GC167 I Feel Very Nervous Anxiety Disorders
Anxiety disorders are a group of mental health conditions characterized by excessive, persistent fear, worry, or nervousness that causes significant distress and impairment in daily functioning.
I Feel Very Nervous: Anxiety Disorders
Lecture Map
Anxiety disorders are common. Anxiety is a normal threat response that becomes clinically important when it is disproportionate or persistent and causes distress or functional impairment. This lecture walks from a simplified limbic-system model through symptoms, diagnostic patterns and management of Generalised Anxiety Disorder (GAD), Panic Disorder, and Specific, Social and Agoraphobic anxiety. It also teaches OCD beside them, although DSM-5/DSM-5-TR classifies OCD and trauma-related disorders in separate chapters.
- The role of the limbic system in emotional response and anxiety disorders
- Clinical manifestation of anxiety symptoms
- Common anxiety disorders
- Management of anxiety disorders
Core Concepts and Mechanisms
The slide's amygdala-based neurocircuit is a useful teaching model, not a diagnostic scan or a complete account of anxiety. [1]
| Structure | Role in Anxiety |
|---|---|
| Amygdala | Assigns salience/threat value and supports emotional learning; the red central box in slide 6 integrates bidirectional cortical/contextual input with bodily-response output. |
| Hippocampus | Contextual memory—helps determine whether a stimulus is truly threatening based on past experience. Dysfunction → inability to "turn off" fear in safe contexts. |
| Medial Prefrontal Cortex | Cognitive control & manifestation of anxiety—exerts top-down inhibition on the amygdala. Impaired prefrontal control → excessive anxiety. |
| Hypothalamus & Brain Stem Nuclei | Drive endocrine, autonomic and behavioural components of the bodily threat response. |
| Thalamus | Sensory relay—passes incoming stimuli to the amygdala (fast, crude "low road") and cortex (slow, refined "high road"). |
| Cingulate Gyrus | Emotion regulation and error detection; connects to prefrontal cortex. |
| Fornix, Parahippocampal Gyrus | Part of the limbic circuit connecting hippocampus to hypothalamus. |
How to read slides 4–6: the medial anatomical diagrams locate the cingulate/limbic cortex arching above the corpus callosum, the fornix curving below it toward mammillary/hypothalamic structures, and the hippocampus/amygdala in the medial temporal lobe. Slide 6 then abstracts these structures into bidirectional loops: hippocampal context and medial-prefrontal regulation interact with the amygdala, whose hypothalamic/brainstem outputs generate somatic manifestations. Do not convert this group-level model into “amygdala high/PFC low” as a patient-level diagnostic rule.
Dysregulation of GABA, norepinephrine, and serotonin systems causes anxiety disorder. [1]
| Neurotransmitter System | Normal Function | Role in Anxiety |
|---|---|---|
| GABA | Major inhibitory neurotransmitter | GABA-A signalling is one treatment target. Benzodiazepines are positive allosteric modulators, not direct GABA agonists, and dependence/withdrawal limits their role. |
| Norepinephrine (NE) | Contributes to alerting and autonomic arousal | Can contribute to palpitations, sweating and tremor; this does not make beta-blockers a general treatment for anxiety disorders. |
| Serotonin (5-HT) | Regulates appetite, energy, sleep, mood, libido and cognition | Serotonergic adaptation is one treatment target; SSRIs are evidence-based for several—but not every—anxiety-related disorder and take time to work. |
Why SSRIs for anxiety, not just depression?
SSRIs alter synaptic serotonin rapidly, but clinical benefit depends on slower network/receptor adaptation. Explain delayed benefit and possible early activation (increased anxiety, agitation or insomnia), monitor risk, and titrate appropriately; the mechanism is more complex than one “serotonin deficiency” or single prefrontal–amygdala switch.
Clinical Manifestation of Anxiety Disorders
Psychological symptoms: worrying thoughts, fearful anticipation, irritability, restlessness, sensitivity to noise, difficulty in concentration, subjective poor memory. [1]
High Yield
Somatic presentation is common. Co-morbidity is common. [1] — Many patients present to primary care with physical complaints, NOT psychiatric complaints. You must think of anxiety in any patient with unexplained multi-system somatic symptoms.
| System | Symptoms |
|---|---|
| GI tract | Dry mouth, swallowing difficulty, epigastric discomfort, excessive belching, frequent loose bowel motions |
| Respiratory | Chest constriction, breathing difficulty, hyperventilation |
| Cardiovascular | Palpitation, chest discomfort |
| Genitourinary | Frequency of micturition, erectile failure, lack of libido, increased menstrual discomfort |
| CNS | Tinnitus, blurring of vision, dizziness, headache, muscle aches and stiffness, tremulous hands |
| Others | Disturbed sleep, unpleasant dreams |
Why somatic symptoms occur: The autonomic nervous system (sympathetic activation via hypothalamus/brainstem) produces all these physical manifestations. Patients may undergo extensive medical workups (cardiac, GI, respiratory) before anxiety is considered.
The lecture provides a central diagram showing the spectrum of anxiety-related disorders. [1]
The diagram is historical, not current DSM chapter structure
Slide 12 places panic/GAD/phobias, OCD and acute stress/PTSD around one “anxiety” hub. That is a useful symptom map, but DSM-5/DSM-5-TR separates anxiety disorders, obsessive-compulsive and related disorders, and trauma- and stressor-related disorders. Similar somatic anxiety does not mean the diagnoses are interchangeable.
Panic Disorder
Panic Disorder: Severe anxiety attack — palpitation, chest pain, choking sensation, dizziness, fear of dying, losing control, or going mad. [1]
Key characteristics:
- Unpredictable & sudden onset — not restricted to any particular situation, no obvious precipitating factor [1]
- Recurrent attacks
- Persistent fear of having another attack (anticipatory anxiety)
- Subsequently avoid that situation → may develop phobic symptoms
- May be agoraphobic if attacks occur in various situations [1]
- May become demoralised and depressed [1]
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: [1]
| Physical Symptoms | Cognitive/Dissociative Symptoms |
|---|---|
| Palpitations, pounding heart, accelerated HR | Derealization or depersonalization |
| Sweating | Fear of losing control or going crazy |
| Trembling or shaking | Fear of dying |
| Shortness of breath or smothering | |
| Feeling of choking | |
| Chest pain or discomfort | |
| Nausea or abdominal distress | |
| Feeling dizzy, unsteady, lightheaded, or faint | |
| Chills or heat sensations | |
| Paresthesias |
Note: A panic attack is not itself a diagnosis—it is a specifier. The diagnosis of Panic Disorder requires the recurrence criteria below.
- Recurrent unexpected panic attacks
- At least one attack followed by ≥1 month of one or both:
- Persistent concern about having additional attacks or their consequences
- A significant maladaptive change in behaviour related to the attacks (e.g. avoiding exercise, leaving home)
- Not due to direct physiological effects of a substance or general medical condition
- Not better accounted for by another mental disorder
High Yield Exam Point
The key discriminator for panic disorder is that the attacks are unexpected (uncued)—they are NOT restricted to any particular situation. If attacks only occur in social situations → consider social phobia. If only in crowded/enclosed places → consider agoraphobia. This is a commonly tested distinction.
- Depression
- Other anxiety disorders (e.g. agoraphobia)
- Alcohol and drug abuse
| Category | Examples |
|---|---|
| Physical disorders | Epilepsy, thyroid disease, cardiac disease, vestibular dysfunction, pheochromocytoma |
| Substance abuse | Intoxication or withdrawal |
| Other anxiety disorders | GAD, phobias |
Why these DDx matter: acute chest pain, syncope, focal neurological features, hypoxia, abnormal observations or a new/atypical presentation require proportionate medical assessment. Thyrotoxicosis, arrhythmia, hypoglycaemia, intoxication/withdrawal and—when its characteristic features are present—pheochromocytoma can mimic anxiety. Do not order an indiscriminate “organic screen” for every established typical panic attack.
Management [1]
- Interpretation of body sensation — testing catastrophic interpretations after acute medical danger has been assessed, not prematurely declaring chest pain “just hyperventilation”
- Understanding physiological response to fear — psychoeducation about fight-or-flight
- CBT includes cognitive restructuring, interoceptive exposure, reduction of safety behaviours and graded exposure where avoidance is present; relaxation alone is not the complete treatment. [13]
- Offer evidence-based self-help/CBT according to severity and preference. For longer-term drug treatment, use an SSRI licensed for panic disorder; start low and titrate because activation can initially worsen anxiety. SNRIs or selected TCAs are alternatives after review of overdose, withdrawal and interaction risks. [13]
- NICE advises that benzodiazepines have poorer long-term outcomes and should not be prescribed for panic disorder; sedating antihistamines and antipsychotics are also not treatments for panic disorder. Beta-blockers are not routine panic-disorder therapy. [13]
Phobic Anxiety Disorders
Anxiety is provoked in the presence or anticipation of a specific object: Animals, Heights, Thunders, Darkness, Blood etc. Tendency to avoid the stimulus. Severe distress or functional impairment. [1]
DSM-5 Criteria [1]
- Marked fear or anxiety about a specific object or situation
- Almost always provokes immediate fear or anxiety
- Actively avoided or endured with intense fear
- Out of proportion to actual danger and sociocultural context
- Persistent, typically ≥6 months
- Causes clinically significant distress or functional impairment
- Not better explained by another mental disorder
Special note on Blood-Injection-Injury (BII) phobia: Unlike other phobias where the autonomic response is sympathetic activation (tachycardia, hypertension), BII phobia uniquely causes a vasovagal response (initial tachycardia then profound bradycardia and hypotension → fainting). This is why patients with needle phobia actually faint rather than just feel anxious.
Away from home. In crowds or situations they cannot leave easily that provoke anxiety and avoidance: Buses, Trains, MTR, Supermarket, Queue, Hairdresser's chair, Cinema. Need to be accompanied. Severe → Housebound. [1]
DSM-5 Criteria [1]
- Marked fear or anxiety about TWO (or more) of five situations:
- Using public transportation
- Being in open spaces
- Being in enclosed places
- Standing in line or being in a crowd
- Being outside of the home alone
- Fears situations because escape might be difficult or help might not be available
- Almost always provokes fear/anxiety
- Actively avoided, require companion, or endured with intense fear
- Out of proportion, persistent ≥6 months, causes significant distress/impairment
- Not better explained by another mental disorder
Agoraphobia ≠ just 'fear of open spaces'
Agoraphobia literally means "fear of the marketplace" but it is really about fear of situations where escape is difficult or help unavailable if panic symptoms develop. In DSM-5, agoraphobia is a separate diagnosis from panic disorder (you can have agoraphobia without panic disorder, and vice versa). In ICD-10, it is specified "with or without panic disorder." [2]
Anxious in situations observed, criticized, embarrassment or humiliation. Speak in small group. Introduced to stranger. Eat in public, write in public. Fear of angry, rejecting face, avoid eye-contact. Blushing and trembling. [1]
DSM-5 Criteria [1]
- Marked fear about social situations with possible scrutiny by others
- Fears acting in a way or showing anxiety symptoms that will be negatively evaluated
- Almost always provokes fear/anxiety
- Avoided or endured with intense fear
- Out of proportion, persistent ≥6 months
- Causes clinically significant distress/impairment
- Not attributable to substance or medical condition
- Not better explained by another mental disorder
- If another medical condition present, fear is clearly unrelated or excessive
Key point: The fear is specifically about being negatively evaluated by others, not about the situation itself. This distinguishes social phobia from agoraphobia (where the fear is about being unable to escape).
- Depression
- Alcohol and drug abuse
- Panic disorder with agoraphobia
| DDx for anxiety symptoms | DDx for avoidance features |
|---|---|
| Physical disorder, substance abuse | Personality disorder, psychosis, depression |
Why avoidance DDx matters: Avoidant personality disorder shows pervasive social avoidance but from a core sense of inadequacy (not discrete fear episodes). Psychosis may cause avoidance due to persecutory delusions. Depression causes withdrawal from activities due to anhedonia, not fear.
Management of Phobic Disorders [1]
- Targeting the avoidance (hierarchy list) — construct a graded list of feared situations from least to most anxiety-provoking
- Exposure techniques: Graduated, repeated, prolonged, clear tasks
- Real-life and imaginal exposure
- Home-based, relative support
- Relaxation exercise
- Social phobia specifically:
- Social skill training
- Cognitive treatment for fear of negative evaluation from others
- Specific phobia: exposure-based therapy is the core treatment; do not relabel the slide's general drug list as first-line pharmacotherapy.
- Social anxiety disorder: offer disorder-specific individual CBT first. If an adult declines CBT and prefers medication, NICE recommends escitalopram or sertraline; other SSRIs/SNRI and only later MAOI options follow a staged specialist pathway. Do not routinely offer benzodiazepines, TCAs, anticonvulsants or antipsychotics for adult social anxiety. [14]
- Performance-only symptoms: propranolol may reduce peripheral tremor/palpitations in selected cases after contraindication assessment, but it does not treat the core fear/avoidance learning and is not a general phobia treatment.
Generalised Anxiety Disorder (GAD)
Excessive worries and anxiety. Free floating anxiety. Apprehensive expectation. Psychological & somatic manifestation of anxiety occur most of the time. [1]
"Free-floating" anxiety means the anxiety is not tied to any particular object, situation, or event—it just "floats" around, attaching to whatever is currently in the person's mind. This distinguishes GAD from phobias (situational) and panic disorder (episodic).
1. Excessive anxiety & worry, occurring more days than not for at least 6 months, about a number of events or activities [1]
2. The person finds it difficult to control the worry [1]
3. Associated with ≥3 of the following 6 symptoms: [1]
| GAD symptom (≥3 required in adults) | What it means clinically |
|---|---|
| Restlessness or feeling keyed up/on edge | Persistent physiological/cognitive tension |
| Being easily fatigued | Sustained arousal and poor sleep can be exhausting |
| Difficulty concentrating or mind going blank | Attention is captured by worry |
| Irritability | Low tolerance under chronic arousal |
| Muscle tension | A useful discriminator from uncomplicated low mood |
| Sleep disturbance | Difficulty falling/staying asleep or unsatisfying sleep |
4. Causes clinically significant distress & functional impairment [1] 5. Not due to direct physiological effects of substance or medical conditions [1] 6. Not explained by another mental disorder [1]
2/3 of GAD patients have other psychiatric diagnoses [1]
- Depression
- Other anxiety disorders (e.g. panic, social anxiety)
- Personality disorder (e.g. anankastic, paranoid, avoidant) — note "anankastic" = obsessive-compulsive personality disorder
- Alcohol and drug abuse
| DDx | Discriminating Feature |
|---|---|
| Depression | Depressive rumination focuses on past events with guilt/worthlessness; GAD worry focuses on future events. Early morning waking, diurnal mood variation, and suicidal thoughts are uncommon in pure GAD. |
| Panic Disorder | Unexpected (uncued) panic attacks are unusual in GAD. Panic patients fear acute catastrophe ("I'm having a heart attack"); GAD patients have persistent, diffuse worry. |
| Social Anxiety | Worry is mainly about social evaluation in SAD; in GAD, worry occurs regardless of social context. |
| OCD | OCD obsessions tend to be about primal fears (contamination, harm) with ritualistic compulsions; GAD worries are about everyday concerns. |
| Hypochondriasis | Principally about illness; GAD about multiple topics. |
| Physical illness | Thyrotoxicosis, hypoglycaemia, pheochromocytoma, cardiac arrhythmia, COPD/asthma, Cushing's disease [2] |
The GAD-7 is a validated 7-item screening and severity-monitoring questionnaire, not a stand-alone diagnosis. Each item is scored 0–3 (not at all → nearly every day). Common score bands are:
| Score | Severity |
|---|---|
| 0–4 | Minimal anxiety |
| 5–9 | Mild anxiety |
| 10–14 | Moderate anxiety |
| 15–21 | Severe anxiety |
High Yield - GAD-7 Score of 10
A GAD-7 score of 10 falls in the conventional moderate band. This was directly tested in the 2024 Fourth Summative MCQ Q77 [10]. Clinically, confirm duration, impairment, differential diagnoses and risk rather than diagnosing from the score alone.
Obsessive-Compulsive Disorder (OCD)
Note: In DSM-5, OCD is classified separately from anxiety disorders (under "Obsessive-Compulsive and Related Disorders"). However, the lecture includes it within the anxiety spectrum, and it is taught in this context for the exam.
Recurrent intrusive thoughts, urges or images (obsessions) and/or repetitive behaviours or mental acts (compulsions) are the core pattern. [1]
Key conceptual points:
- Obsessions are ego-dystonic (the patient recognises them as unwanted and distressing—they are NOT delusional)
- Compulsions are performed to reduce the anxiety caused by obsessions, but they are excessive and not realistically connected to preventing the feared outcome
- Insight ranges from good/fair to poor or absent/delusional and is specified accordingly; preserved insight is not mandatory.
- Active resistance is not required. Attempts to suppress/neutralise thoughts and covert mental rituals may be present, but some patients no longer resist after a chronic course.
1. Contamination with cleaning 2. Doubt with checking 3. Precision & symmetry with ordering, counting, repeating and slowness 4. Religious, sexual, aggressive obsession [1]
Hoarding is now a separate DSM diagnosis unless the accumulation is directly driven by OCD obsessions/compulsions. Intrusive aggressive or sexual obsessions are unwanted thoughts and do not imply intent; assess actual risk rather than assuming either danger or safety.
Obsessions (both required):
- Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted, causing marked anxiety
- The individual attempts to ignore, suppress, or neutralize them
Compulsions (both required):
- Repetitive behaviours (hand washing, ordering, checking) or mental acts (praying, counting) that the individual feels driven to perform
- Aimed at preventing/reducing anxiety or preventing a dreaded event, but not connected in a realistic way or clearly excessive
Additional criteria:
- Time consuming (> 1 hour/day), or cause marked distress, or functional impairment [1]
- Not due to substance
- Not better explained by another mental disorder
Management of OCD [1]
- Psychoeducation
- Psychological support and reassurance
- Exposure and ritual prevention (ERP) — the gold standard: expose patient to anxiety-provoking stimulus while preventing the compulsive ritual
- Do not make thought stopping or distraction the central treatment: they can become neutralising/safety behaviours. CBT with exposure and response prevention (ERP) exposes the trigger/obsessional uncertainty while preventing overt and covert rituals, allowing new learning without reassurance or neutralisation. [15]
- Cognitive change: challenging catastrophic thinking:
- "If I don't do it perfectly, then I've done it horribly" → all-or-nothing thinking [1]
- "If something bad is going to happen, it is much more likely to happen to me or someone I love" → inflated responsibility [1]
- Modification of responsibility beliefs — consider evidence for less threatening alternative explanations [1]
- SSRIs are first-line medication options; response may take longer and sometimes requires doses toward the licensed upper range, with adverse-effect monitoring.
- Clomipramine is effective but has greater anticholinergic, cardiac and overdose toxicity and is usually considered after an SSRI pathway, with appropriate ECG/BP and interaction precautions.
- Antipsychotic augmentation is a specialist treatment-resistant strategy, not routine first-line OCD therapy. [15]
The broad drug list on slide 36 is a menu, not an algorithm. Explain the diagnosis, assess risk/comorbidity/substances, agree goals, and select an intervention for the specific disorder and severity. [13–15]
| Disorder | Psychological treatment | Medication framing |
|---|---|---|
| GAD | Education/active monitoring → CBT-based self-help or psychoeducation → high-intensity CBT or applied relaxation as needed | If drug treatment is chosen, an SSRI (NICE suggests sertraline for cost-effectiveness), then another SSRI/SNRI. Pregabalin only if SSRIs/SNRIs are not tolerated, with misuse/dependence and pregnancy risk review. Benzodiazepines only as a short-term crisis measure. [13] |
| Panic disorder ± agoraphobia | Panic-focused CBT with interoceptive/cognitive and situational exposure; self-help for milder illness | A licensed SSRI if medication is selected; SNRI/TCA alternatives after risk review. NICE says not to prescribe benzodiazepines for panic disorder. [13] |
| Social anxiety disorder | Disorder-specific individual CBT is preferred | Escitalopram or sertraline if an adult declines CBT and prefers medication; staged alternatives only after review. [14] |
| Specific phobia | Graded in-vivo exposure; applied tension for blood-injection-injury fainting | No routine maintenance medication |
| OCD | CBT with ERP, intensity matched to impairment | SSRI; clomipramine or augmentation only after an adequate staged/specialist pathway. [15] |
Start antidepressants with discussion of early activation, delayed benefit, adverse effects, suicide/self-harm monitoring where relevant, interactions and withdrawal; do not stop abruptly. TCAs/MAOIs have greater toxicity or interaction burdens and are not casual “phobia drugs.”
Exam Trap: BZDs in Long-Term Management
Benzodiazepines carry tolerance, dependence, cognitive/psychomotor and withdrawal risks. NICE advises no benzodiazepines for panic disorder, and for GAD only a short-term crisis measure. Antipsychotics and mood stabilisers are not generic long-term anxiety treatments. [13]
Screening Questions for Anxiety Disorders [4]
| Disorder | Screening Question |
|---|---|
| Social Anxiety | "When you are in a situation where people can observe you, do you feel nervous and worry that they will judge you?" |
| GAD | "Do you consider yourself a worrier?" |
| Panic Disorder | "Have you ever experienced a panic attack?" |
| PTSD | "Have you ever had anything happen that still haunts you?" |
| OCD | "Do you get thoughts stuck in your head that really bother you, or need to do things over and over like washing your hands, checking things or counting?" |
Clinical Approach
- Presenting complaint: "What brings you in today?" — many present somatically
- Characterise the anxiety:
- Onset, duration, course (episodic vs continuous)
- Triggers (situational → phobia; none → panic disorder; generalised → GAD)
- Content of worry
- Associated symptoms: Psychological + somatic
- Avoidance behaviours: What situations does the patient avoid?
- Impact on function: Work, relationships, daily activities
- Comorbidities: Screen for depression (low mood, anhedonia), substance use, suicidal ideation
- Medical history & medications: Rule out organic causes
- Family history: Genetic contribution
- Premorbid personality: Anxious temperament, perfectionism
- Mental state examination (MSE): appearance/behaviour (restless, fidgety), mood/affect (anxious), speech (may be rapid but true pressured speech suggests mania), thought form/content (worries, obsessions, suicidality), perception and cognition
- Physical examination: Thyroid (goitre, tremor, tachycardia), cardiovascular (arrhythmia), neurological
There is no universal “anxiety blood panel.” Investigate according to history, observations and examination: for example ECG for palpitations/syncope or cardiac risk; thyroid or glucose testing when the phenotype suggests it; toxicology only when it will change management. Test for pheochromocytoma only with an appropriate syndrome/risk—not as routine screening for panic—and use the locally recommended metanephrine pathway rather than memorising a blanket 24-hour urine order.
It is not uncommon to have difficulties during interview with patients with anxiety disorder. [9]
| Helpful Techniques | Unhelpful Approach |
|---|---|
| Address the anxious feeling directly | Abruptly imposing a label without explanation or collaboration [9] |
| Ask specific, structured questions | Vague, open-ended questions when patient is very anxious |
| Clarification and explanation | Dismissing symptoms |
The 2023 MCQ answer was “give a diagnostic label,” but this should not be converted into hiding a diagnosis. Current good care communicates a formulation/diagnosis sensitively, explains uncertainty and treatment options, checks understanding and uses shared decisions. NICE explicitly recommends early identification and communication of GAD. [13]
| Feature | GAD | Panic Disorder | Agoraphobia | Social Phobia | Specific Phobia | OCD |
|---|---|---|---|---|---|---|
| Nature of anxiety | Continuous, free-floating | Episodic, spontaneous | Situational | Social situations | Specific object/situation | Obsessional thoughts |
| Trigger | None specific | None ("unexpected") | Crowds, public transport, open/enclosed spaces | Being observed/judged | Specific stimulus | Intrusive thoughts |
| Key fear | Multiple worries | Dying, losing control | Cannot escape, no help | Negative evaluation | The object itself | Consequences of not performing ritual |
| Avoidance | Minimal/diffuse | May develop agoraphobia | Yes—confined/crowded places | Social situations | The stimulus | Triggers of obsessions |
| Duration criterion | ≥6 months | ≥1 month of concern after attack | ≥6 months | ≥6 months | ≥6 months | Time-consuming ( > 1hr/day) |
| First-line Rx | SSRI/SNRI + CBT | SSRI + CBT | SSRI + Exposure | SSRI + CBT/Social skills | Exposure therapy | SSRI/Clomipramine + ERP |
This was tested in 2023 MCQ Q75. [9]
| Feature | More suggestive of Depression | More suggestive of GAD |
|---|---|---|
| Sleep | Early morning waking | Difficulty falling asleep (initial insomnia) |
| Appetite/Weight | Weight gain or loss (but weight gain is more specific to depression in the exam context) | Usually preserved |
| Concentration | Poor concentration (present in both) | Poor concentration (present in both) |
| Muscle tension | Less prominent | Key feature |
| Mood | Persistent low mood, anhedonia | Anxious, worried |
| Rumination content | Past failures, guilt, worthlessness | Future worries |
| Trap | How to Avoid |
|---|---|
| Confusing panic disorder with agoraphobia | Panic disorder = unexpected attacks. Agoraphobia = anxiety in specific situations (crowded, enclosed, away from home). Panic patients may develop agoraphobia secondarily. |
| Missing medical/substance mimics | Use red flags, history, observations and examination to guide proportionate tests; do not reflexively order every rare mimic for a typical established presentation. |
| GAD vs Depression overlap | Weight change, early morning waking, diurnal variation, anhedonia, suicidal ideation → Depression. Muscle tension, future-oriented worry, difficulty falling asleep → GAD. Both share: poor concentration, fatigue, irritability, sleep disturbance. |
| OCD: obsessions vs delusions | Obsessions are intrusive/unwanted and linked to distress or neutralising acts, but insight may be good, poor or absent. Diagnose from the whole syndrome; poor insight alone does not exclude OCD. |
| Treating all anxiety with the same drug list | Specific phobia is exposure-led; social anxiety prefers disorder-specific individual CBT; panic/GAD/OCD have different medication pathways. Benzodiazepines are not a panic-disorder treatment and are only a short-term crisis measure in GAD. |
| Clomipramine vs Imipramine | Clomipramine = OCD. Imipramine = Panic disorder. Both are TCAs but have different primary indications. |
| Duration criteria | GAD: ≥6 months. Phobias: ≥6 months. Panic disorder: ≥1 month of concern after attack. OCD: no specific duration but > 1hr/day. |
| DSM-5 classification of OCD | OCD is no longer under "Anxiety Disorders" in DSM-5 — it has its own category. But the lecture (and exam) may still group it with anxiety disorders. |
High Yield Summary
-
Anxiety disorders are common and often present somatically.
- The slide's amygdala–hippocampus–medial-PFC–hypothalamus/brainstem circuit links threat meaning/context/control with bodily output. It is a teaching model, not a diagnostic biomarker.
-
Somatic presentation is common and co-morbidity is common
- always screen for depression and substance use.
-
Key disorders
- GAD = difficult-to-control worry ≥6 months + associated symptoms; Panic Disorder = recurrent unexpected attacks + ≥1 month concern/behavioural change; Specific Phobia = disproportionate stimulus fear ≥6 months; Agoraphobia = fear in ≥2 of 5 escape/help situations; Social Anxiety = fear of negative evaluation; OCD = obsessions and/or compulsions that are time-consuming, distressing or impairing. Insight can vary.
-
Treatment is diagnosis-specific
- Panic: panic-focused CBT and/or a licensed SSRI; no benzodiazepines under NICE.
- GAD: stepped CBT-based care or SSRI/SNRI; pregabalin only when those are not tolerated; benzodiazepine only briefly in a crisis.
- Social anxiety: disorder-specific individual CBT preferred; escitalopram/sertraline if an adult prefers medication. Specific phobia: exposure-based therapy.
- OCD: CBT with ERP and/or an SSRI; clomipramine/augmentation only within a staged pathway.
-
Exam priorities
- Know DSM criteria and panic–agoraphobia–GAD discriminators. A GAD-7 score of 10 is in the conventional moderate band but is not diagnostic. Communicate diagnoses sensitively rather than avoiding them.
Active Recall - Anxiety Disorders
[1] Lecture slides: GC 167. I feel very nervous Anxiety disorders.pdf (all pages) [2] Senior notes: Ryan Ho Psychiatry.pdf (pages 170-181) [3] Lecture slides: GC 017. Common mental health problems in primary care.pdf (page 4) [4] Lecture slides: GC 171. Stress-related disorders and obsessive-compulsive disorder (Post-traumatic stress disorder adjustment disorder, acute stress disorder)_rev.pdf (pages 7, 42-43) [5] Lecture slides: CFB (PSY02) Classification and Diagnosis of Psychiatric Illness.pdf (page 40) [6] Lecture slides: Seminar 2 - Psychopathology - Dr Simon SY Lui_1_9_2025.pdf (page 14) [7] AOS material: AOS - Psych.md [9] Past papers: 2023 Fourth Summative MCQ.pdf (pages 28, 36 — Q75, Q95) [10] Past papers: 2024 Fourth Summative MCQ.pdf (page 28, Q77) [13] NICE. Generalised anxiety disorder and panic disorder in adults: management (CG113), updated 2026. [14] NICE. Social anxiety disorder: recognition, assessment and treatment (CG159), reviewed 2024. [15] NICE. Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31).
GC166 I Cannot Help Myself, Taking These Pills Just Feels Good Substance Abuse And Addiction
Substance abuse and addiction is a chronic relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting neuroplastic changes in brain reward, motivation, and self-control circuits.
GC168 I Heard Those Newer Drugs Are Better Than My Current Psychiatric Medications
A clinical education session addressing patient concerns about switching established psychiatric medications to newer agents, emphasizing that newer psychotropic drugs are not inherently superior and that treatment decisions should be individualized based on efficacy, side-effect profiles, and patient response.