Page 9 of 11
PS7.1,PS8.1 | Anxiety Spectrum Disorders — Graded Quiz
Click any question card to reveal the correct answer.
A 52-year-old woman presents with excessive, uncontrollable worry about her children's health, her husband's business, and her own health on most days for the past 9 months. She reports fatigue, muscle tension, and difficulty falling asleep. Physical examination and thyroid function tests are normal. Which diagnostic criterion MOST distinguishes Generalised Anxiety Disorder (DSM-5) from normal worry?
The DSM-5 hallmark of GAD is excessive, uncontrollable worry across multiple domains for ≥6 months, causing significant functional impairment. This chronicity and pervasiveness distinguishes it from normal worry.
GAD (DSM-5): excessive worry on ≥more days than not for ≥6 months about multiple domains, difficulty controlling worry, ≥3 of 6 somatic symptoms (adults), functional impairment, exclusion of substances/GMC/other mental disorder.
Palpitations and sweating are non-specific somatic symptoms. Worry restricted to one domain (e.g., health only) raises consideration of Illness Anxiety Disorder. Nocturnal panic attacks point to Panic Disorder.
Click to reveal answer
A 24-year-old medical student has received a prescription for escitalopram 10 mg/day for Social Anxiety Disorder. At her 4-week follow-up she reports no improvement and asks for a more effective option. The most appropriate response is:
SSRIs have a delayed onset of anxiolytic action, typically requiring 4–12 weeks for full therapeutic benefit. A 4-week trial is insufficient to judge SSRI efficacy in anxiety disorders.
SSRI onset of anxiolytic action: 4–12 weeks (full effect). Do not declare SSRI failure before an 8–12 week adequate-dose trial. Premature switching risks a revolving-door pattern and delays definitive treatment.
SSRIs are effective for Social Anxiety Disorder but require an adequate trial (8–12 weeks). Adding benzodiazepines and switching prematurely both risk premature abandonment of an effective therapy.
Click to reveal answer
In a patient with Panic Disorder and a history of alcohol use disorder, which of the following pharmacological agents is MOST appropriate as first-line treatment?
SSRIs (sertraline, paroxetine) are first-line pharmacotherapy for Panic Disorder. In a patient with alcohol use disorder, benzodiazepines are contraindicated due to high cross-dependence risk.
Contraindications to benzodiazepines include: personal or family history of substance use disorder, history of benzodiazepine misuse, concurrent sedative use, respiratory insufficiency, and sleep apnoea. SSRIs are safe and effective alternatives.
All three benzodiazepine options (alprazolam, lorazepam, clonazepam) are contraindicated or strongly cautioned in patients with a history of substance use disorder due to cross-dependence and abuse potential.
Click to reveal answer
A 35-year-old woman was involved in a severe domestic violence incident 5 weeks ago. She now presents with re-experiencing (flashbacks, nightmares), persistent emotional numbing, hypervigilance, and avoidance of her neighbourhood. She has been symptomatic since the incident. What is the diagnosis under DSM-5?
DSM-5 PTSD requires symptoms from all four clusters (intrusion, avoidance, negative alterations in cognition/mood, hyperarousal) persisting for >1 month after a traumatic event. At 5 weeks, she crosses the 1-month threshold.
DSM-5 PTSD threshold: symptoms (intrusion + avoidance + negative cognitions/mood + hyperarousal) present >1 month after a qualifying traumatic event. At 5 weeks, ASD is no longer appropriate — PTSD is now the diagnosis. Prompt specialist referral is required.
ASD applies to the 3-day to 1-month window post-trauma. At 5 weeks the diagnosis must transition to PTSD if criteria are met. Adjustment Disorder does not require the specific PTSD symptom clusters and typically follows non-traumatic stressors.
Click to reveal answer
A 45-year-old businessman lost his long-running enterprise due to bankruptcy 4 months ago. He has since had persistent worry, poor sleep, and reduced motivation, but fully meets no criteria for depression or any anxiety disorder. His symptoms began 3 weeks after the bankruptcy. According to ICD-11, which of the following is true about Adjustment Disorder in his case?
ICD-11 Adjustment Disorder: onset ≤1 month after stressor, symptoms expected to resolve within 6 months of the stressor or its consequences ending (or within 6 months if the stressor is chronic and ongoing). Beyond 6 months, reconsider the diagnosis.
ICD-11 Adjustment Disorder: onset ≤1 month; expected resolution within 6 months of stressor ending. If stress is chronic (business consequences ongoing), 6 months runs from stressor resolution. Adjustment Disorder is an exclusionary diagnosis — cannot be made if criteria for another disorder are met.
The 3-month resolution criterion applies to the DSM-5 specifier 'Acute' (resolves within 6 months) concept. ICD-11 uses 6 months. The stressor need not be traumatic — any identifiable stressor qualifies. Adjustment Disorder is diagnosed only when criteria for another mental disorder are not met.
Click to reveal answer
A primary care physician screens a 28-year-old flood survivor presenting 6 weeks post-event with nightmares, avoidance of water, emotional constriction, and hyperstartle. She scores positive on the PCL-5. What is the PRIMARY management action at this level?
The competency PS8.1 explicitly requires 'appropriate referral' for stress-related disorders. PTSD (>1 month post-trauma) requires specialist-delivered Trauma-Focused CBT or EMDR — the primary care role is to recognise and refer promptly.
Primary care physician's role in PTSD: screen → safety assessment → psychoeducation and support → REFER to psychiatry/trauma-trained psychologist. Evidence-based treatments (TF-CBT, EMDR) require specialist training not available in primary care.
Benzodiazepines are not recommended in PTSD (impair fear extinction, risk dependence). Antipsychotics are not first-line for PTSD. Watchful waiting at 6 weeks with established PTSD symptomatology delays necessary specialist intervention.
Click to reveal answer
A 40-year-old woman diagnosed with Panic Disorder reports that she cannot tolerate any somatic sensations without believing she is having a heart attack. She has been hospitalised three times in the past year, always with normal cardiac workup. Aside from pharmacotherapy, which psychological intervention has the BEST evidence for Panic Disorder?
CBT is the gold-standard psychological treatment for Panic Disorder. It includes psychoeducation, cognitive restructuring (challenging catastrophic misinterpretations of somatic sensations), and interoceptive exposure (deliberately inducing sensations to reduce fear).
CBT for Panic Disorder: core components are (1) psychoeducation about panic physiology; (2) cognitive restructuring of catastrophic misinterpretations; (3) interoceptive exposure to feared body sensations; (4) in-vivo exposure for agoraphobic avoidance. Combined CBT + SSRI is superior to either alone in severe cases.
Supportive therapy and psychodynamic therapy have limited evidence specifically for Panic Disorder. Hypnotherapy is not a first-line evidence-based treatment for Panic Disorder.
Click to reveal answer
A 19-year-old student witnessed her roommate attempt suicide 2 weeks ago. She presents with intrusive images of the event, insomnia, hypervigilance, feeling detached from others, and inability to attend classes. Medical history is unremarkable. Which feature, if present, would MOST support referring her for specialist care rather than expectant primary care management?
Active suicidal ideation or self-harm risk is an absolute indication for urgent psychiatric referral, irrespective of the primary diagnosis. Safety risk always supersedes stepwise care algorithms.
Referral triggers in stress-related disorders: (1) active suicidality/self-harm; (2) severe functional impairment; (3) comorbid psychosis; (4) symptoms crossing from ASD to PTSD (>1 month); (5) inadequate response to initial primary care management. Safety risk is always a priority trigger.
Symptom duration at 2 weeks falls within the ASD window and does not by itself mandate specialist referral (watchful waiting with follow-up may be appropriate). Mild sleep disturbance and available family support are reassuring features.
Click to reveal answer
A 33-year-old man with GAD has been stable on paroxetine 20 mg for 18 months. He asks when he can stop the medication. According to evidence-based guidance, what is the MINIMUM recommended duration of maintenance pharmacotherapy after remission for GAD?
Clinical guidelines recommend at least 12 months of maintenance pharmacotherapy after remission of GAD to reduce relapse risk, especially given the chronically relapsing nature of the disorder.
Maintenance treatment for GAD: minimum 12 months after achieving remission, then taper gradually (do not stop abruptly) under supervision. Patients with frequent relapses, severe impairment, or comorbid depression may require longer-term treatment.
Both 3 and 6 months are insufficient maintenance durations for GAD — relapse risk is high with early discontinuation. Lifelong treatment is not universally mandated but may be appropriate in severe, recurrent cases.
Click to reveal answer
Which of the following CORRECTLY pairs a stress-related disorder with its key distinguishing feature?
DSM-5 Acute Stress Disorder: symptoms begin and are present within the 3-day to 1-month post-trauma window. This is the accurate temporal criterion and distinguishes ASD from PTSD (>1 month) and Adjustment Disorder (any stressor, ICD-11 onset ≤1 month).
High-yield exam table: ASD (DSM-5) = traumatic stressor, symptoms 3 days–1 month; PTSD = traumatic stressor, symptoms >1 month; Adjustment Disorder = any stressor, onset ≤1 month (ICD-11) or ≤3 months (DSM-5), resolution expected ≤6 months after stressor ends.
Adjustment Disorder follows any identifiable stressor — not necessarily traumatic. PTSD cannot be diagnosed until symptoms exceed 1 month. ICD-11 Adjustment Disorder onset is ≤1 month (not 3 months — that is the DSM-5 criterion).
Click to reveal answer