoraphobia.

What are the common treatments for separation anxiety disorder?

Specific Symptoms of Separation Anxiety Disorder

Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:

  • recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
  • persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
  • persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
  • persistent reluctance or refusal to go to school or elsewhere because of fear of separation
  • persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
  • persistent reluctance or refusal to go to sleep without being near a near a major attachment figure or to sleep away from home
  • repeated nightmares involving the theme of separation
  • repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated

The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

The disturbance does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and, in adolescents and adults, is not better accounted for by panic disorder with agoraphobia.


DSM-5 diagnostic code 309.21.

Separation Anxiety Disorder Symptoms

Anxiety & Panic

Acute stress disorder is characterized by the development of severe anxiety, dissociation, and other symptoms that occurs within one month after exposure to an extreme traumatic stressor (e.g., witnessing a death or serious accident). As a response to the traumatic event, the individual develops dissociative symptoms. Individuals with acute stress disorder have a decrease in emotional responsiveness, often finding it difficult or impossible to experience pleasure in previously enjoyable activities and frequently feel guilty about pursuing usual life tasks.

A person with acute stress disorder may experience difficulty concentrating, feel detached from their body, experience the world as unreal or dreamlike, or have increasing difficulty recalling specific details of the traumatic event (dissociative amnesia).

In addition, at least one symptom from each of the symptom clusters required for posttraumatic stress disorder is present. First, the traumatic event is persistently re-experienced (e.g., recurrent recollections, images, thoughts, dreams, illusions, flashback episodes, a sense of reliving the event, or distress when exposed to reminders of the event). Second, reminders of the trauma (e.g., places, people, activities) are avoided. Finally, hyperarousal in response to stimuli reminiscent of the trauma is present (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, an exaggerated startle response, and motor restlessness).

Specific Symptoms of Acute Stress Disorder:

Acute stress disorder is most often diagnosed when an individual has been exposed to a traumatic event in which both of the following were present:

  • The person experienced, witnessed, or was confronted with (e.g., can include learning of) an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
  • Though not required, the person’s response is likely to involve intense fear, helplessness, or horror.

Either during or following the distressing event, the individual has 3 or more of the following dissociative symptoms:

  • A subjective sense of numbing, detachment, or absence of emotional responsiveness
  • A reduction in awareness of his or her surroundings (e.g., “being in a daze”)
  • Derealization
  • Depersonalization
  • Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress when exposed to reminders of the traumatic event.

Acute stress disorder is also characterized by significant avoidance of stimuli that arouse recollections of the trauma (e.g., avoiding thoughts, feelings, conversations, activities, places, people). The person experiencing acute stress disorder also has significant symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

For acute stress disorder to be diagnosed, the problems noted above must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

The disturbance in an acute stress disorder must last for a minimum of 3 days and a maximum of 4 weeks, and must occur within 4 weeks of the traumatic event. Symptoms also can not be the result of substance use or abuse (e.g., alcohol, drugs, medications), caused by or an exacerbation of a general or preexisting medical condition, and can not be better explained by a a brief psychotic disorder.


This disorder has been updated according to DSM-5 criterion

Acute Stress Disorder Symptoms

Selective Mutism Symptoms

Anxiety & Panic

Selective mutism is a type of anxiety disorder whose main distinguishing characteristic is the persistent failure to speak in specific social situations (e.g., at school or with playmates) where speaking is expected, despite speaking in other situations.

Selective mutism interferes with educational or occupational achievement or with social communication, and in order for it to be diagnosed, it must last for at least 1 month and is not limited to the first month of school (during which many children may be shy and reluctant to speak).

Selective mutism should not be diagnosed if the individual’s failure to speak is due solely to a lack of knowledge of, or comfort with, the spoken language required in the social situation. It is also not diagnosed if the disturbance is accounted for by embarrassment related to having a communication disorder (e.g., stuttering) or if it occurs exclusively during a pervasive developmental disorder, schizophrenia, or other psychotic disorder. Instead of communicating by standard verbalization, children with this disorder may communicate by gestures, monosyllabic, short, or monotone utterances, or in an altered voice.

Associated Features

Associated features of selective mutism may include excessive shyness, fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling or oppositional behavior, particularly at home. There may be severe impairment in social and school functioning. Teasing or scapegoating by peers is common. Although children with this disorder generally have normal language skills, there may occasionally be an associated communication disorder (e.g., phonological disorder, expressive language disorder, or mixed receptive-expressive language disorder) or a general medical condition that causes abnormalities of articulation.

Anxiety disorders (especially social phobia), mental retardation, hospitalization, or extreme psychosocial stressors may be associated with the disorder.

Immigrant children who are unfamiliar with or uncomfortable in the official language of their new host country may refuse to speak to strangers in their new environment (which is not considered selective mutism).

Selective mutism seems to be rare, being found in fewer than 0.05 percent of children seen in general school settings. Selective mutism is slightly more common in females than in males.


Criteria summarized from: Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC: American Psychiatric Association.

Selective Mutism Symptoms

Selective Mutism Symptoms

Anxiety & Panic

Cessation or reduction in alcohol use, especially after a period of heavy and prolonged drinking, results in alcohol withdrawal. Medical attention should be sought for severe symptoms of alcohol withdrawal. Treatment usually involves hospitalization (i.e., inpatient detox) with medication. See more concerning alcohol use disorder treatment.

The symptoms of alcohol withdrawal syndrome develop within several hours to a few days after an individual stops drinking. These can include:

  • Insomnia (trouble sleeping)
  • Autonomic symptoms (including, sweating or racing heart)
  • Increased hand tremors (known as “the shakes”)
  • Nausea and/or vomiting
  • Psychomotor agitation (feeling physically restless, inability to stop moving)
  • Anxiety
  • Seizures (typically the generalized tonic-clonic type, which is characterized by rhythmic, yet jerking movement, especially of the limbs)
  • Hallucinations, or perceptual disturbances of the auditory, tactile, or visual type (the rarest of alcohol withdrawal symptoms)

In order to meet the DSM-5 criteria for alcohol withdrawal syndrome, a person must experience a combination of two of more of these symptoms. Significant distress or impairment in social, occupational, or other important areas of functioning must also be present.  These symptoms must be directly caused by stopping or reducing alcohol intake and not attributable to other medical conditions, a primary mental disorder, or the influence of another substance.

See information about medical treatment of alcohol withdrawal.


This criteria has been updated for the current DSM-5 (2013). 

DSM-5 Alcohol Withdrawal Symptoms