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PS7.1,PS8.1 | Anxiety Spectrum Disorders — PBL Case

CLINICAL SETTING

Setting: Primary Health Centre, semi-urban district. The facilitator distributes Trigger 1 sealed envelopes. Students are reminded that all clinical details emerge progressively — do not seek information beyond the current trigger. The goal is to construct and refine hypotheses, identify learning issues, and arrive at a management and referral decision by Trigger 3.

Trigger 1: The Walk-In Patient

Mr. Vikram Nair, a 36-year-old civil engineer, walks into your primary care clinic on a Tuesday afternoon without an appointment. He appears tense, fidgety, and mildly distressed. He tells you: 'Doctor, I've been feeling very on edge for the past year. I can't stop worrying — about my project deadlines, my children's school performance, my wife's health, whether I've locked the house properly. Everything feels like a threat. I feel exhausted by 2 PM every day, my muscles ache, and I haven't had a proper night's sleep in months. My wife says I've become impossible to live with.' Vital signs: BP 124/80 mmHg, HR 88/min (regular), RR 16/min, Temperature 37.0°C. He does not appear acutely unwell. He denies chest pain, palpitations, or shortness of breath at rest.

DISCUSSION POINTS

  • What is your preliminary differential diagnosis based on Trigger 1? Rank your hypotheses and justify each with the available information.
  • Which anxiety disorders could present this way, and what distinguishing features would you look for in the history to narrow your differential?
  • What are the key elements of the autonomic nervous system and HPA axis response that explain Vikram's somatic symptoms (muscle tension, fatigue, sleep disturbance)? How does understanding the neurobiology help you explain the disorder to the patient?
  • What clarifying questions would you ask in your history, and why is the 6-month duration criterion particularly important here?
  • What medical conditions must be excluded before attributing these symptoms to a primary psychiatric cause? What targeted investigations would you request?
Click to reveal Trigger 2: History Expands — A Recent Crisis (discuss previous trigger first!)

Trigger 2: History Expands — A Recent Crisis

On further history, Vikram tells you that 8 months ago he was the site supervisor when a construction scaffolding partially collapsed. No workers were seriously injured, but Vikram witnessed the incident and feared for the workers' lives for several minutes until it was clear everyone was safe. In the weeks following the incident, he had nightmares about scaffolding collapsing and avoided visiting the construction site. Over the next 2 months these symptoms faded. He insists his current worry — about his children, wife, and deadlines — is quite different from those post-incident reactions and has been building 'for as long as I can remember.' Thyroid function tests come back normal. Random blood glucose is normal. He scores 18 on the GAD-7 (severe range). He denies any history of trauma prior to the scaffolding incident, no current suicidal ideation, and no substance misuse beyond two glasses of beer on weekends. He has tried yoga for 3 months with minimal improvement. He says he cannot take time off work as a project deadline is in 6 weeks.

DISCUSSION POINTS

  • How does the scaffolding incident change your differential? Apply the DSM-5 timeline framework: could this patient simultaneously have had Acute Stress Disorder followed by resolution, and now have a separate GAD diagnosis? What features support each disorder distinctly?
  • Vikram's GAD-7 score is 18 (severe). What does this indicate about the level of functional impairment, and how does it influence your management threshold?
  • The patient tried yoga with 'minimal improvement.' What does this tell you about the severity of GAD? What specific evidence-based psychological intervention would you recommend, and why is it superior to generic relaxation for GAD?
  • Design a pharmacological management plan for Vikram. Which first-line agent would you choose, at what starting dose, and for how long? How would you counsel him about the likely timeline before benefit is felt? What is your explicit position on benzodiazepine use in this patient, and why?
  • Vikram raises a practical barrier: he cannot take sick leave. How does this affect your management approach, and what psychoeducation would you provide to help him understand that treatment does not require stopping work?
Click to reveal Trigger 3: Six Weeks Later — Crisis Deepens (discuss previous trigger first!)

Trigger 3: Six Weeks Later — Crisis Deepens

Vikram returns 6 weeks after starting sertraline 50 mg/day. He reports that the deadline pressure 'broke him' — three weeks ago he had a major confrontation with his project director who told him in front of colleagues that he 'would never amount to anything.' Since that meeting he has been sleeping only 3–4 hours per night, has lost 3 kg in weight, and has been unable to attend site visits. He describes the incident vividly and repeatedly — he cannot get the director's face out of his mind when he closes his eyes. He avoids the office and has called in sick for 2 weeks. He started drinking more heavily (4–5 large drinks nightly) 'to sleep.' His wife calls you separately and mentions he said last week that 'there's no point going on.' On examination today: HR 102/min, BP 138/88 mmHg. He is dishevelled, avoidant of eye contact, and tearful. He admits to passive suicidal ideation ('I keep thinking my family would be better off without me') but denies a plan or intent.

DISCUSSION POINTS

  • What new diagnoses must now be considered in addition to or instead of GAD? Apply the DSM-5 timeline framework to the confrontation incident: could this be Acute Stress Disorder, PTSD, or an Adjustment Disorder superimposed on GAD? Justify your classification.
  • Vikram has disclosed passive suicidal ideation. Conduct a structured risk assessment: what are the static and dynamic risk factors present, what are the protective factors, and what is your overall risk stratification?
  • The patient has started heavy alcohol use as a coping strategy. What are the diagnostic and pharmacological implications of this? How does alcohol misuse interact with sertraline, and how does it affect your benzodiazepine prescribing decision?
  • At this point, does Vikram meet your referral criteria for specialist psychiatric care? List the specific clinical features that drive your referral decision. What safety plan would you establish before he leaves your clinic today?
  • If Vikram is referred and assessed with PTSD (the confrontation as a qualifying psychological trauma), what evidence-based treatments (Trauma-Focused CBT, EMDR) would a psychiatrist consider, and why are they beyond the primary care scope?

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PS7.1] What are the DSM-5 diagnostic criteria for GAD, and how does the 6-month duration criterion distinguish it from normal worry and other anxiety disorders?
  2. [PS7.1] What is the evidence base for first-line pharmacological and psychological treatment of GAD at primary care level, and what is the role of benzodiazepines?
  3. [PS8.1] How do ASD, PTSD, and Adjustment Disorder differ in stressor type, symptom timeline, and symptom clusters (DSM-5 and ICD-11)?
  4. [PS8.1] What are the referral criteria for stress-related disorders from primary care to specialist psychiatric services, and what is the primary care physician's role in safety planning?
  5. [PS7.1] What are the risks of benzodiazepine dependence, and how should a primary care physician manage a patient who presents with benzodiazepine dependence alongside an anxiety disorder?