208 Anxiety Disorders
Comorbidity
Social anxiety disorder is often comorbid wi th other anxiety disorders, major depressive
disorder, and substance use diso rders, and the onset of social anxiety disorder generally
precedes that of the other disorders, except for specific phobia and separation anxiety dis-
order. Chronic social isolation in the course of  a social anxiety disorder may result in major
depressive disorder. Comorbidity with depression is high also in older adults. Substances
may be used as self-medication for social fe ars, but the symptoms of substance intoxica-
tion or withdrawal, such as trembling, may also be a source of (further) social fear. Social
anxiety disorder is frequently comorbid with  bipolar disorder or body dysmorphic disor-
der; for example, an individual has body dysmorphic disorder co ncerning a preoccupa-
tion with a slight irregularity of her nose, as  well as social anxiety disorder because of a
severe fear of sounding unintelligent. The mo re generalized form of social anxiety disor-
der, but not social anxiety di sorder, performance only, is often comorbid with avoidant
personality disorder. In children, comorbidities with high-functioning autism and selec-
tive mutism are common.
Panic Disorder
Diagnostic Criteria 300.01 (F41.0)
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear
or intense discomfort that reaches a peak within minutes, and during which time four
(or more) of the following symptoms occur:
Note:  The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.