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PS7.1,PS8.1 | Anxiety Spectrum Disorders — Practice Quiz
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A 34-year-old software engineer presents with persistent, uncontrollable worry about work performance, family health, and finances for the past 8 months. She reports difficulty concentrating, muscle tension, irritability, and poor sleep. There is no identifiable trigger, and symptoms are present on most days. Medical causes have been excluded. Which of the following is the most appropriate FIRST-LINE pharmacological treatment?
Correct. SSRIs (e.g., sertraline, escitalopram) are the first-line pharmacological agents for GAD, per ICD-11 and DSM-5 guidelines. They have established efficacy and a favourable safety profile for long-term use.
SSRIs are first-line for GAD; benzodiazepines are adjuncts for short-term use (≤2–4 weeks) only due to dependence risk. Duration of GAD diagnosis requires ≥6 months of excessive worry (DSM-5).
Review first-line pharmacotherapy for GAD. Benzodiazepines (alprazolam) are appropriate only for short-term adjunctive use due to dependence risk. Beta-blockers address somatic symptoms only. Antipsychotics are not indicated here.
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A 28-year-old woman is brought to the emergency department after a sudden episode of chest pain, palpitations, shortness of breath, dizziness, and an intense fear of dying. The episode peaked within 10 minutes and resolved spontaneously in 20 minutes. ECG and troponin are normal. She reports three similar episodes in the past month and now fears leaving home. Which diagnosis best fits this presentation?
Correct. Recurrent unexpected panic attacks (peaking within 10 minutes), followed by ≥1 month of anticipatory fear and behavioural change (home avoidance = agoraphobia), meets DSM-5 criteria for Panic Disorder with Agoraphobia.
Panic Disorder: recurrent unexpected attacks + ≥1 month anticipatory concern or maladaptive behaviour. Agoraphobia arises from avoidance of situations where escape may be difficult. Always exclude cardiac/medical causes first.
GAD features pervasive worry without discrete attacks. ASD requires a traumatic precipitant. Specific phobia involves fear of a defined object/situation, not unexpected attacks. Review the cardinal features of Panic Disorder.
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During a routine primary care visit, a 45-year-old male farmer endorses the following: avoiding crowded markets for 2 years, intense distress when he must stand in a queue, and relief when accompanied by a trusted family member. He denies panic attacks, pervasive worry, or a traumatic history. Which is the most likely diagnosis?
Correct. The patient avoids multiple agoraphobic situations (crowds, queues) and seeks a companion — classic agoraphobia without a history of panic disorder. DSM-5 allows agoraphobia as an independent diagnosis.
Agoraphobia (DSM-5): marked fear of ≥2 agoraphobic situations (public transport, open spaces, enclosed spaces, queues, crowds) due to fear of escape difficulty or unavailable help. It can exist independently of Panic Disorder.
Social Anxiety Disorder centres on fear of scrutiny/embarrassment in social performance situations — not just crowded or open spaces. GAD is pervasive worry. Panic Disorder requires recurrent unexpected attacks.
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A 38-year-old teacher has been prescribed lorazepam 1 mg twice daily for 6 months by a colleague for 'nerves.' She now requests a repeat prescription, reporting she cannot function without it. On attempting to skip a dose she develops tremors, sweating, and palpitations. The most appropriate NEXT step is:
Correct. Benzodiazepine dependence should be managed by switching to a long-acting agent (diazepam) at an equivalent dose, then tapering over weeks to months, while initiating an SSRI for the underlying anxiety. Abrupt withdrawal risks seizures.
Benzodiazepine dependence management: (1) switch to equivalent diazepam (long half-life, smoother taper); (2) reduce dose by ~10% every 1–2 weeks; (3) concurrently start an SSRI for the underlying anxiety disorder. Never withdraw abruptly.
Abrupt discontinuation of long-term benzodiazepines risks life-threatening withdrawal seizures. Continuing or increasing the dose perpetuates dependence. A structured switch-and-taper protocol with concurrent SSRI is the standard approach.
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A 27-year-old woman witnessed her colleague die in a road accident 10 days ago. She now presents with intrusive flashbacks, nightmares, hypervigilance, emotional numbing, and avoidance of driving. She meets full symptom criteria. Which diagnosis applies under DSM-5?
Correct. DSM-5 Acute Stress Disorder (ASD): traumatic event + PTSD-like symptoms (intrusion, avoidance, hyperarousal, negative mood, dissociation) present for 3 days to 1 month after the trauma. At 10 days, ASD is the correct label.
DSM-5 timeline: ASD = 3 days–1 month post-traumatic stressor; PTSD = >1 month. If the same patient presents at 5 weeks with ongoing symptoms, the diagnosis transitions to PTSD. Adjustment Disorder can follow any stressor but lacks the specific intrusion/avoidance clusters.
PTSD requires symptoms persisting >1 month post-trauma. Adjustment Disorder is triggered by a non-traumatic stressor and does not require the specific PTSD symptom clusters. Review the DSM-5 timeline framework for stress-related disorders.
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A 42-year-old bank manager was retrenched 6 weeks ago. Since then he has been persistently low in mood, unable to concentrate at work interviews, and withdrawing from family. He denies a full depressive syndrome, suicidal ideation, or a prior traumatic event. He meets criteria for emotional and behavioural symptoms that are disproportionate to the stressor. Per ICD-11, the onset of symptoms must be within how many months of the stressor for an Adjustment Disorder diagnosis?
Correct. ICD-11 specifies symptom onset within 1 month of the identifiable stressor for Adjustment Disorder. (Note: DSM-5 uses a 3-month onset window — a common exam distinction.)
Adjustment Disorder onset criteria: ICD-11 = within 1 month of stressor; DSM-5 = within 3 months. Both require symptoms to resolve within 6 months of stressor removal. Knowing both is essential for MBBS examinations.
This tests the ICD-11 vs DSM-5 distinction. ICD-11: onset ≤1 month. DSM-5: onset ≤3 months. Referencing which system you are using in clinical documentation is important.
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A 32-year-old survivor of a train derailment presents 7 weeks after the accident with persistent re-experiencing, avoidance of trains and crowded stations, hypervigilance, emotional detachment, and negative self-blame cognitions. He scores high on a validated PTSD screen. As a primary care physician, which is the MOST appropriate action?
Correct. PTSD (symptoms >1 month post-trauma) requires specialist psychological interventions — Trauma-Focused CBT (TF-CBT) or EMDR — which are beyond primary care scope. Referral to a psychiatrist or trauma-trained clinician is the appropriate action under PS8.1.
Primary care role in PTSD: (1) recognise via screening (PCL-5 or similar); (2) provide immediate psychosocial support and safety; (3) REFER promptly to specialist — Trauma-Focused CBT and EMDR are the evidence-based treatments, not available at primary care level. Benzodiazepines are not recommended in PTSD.
PTSD management in primary care is limited to initial support and facilitated referral. Benzodiazepines are relatively contraindicated in PTSD (risk of numbing/dependence). Watchful waiting at 7 weeks, when criteria are fully met, delays necessary specialist care.
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A college student presents 3 weeks after failing her final examinations (a non-traumatic life stressor). She has tearfulness, poor concentration, and reduced academic engagement but no anhedonia, neurovegetative symptoms, or suicidal ideation. Symptoms began 2 weeks after the exam results. Which diagnosis under DSM-5 is MOST appropriate?
Correct. An identifiable non-traumatic stressor (exam failure), emotional symptoms disproportionate to it, onset within 3 months (DSM-5), and sub-threshold for a full depressive episode = Adjustment Disorder with Depressed Mood.
Adjustment Disorder (DSM-5): emotional or behavioural symptoms in response to an identifiable stressor, onset ≤3 months, clinically significant distress disproportionate to the stressor, and does not meet criteria for another mental disorder. Specifier: with depressed mood, anxious mood, mixed anxious and depressed mood, disturbance of conduct, or mixed disturbance.
Major Depressive Episode requires ≥5 depressive symptoms for ≥2 weeks including anhedonia or depressed mood — not met here. ASD requires a traumatic event. Persistent Depressive Disorder requires ≥2 years duration.
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A 30-year-old dentist presents with intense fear and avoidance of social gatherings, public speaking, and eating in public, fearing he will embarrass himself. Symptoms have been present for 4 years and cause significant occupational impairment. He has tried one SSRI for 8 weeks with minimal benefit. What is the MOST appropriate next management step?
Correct. Cognitive Behavioural Therapy with exposure (CBT-E) is first-line psychological treatment for Social Anxiety Disorder and should be combined with or substituted for pharmacotherapy when one agent alone is insufficient. Both SSRI and CBT have Level A evidence.
Social Anxiety Disorder management: first-line = SSRI + CBT with exposure (graded exposure to feared social situations). If one SSRI fails after 8–12 weeks at adequate dose, trial a second SSRI or add CBT before escalating. PRN benzodiazepines undermine exposure therapy.
Antipsychotic augmentation lacks evidence for Social Anxiety Disorder. PRN benzodiazepines before social events perpetuate avoidance and dependence. Brain imaging is not indicated in the absence of neurological features.
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