PS7.1 | Anxiety Disorders in Primary Care — Summary & Reflection

KEY TAKEAWAYS

Key takeaways — Anxiety Disorders in Primary Care:

1. Four main anxiety disorders seen in primary care: GAD (pervasive worry ≥6 months, DSM-5), Panic Disorder (recurrent unexpected attacks + ≥1 month anticipatory concern), Social Anxiety Disorder (fear of scrutiny ≥6 months), Specific Phobia (circumscribed fear ≥6 months).

1. Always exclude medical mimics first: TSH (hyperthyroidism), ECG/Holter (arrhythmia), fasting glucose (hypoglycaemia in diabetics), urine catecholamines (if episodic hypertension + palpitations → phaeochromocytoma).

1. Diagnosis is DSM-5 system-attributed: GAD ≥6 months is DSM-5; ICD-11 says 'several months' without fixing a number. State which system you are using in clinical documentation.

1. SSRIs are first-line pharmacotherapy for all anxiety disorders. Allow 4–6 weeks for response. Warn about the transient early worsening of anxiety.

1. Benzodiazepines: short-term bridging only (≤2–4 weeks). Never prescribe as maintenance — physical dependence develops within weeks; withdrawal resembles severe anxiety.

1. CBT is the gold-standard psychological treatment — even brief psychoeducation in primary care improves outcomes.

1. Refer when: two pharmacotherapy trials fail; comorbid psychosis/bipolar; suicidality; substance dependence; diagnostic uncertainty.

REFLECT

Think back to the schoolteacher in our opening scenario — 9 months of constant worry, two cardiologist visits, a normal workup, and a belief that she is 'going mad.' Consider the following questions honestly:

1. If you were her cardiologist, what clinical cues might you have picked up during those two visits that could have prompted a psychiatric referral earlier?
2. When you explain to a patient that her anxiety is caused by 'a sensitised nervous system' and not 'weakness,' how might you word that in simple, non-stigmatising language in Tamil or Hindi?
3. The schoolteacher lives in a rural taluk with no access to a psychologist. How would you adapt the CBT principles you have learned today for delivery in a 10-minute primary care consultation?
4. A colleague says 'just give her diazepam — she's a busy professional, she doesn't have time for therapy.' How would you respond, using the clinical evidence you now have?