Anxiety, obsessive-compulsive, trauma-related and stressor-related disorders
This domain tests duration thresholds, the panic-attack definition, and the sequencing of psychotherapy versus medication in OCD and PTSD.
Core rules
- Panic attack: four of thirteen symptoms peaking within minutes; panic disorder requires recurrent unexpected attacks plus one month of anticipatory anxiety or maladaptive behaviour.
- Generalized anxiety disorder: excessive worry across domains for at least six months, difficult to control, with three of six symptoms.
- Social anxiety disorder (marked fear of scrutiny, six months or more), separation anxiety disorder, selective mutism, agoraphobia.
- OCD: obsessions and/or compulsions consuming more than one hour daily or causing impairment; specifiers for insight and for tic-related presentation. First-line treatment is CBT with exposure and response prevention, or an SSRI at higher doses than in depression; clomipramine is second-line; antipsychotic augmentation is for refractory cases.
- PTSD requires criterion A exposure (actual or threatened death, serious injury, sexual violence), at least one intrusion symptom, one avoidance symptom, two negative cognition/mood symptoms and two arousal/reactivity symptoms, lasting more than one month. Acute stress disorder covers three days to one month. Adjustment disorder begins within three months of a stressor and does not meet criteria for another disorder.
- First-line PTSD treatments: trauma-focused CBT, prolonged exposure, cognitive processing therapy and EMDR; sertraline and paroxetine are the approved SSRIs. Prazosin is used for nightmares but trial evidence is mixed.
Worked example
Six weeks after a road crash a man has intrusive images, avoids driving, feels numb and startles easily. Symptoms persist beyond one month, so the diagnosis is PTSD, not acute stress disorder; first-line treatment is trauma-focused psychotherapy, with an SSRI if psychotherapy is unavailable or refused.
Traps
Confusing acute stress disorder and PTSD by timing; diagnosing OCD when the belief is delusional in strength (use the absent-insight specifier); using standard antidepressant doses for OCD; prescribing benzodiazepines as maintenance therapy.