Unit 457 April 2010

Anxiety disorders
 check Anxiety disorders

Medical Editor in Chief

April 2010 Unit 457 Dr Jenni Parsons
Anxiety disorders Medical Editor
Dr Kath OConnor
Program Coordinator
From the editor 2 Sharon Benson
Case 1 Jeffreys persistent worries 3 Graphic Designer
Jason Farrugia
Case 2 Toms social difficulties 7 Illustrator
Christopher Nielsen
Case 3 Amandas panic 11
Authors
Case 4 Jims distressing thoughts 13 Richard Moulding
Maja Nedeljkovic
Case 5 Pauls nightmares and anxiety 17 Michael Kyrios
References 20 Reviewers
Dr Nickolai Titov
Resources 21 Dr Ralph Lewis

QA&CPD Program requirements 22

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 check Anxiety disorders

From the editor

This unit of check looks at anxiety disorders with clinical scenarios relating to generalised
anxiety disorder (GAD), social anxiety disorder, anxiety disorder not otherwise specified, panic
disorder, obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD).
Anxiety disorders are common, affecting 14.4% of Australian adults in a 12 month period.1
Accurate diagnosis and exclusion of differential diagnoses is important. Management involves
psychoeducation, psychological and stress management strategies and, in some cases,
pharmacological strategies.
The authors are from the Faculty of Life and Social Sciences at Swinburne University of
Technology in Melbourne, Victoria. They bring a wealth of clinical, research and teaching
experience to the topic. The authors of this unit are:
Richard Moulding, BSc(Hons), MPsych, PhD, MAPS, PsyCHE Research Centre, Faculty of Life
& Social Sciences, Swinburne University of Technology, Victoria. His interests include anxiety
disorders, obsessive compulsive spectrum disorders, hoarding, evidence based psychological
therapy and primary care
Maja Nedeljkovic, BSc(Hons), MPsych, PhD., MAPS, PsyCHE Research Centre, Faculty
of Life & Social Sciences, Swinburne University of Technology. Her interests include
depression and anxiety disorders, obsessive compulsive spectrum disorders, hoarding,
e-therapy and public health
Michael Kyrios, BA, DipEdPsych, MPsych, Ph.D, FAPS, Director, Brain Sciences Institute and
Director, PsyCHE Research Centre, Faculty of Life & Social Sciences, Swinburne University of
Technology. His interests include anxiety disorders, obsessive compulsive spectrum disorders,
depression, mental health in chronic medical conditions and primary care.
The learning objectives of this unit are to:
r ecognise the clinical features of GAD, social anxiety disorder, panic disorder, anxiety
disorder not otherwise specified, OCD and PTSD
a
 ppreciate that a number of clinical tools are available to help in the diagnosis and
assessment of anxiety disorders
r ecognise the importance of asking patients with anxiety disorders about depressive
symptoms and risk of harm to self or others
u
 nderstand the importance of psychoeducation and relaxation strategies in the management
of anxiety disorders
a
 ppropriately manage and/or refer patients for management of GAD, social phobia, panic
disorder, anxiety disorder not otherwise specified, OCD and PTSD
a
 ppreciate that a number of clinical tools, including online tools, are available to aid in the
treatment of anxiety disorders.
We hope this unit will assist you to confidently assess and manage patients who present in the
general practice setting with symptoms of anxiety.

Warm regards

Kath OConnor
Medical Editor

1. Australian Bureau of Statistics. National survey of mental health and wellbeing: summary of results.
ABS Cat. no. 4326.0. Canberra: ABS, 2007.

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 check Anxiety disorders

Case 1

Jeffreys persistent worries Question 1

Jeffrey, aged 46 years, is an IT consultant who is What is the likely diagnosis?
married with two children, aged 10 and 12 years. Due
to the retirement of his previous general practitioner,
he presents to you for the first time with concerns
about his health, family and the future. A letter from
his previous GP details an incident about 2 months ago
in which Jeffrey experienced shortness of breath and
an irregular heart beat while playing tennis. He was
thoroughly investigated for an organic cause (normal
electrocardiogram, Holter monitor, stress test, thyroid
function tests, full blood examination and biochemistry)
and none was found. His GP had no concerns regarding
substance or medication use and abuse. Question 2
Since the incident, Jeffrey has noticed similar What differential diagnoses do you need to consider?
symptoms occurring intermittently. He also describes
other aches and pains over the past few years,
including headaches, and neck and back pain. He
attributed these to general tiredness and stress, and
says that for a number of years he has experienced high
levels of stress and anxiety associated with work and
home responsibilities. He is concerned about the future,
his work performance, money, and his ability to keep his
job and provide for his family.
He says that he constantly feels tired and overwhelmed,
and has barely managed to keep his head above water
Question 3
for the past decade. His previous GP and a counsellor
at work suggested stress management strategies such What further information will help you confirm your
as tennis and morning jogs. He kept fit doing these diagnosis and exclude differential diagnoses?
activities until 2 months ago when he had the episode of
shortness of breath and irregular heart beat. Around the
time of this episode, a colleague of similar age at work,
died suddenly from a heart attack. Since then, this and
all the other worries have been constantly on his mind.
Jeffrey says he trusts his former GPs opinion that he
is physically okay but even the smallest probability of
having a heart attack like his colleague has started a
barrage of thoughts and scenarios running through
his mind. He fears becoming seriously ill and not being
able to support his familys commitments such as the
mortgage, school fees, and even basic needs. He says,
I know its ridiculous to worry so much about all this. Question 4
Despite constant reassurance from his wife, he cannot What clinical tools may help with your further
seem to get any peace from the thoughts. assessment?
Jeffrey says he feels exhausted and overwhelmed, is
constantly preoccupied with his worries, and has trouble
concentrating at work. He feels unable to engage
normally with his family, particularly his children. He has
had enough of the worries and is desperate to find out
what is happening and whether you can help him.

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Case 1

Question 5 Answer 1

Your further assessment supports your diagnosis. What Jeffreys most recent health concerns seem to be
is your management plan? part of a more general pattern of worries over several
years. He describes frequent and persistent worries
about his health, his family and his capacity to provide
for them. The most recent concerns seem to have
been precipitated by the unexpected death of a
work colleague and the experience of physiological
symptoms (irregular heart beat, shortness of breath,
fatigue, muscle tension), emotional symptoms
(irritability, feeling on edge), and cognitive symptoms
(difficulty concentrating, frequent worries). His worries
seem to be persistent, very distressing and interfere
with Jeffreys day-to-day functioning (difficulties
concentrating at work, loss of interest in leisure and
family activities, difficulty sleeping, feeling tense). The
nature of the symptoms and medical investigations
provide no indication of a physical/physiological cause
for the symptoms.
Overall, Jeffreys current difficulties seem consistent
with symptoms of GAD. In Australia, according to the
National Survey of Health and Well-Being,1 GAD is one
of the more common anxiety disorders, affecting 5.9%
of Australian adults in a 12 month period (4.4% males,
7.3% females). Along with panic disorder, GAD tends to
be one of the most common diagnoses in primary care.2
Most individuals with GAD describe being nervous
throughout their lives, although it tends to worsen during
times of stress (Table 1).

Table 1. Abbreviated criteria for GAD in the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition Text Revision (DSM-IV)3
A. Excessive anxiety and worry (apprehensive expectation)*, occurring more days than not for at least 6 months, about a number of events or
activities (such as work or school performance)
B. The person finds it difficult to control the worry
C. The anxiety and worry are associated with three (or more) of the following six symptoms**, with at least some symptoms present for more days
than not for the past 6 months.
Note: Only one item is required in children.
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or the mind going blank
Irritability
Muscle tension
Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
* The anxiety and worry must not be confined to another disorder (eg. being embarrassed in public), be due to the direct physiological effects of a
substance or a general medical condition, and must cause clinically significant distress or impairment
** There may be trembling, twitching, feeling shaky, and muscle aches or soreness associated with the muscle tension. Many individuals also
experience somatic symptoms (eg. sweating, nausea, or diarrhoea) and an exaggerated startle response. Other symptoms of anxiety are also
often present (eg. heart palpitations, shortness of breath, dry mouth, dizziness)

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Answer 2
Differential diagnoses to consider include:
Other anxiety disorders
These include panic disorder, specific phobias, social
phobia, OCD, acute and PTSDs, substance induced
anxiety disorder, and anxiety disorder due to general
medical condition. Generalised worries are the central
symptom of GAD, and include worries about the long
term effects of worrying itself (ie. worrying is dangerous;
worrying can be harmful to my health; worrying means
my thoughts are out of control). By contrast, in other
anxiety disorders, the anxiety is focused on specific
thought content such as misinterpretation of physiological
symptoms in panic disorder; specific objects (eg. animals)
or situations (eg. storms, heights, enclosed spaces) in
specific phobias; fear of negative social judgments and
embarrassment in social phobia (social anxiety disorder);
themes such as contamination, personal responsibility
and morality, and doubts about safety in OCD; and an
actual or threatened traumatic event where death or
serious injury, or threat to the physical integrity of self/
others was evident in acute and PTSDs.3
At this stage, Jeffreys symptoms seem to be better
explained as part of a more general set of worries
(although this needs to be confirmed). Panic disorder
is unlikely as Jeffrey does not misinterpret specific
cardiovascular symptoms as indicative of impending
death, nor does he experience repeated unexpected
panic attacks. Social phobia is unlikely as Jeffreys
symptoms do not occur not in response to social
situations. Obsessive compulsive disorder can be
discounted as there are no specific concerns about
contamination and morality, causing harm, or the
experience of a pivotal sense of personal responsibility
over issues relating to the prevention of dangerous
outcomes and/or the need to compensate for them.
There is no indication of substance induced anxiety
disorder, although substance abuse needs to be
specifically enquired about. Anxiety disorder due to
general medical condition is unlikely in the setting of
normal investigations from Jeffreys previous GP.
Hypochondriasis
Hypochondriasis is a somatoform disorder where the
individual has a preoccupation with the idea of having
(or the idea that one has had) a serious disease, based
on the persons misinterpretation of bodily symptoms
as indicative of a specific serious disease, where the
preoccupation persists despite medical evaluation and
reassurance. Jeffrey seems to have some insight about
his health concerns and the lack of a physiological basis
for them, and has not engaged in excessive search
for evidence of heart problems. This provides further
support for GAD rather than hypochondriasis.
check Anxiety disorders
Case 1
Major depression
A diagnosis of major depression also needs to be
discounted. Patients presenting with depression are
also preoccupied with negative thoughts. However, in
such cases, depressed patients are preoccupied with
past events, express self criticism and guilt, and also
experience anhedonia (loss of pleasure) and/or lowered
mood. Nonetheless, psychiatric comorbidity between
GAD and major depression is common, with the most
recent Australian data indicating that having GAD
increases the likelihood of having depression (odds
ratio of 28.9).4
Ceasing benzodiazepine use
Ceasing benzodiazepine use can be associated with
anxiety, sensitivity to sound, light, smell and taste,
feelings of imbalance, gastointestinal symptoms,
aches, pains and muscle spasms, vertigo and rebound
insomnia. In Jeffreys case, there is no history to
suggest benzodiazepine withdrawal.
Answer 3
More detailed history around the main symptoms (ie.
nature, content and extent of worries) and the history
of worrying is required. Generalised anxiety disorder
often has an early onset, multiple episodes over the
lifetime often associated with stressful life events,
and a waxing and waning course. Information about
Jeffreys response to the worries throughout his life is
important for diagnostic clarification and to determine
the treatment approach.
It is important to gauge the level of insight Jeffrey
has regarding his health concerns in order to exclude
hypochondriasis. Does he believe he has a heart
condition or recognise that his concerns are anxiety
driven? Does he try to cope by seeking to have more
tests to confirm a physical diagnosis or is looking for
anxiety relief? A drug history asking about prescribed
and over-the-counter medication use, alcohol intake
and other drug use is important to exclude substance
induced anxiety disorder. Further questioning about
depressive symptoms is also important.
Answer 4
To quantify Jeffreys level of anxiety, an anxiety
checklist or self report inventory such as Depression
Anxiety Stress Scales-215 or the Penn State Worry
Questionnaire6 may be useful. These types of
questionnaires can be used to track the severity of
symptoms over time. Other questionnaires include the
K-10 which measures general distress and the Patient
Health Questionnaire-9, which assesses depression.7
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 check Anxiety disorders
Case 1
Answer 5
Jeffreys management plan could include:
Psychoeducation
Psychoeducation about the nature of anxiety, its purpose
and how it can present is important when dealing with
someone with any anxiety disorder, and particularly with
GAD. In most cases, on top of their presenting worries
(eg. health problems, finances, family), individuals with
anxiety problems will also suffer worry about worry
(eg. that anxiety is dangerous, that they are going crazy
or losing it), which clearly exacerbates any anxiety
problem, and is suggested to be one perpetuating factor
in GAD.8 For this reason, psychoeducation itself may
help alleviate some of the symptoms. Psychoeducation is
also an important lead-in to some treatment options (eg.
relaxation, cognitive behaviour therapy [CBT], exercise,
yoga). General practitioners are in an excellent position
to provide such information, as a trusted and authoritative
source of information about health and physiology.
Explain to Jeffrey that he is experiencing normal anxiety
symptoms and they are not dangerous, despite being
somewhat unpleasant. On the contrary, anxiety is
essential to avoid danger and moderate anxiety actually
improves performance (eg. exams, work).
It may help to describe the fight/flight model of anxiety,
and refer specifically to Jeffreys individual symptoms
and their purpose. For example, the experience of
difficulty breathing can be explained as an increase in
breathing frequency in order to increase the amount of
oxygen entering the body as well as a rapid heartbeat
which allows the body to transport oxygen to the muscles
for energy and remove waste products more quickly.
These changes are designed to help the body respond to
a threat. However, during hyperventilation the increased
oxygen in the bloodstream and increased expulsion of
carbon dioxide can actually reduce the level of oxygen
supplied to the heart and lungs (Bohr Effect). This can
lead to heart and chest pain and arrhythmias such as
those experienced by Jeffrey. Other symptoms (eg.
shakiness, fatigue, tenseness, blurred vision, dry mouth,
hot flushes, sweating), may be linked to anxiety and the
fight/flight reaction, or to the effects of hyperventilation.
Psychological and stress management strategies
Basic relaxation methods (eg. progressive muscle
relaxation) and breathing control can help to reduce the
physical symptoms of anxiety. Planning these activities
can also reduce the focus on stressors. Activities that
involve moderate physical activity or breathing control
can be particularly useful as they can help reduce
physiological symptoms of anxiety.
While heart disease has been excluded in Jeffreys case,
it may be helpful to explain to him the differences between
physical symptoms of exercise/anxiety and those of
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cardiac disease, eg. the difference in the sharp pain of a
panic attack compared to the crushing or distributed pain
usually accompanying a heart attack.2 If there are any
avoided activities, then gradual exposure to feared events
or stimuli may help. Structured problem solving can help
deal with real life stressors and has been shown to be
effective; it can be easily administered by GPs.9
General practitioner assisted bibliotherapy (the use of
books to address emotional or behavioural issues) or
computerised treatment may be helpful (see Resources).
A range of internet resources for GAD are available,
including the National e-Therapy Centre for Anxiety
Disorders (see Resources) which includes a diagnostic
tool and a 12 week treatment for GAD that can be self
directed, assisted by an online therapist, or monitored by
a GP or other mental health professional.
Referral to a clinical psychologist for psychotherapy
can be extremely helpful and is supported by Medicare
through the Better Access to Mental Health Services
scheme (see Resources). In particular, CBT is effective,
focusing on addressing beliefs that may underlie
the anxiety, increasing the individuals intolerance
of uncertainty and developing more adaptive beliefs
about worry (eg. worrying will not likely help me solve
problems rationally or worrying cannot kill me). Applied
relaxation is also effective for GAD, although it is not as
effective for other problems such as panic disorder.10
Pharmacological
Specific serotonin reuptake inhibitors (SSRIs) are
the treatment of choice, and paroxetine, venlafaxine,
and escitalopram have been indicated for GAD by
the Therapeutic Goods Administration. However, only
escitalopram is listed on the Pharmaceutical Benefits
Scheme (PBS) for this indication (Table 2).
Table 2. PBS listing for SSRIs used in anxiety
disorders*
Escitalopram Listed as a restricted benefit for the treatment of
major depressive disorder (MDD) and treatment of
moderate to severe GAD in a patient who has not
responded to nonpharmacological therapy, and
for whom a GP Mental Health Care Plan, as
described under Item 2710 of the Medicare
Benefits Schedule, has been prepared, or
who has been assessed by a psychiatrist
Fluoxetine and Listed as a restricted benefit for MDD and OCD
Fluvoxamine
Paroxetine Listed as a restricted benefit for MDD, OCD and
panic disorder
Sertraline Listed as a restricted benefit for MDD, OCD and
panic disorder where other treatments have
failed or are inappropriate
* Refer to www.pbs.gov.au
 check Anxiety disorders

Case 2

Toms social difficulties Tom is the first of two children in his family; his sister is
Tom is a 13 year old boy who has just finished his first 2 years younger than him. From reports by the parents
year of high school. He presents with his parents who and Tom, and your observations, it seems that the family
are concerned about his increasing social difficulties. relationships are loving and warm. Toms parents seem
They tell you that over the past year Tom has become supportive and have encouraged him to socialise more.
increasingly withdrawn. He has been spending more However, this seems to have had the opposite effect,
time at home and in his room, where he hides if with Tom becoming even more avoidant. His marks
someone outside his extended family is visiting the at school have deteriorated, particularly for subjects
house. Toms teachers are concerned that he has not requiring greater class participation (eg. English).
participated in class or group activities. He avoids Despite his difficulties, Tom has continued to attend
speaking in front of the class and seems to find it school regularly. He reports having stomach aches
difficult to socialise during class breaks. He tends to before going to school, particularly on days when he
spend most of his nonclass time with one other boy may be required to speak in front of the class. Tom has
rather than with a range of his peers. always been a bit shy but his anxiety has increased
dramatically over the past year, coinciding with the start
Tom is difficult to engage but after a few minutes and
of high school.
numerous empathetic statements from you, he is able
to overcome his evident shyness. You ask him how he
feels around people he doesnt know well. He says he Question 1
feels self conscious, uncomfortable and nervy, and
What is your provisional diagnosis?
constantly worries what they think about him. Tom
describes fear in any situation where there is a crowd or
he may be the focus of other peoples attention including
meeting new people, speaking in front of the class,
talking to teachers or peers, using the toilets at school
or shopping centres, lining up for tickets at the cinema
and eating in public.
You ask Tom what he is afraid of. He says he fears
saying or doing the wrong thing or not knowing what
to say or do, and that others will think badly of him
as a result. The fear is so intense that he can get
into a complete panic and needs to get out of the Question 2
situation immediately. When he is in a panic, he has What differential diagnoses would you need to consider?
an increased heart rate, chest discomfort, shortness of
breath, sweating, and feels like he is going completely
blank. He believes others can see these symptoms and
would think he is pathetic for having them. Tom says he
has two good friends he feels comfortable with, one is
a neighbour and the other attends the same school as
him. However, Toms parents noted that he has been
going out less over the past few months. Tom says it
takes too much energy to work out what to wear: he is
very concerned about his appearance and how he may
appear to others.
Question 3
What further information would help you formulate your
diagnosis and exclude differential diagnoses?

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Case 2

Answer 1

Question 4 Toms presentation is consistent with a diagnosis of

social phobia (social anxiety disorder), generalised type.
What clinical tools may help with your further
He reports a fear of embarrassment across a range
assessment?
of situations, and has experienced intense anxiety
at times in the form of a panic attack. Tom reports
concerns about how he is perceived by others and
feeling embarrassed at the anxiety symptoms, along with
physiological symptoms consistent with panic (Table 3).
In Australia, 3.8% of males and 5.7% of females have
social phobia over a 12 month period, according to the
latest survey.1 Social phobia typically begins in the mid
teenage years, sometimes following childhood shyness.
Social phobia often is continuous and lifelong. There is
some evidence for a familial pattern in occurrence.
Question 5
Your further assessment supports your diagnosis of Table 3. Abbreviated DSM-IV criteria for social
social phobia (social anxiety disorder). What is your
phobia3
management plan? A. A marked and persistent fear of one or more social or performance
situations in which the person is exposed to unfamiliar people
or to possible scrutiny by others. The individual fears that he or
she will act in a way (or show anxiety symptoms) that will be
humiliating or embarrassing.
Note: in children, there must be evidence of the capacity for age
appropriate social relationships with familiar people and the anxiety
must occur in peer settings, not just in interactions with adults
B. Exposure to the feared social situation almost invariably provokes
anxiety, which may take the form of a situationally bound or
situationally predisposed panic attack
Note: in children, the anxiety may be expressed by crying,
tantrums, freezing, or shrinking from social situations with
unfamiliar people
C. The person recognises that the fear is excessive or unreasonable.
Note: in children, this feature may be absent
D. The feared social or performance situations are avoided or else
are endured with intense anxiety or distress

Answer 2
There are several differential diagnoses to consider
in Tom:
Normal anxiety
Some normal anxiety would be expected in the
transitional period of moving from primary to high
school. In deciding whether Toms difficulties warrant
a diagnosis of social phobia, you need to consider the
level of intensity of the anxiety, extent of the avoidance
and extent to which these interfere with his functioning.
Panic disorder
The symptoms that Tom reports when his anxiety
is intense (eg. rapid heart beat, chest discomfort,
shortness of breath, sweating, blushing) are consistent
with a panic attack. In Toms case, his panic attacks are
likely to be features of social phobia because they occur
in social situations and are triggered by his intense fear
of negative social evaluation. If the attacks occurred in
other situations (eg. unexpectedly while at home alone)

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and Tom showed a persistent fear of further attacks (ie.
a fear of panic), panic disorder could be considered as
a diagnosis.
Separation anxiety disorder
Toms symptoms began before 18 years of age so this
diagnosis can be considered. However, Toms fears
relate to social embarrassment rather than separation,
so social phobia is a more appropriate diagnosis.
Avoidant personality disorder
If Toms symptoms continue into early adulthood, then
the personality disorder diagnosis, avoidant personality
disorder, may also be applicable. Avoidant personality
disorder is very similar to generalised social phobia
and concerns a pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluation.
Depression
Tom has not volunteered any specific depressive
features, but it is important to ask about these as this is
an important diagnosis which should not be missed and
may interfere with treatment.
Generalised anxiety
In Toms case, social phobia is more likely as his anxiety
is triggered in social situations by his intense fear of
negative social evaluation. However, it is important to
ask about more general anxiety symptoms as these may
interfere with treatment.
Substances/drugs
Use of substances or drugs does not necessarily
preclude a diagnosis of social phobia these more
commonly follow the problem and work as maladaptive
coping mechanisms.
Schizophrenia prodrome
The median age of onset for psychosis is typically
around 21 years in males and older in females but
can occur in individuals as young as Tom (or even
younger). Unfortunately, the prodromal symptoms
of schizophrenia tend to be nonspecific (eg. social
withdrawal, cognitive decline, anxiety, and perhaps
some limited psychotic symptoms). However, if there is
no family history of psychosis in first degree relatives
and no developmentally abnormal psychotic symptoms,
a prodrome is unlikely in this case.
Answer 3
Enquiring about the specific focus of Toms concerns
can be helpful in distinguishing social phobia from panic
disorder. For example, panic attacks in social phobia are
usually triggered by an extreme concern about being
negatively evaluated by others. More information about
the extent of the fear of negative social evaluation will
help clarify the diagnosis and specific details about the
type of feared situations and the misinterpretation of
check Anxiety disorders
Case 2
social cues will aid in treatment planning (eg. in order
to create a fear hierarchy as will be discussed later). It
is also important to consider the impact of the current
difficulties on Toms social, school and leisure activities
and ask about symptoms of more generalised anxiety
and depression. Further information regarding his school
life may be helpful, particularly asking about any major
difficulties such as teasing and bullying which often
precipitate and exacerbate social anxiety. If there is any
suggestion of abuse this should be assessed further.
As with other emotional disorders, it is important
to assess for possible predisposing, precipitating,
perpetuating and protective factors. It is likely that a
range of biological and environmental factors have made
Tom vulnerable to developing his current difficulties.
It is possible that there is a biological vulnerability to
developing anxiety (such as an inherited tendency to
develop anxiety under stress).11,12 It is important during
the history taking process to gather more information
regarding a possible history of anxiety difficulties in the
family. Even if no such history is reported, the indication
by Toms parents that he has always been a shy child
provides some indication of a temperamental factor or
biological vulnerability.
The anxiety seems to have increased over the past year,
which coincides with Tom transitioning from childhood
to adolescence; this is common in social phobia. This
transition is accompanied by major biological, physical,
psychological and social changes. Physically, there is
increased awareness of ones changing body and an
increased concern with how one is perceived socially.
Also, environmental or social demands increase
dramatically during this period. Peer relationships
become increasingly important and the transition into
a new environment (eg. primary to secondary school)
places further challenges in terms of forming and/or
maintaining such relationships. These are likely to have
precipitated Toms difficulties, eg. he expressed concern
about what he wore and how he appeared to others
to such an extent that this often prevented him from
participating in social activities.
Toms problems may be maintained by avoidance
behaviours and possibly by unhelpful thinking styles
(cognitive factors). It has been suggested that people
with social phobia have a range of distorted thoughts
(cognitions) concerning what might happen in social
situations (eg. Im bound to make a fool of myself) and
regarding their self evaluation of how they performed
in the situation (eg. they could see I didnt know what
I was talking about). The cognitive aspect of social
phobia frequently involves fear of negative evaluation
by others, selective attention to negative aspects of
how one responded in a social situation and very high
standards for how one should behave and appear in
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 check Anxiety disorders
Case 2
these contexts.13 For example, Tom says he is concerned
about how he appears to others and that he is worried
others will think badly of him because he might not
know what to say, or he would say the wrong thing in
a situation. Consequently, he avoids these situations.
This avoidance is viewed as a key maintaining feature
in social phobia. As with other anxiety disorders, such
avoidance prevents the person from learning to be
nonfearful in difficult situations. If they are able to
actually confront the feared situation, the person can
start to disconfirm negative predictions of what might
happen). More information about the situations that
are avoided and the predominant cognitions in these
situations can help the clinician to plan treatment.
Answer 4
Self report measures such as the Brief Fear of Negative
Evaluation Scale14 or the Liebowitz Social Anxiety
Scale15 may be helpful. An age appropriate scale to
assess anxiety in adolescents has been developed by
Spence and associates in Australia16 (see Resources).
These scales provide quantitative information on the
level of anxiety symptoms.
Diary methods whereby the patient or, in the case of
socially anxious children, parents or teachers and
even peers monitor the situations in which the anxiety
occurs, can help gather information about the specific
type of feared situations and the misinterpretation of
social cues. This method can also be used to gather
information about the cognitive and behavioural
processes that occur in such situations. For example,
along with the types of situations in which Tom
experiences anxiety, he can also record what is going
through his mind in such situations, as well as his
responses to the situations.
In social phobia, as with all of the anxiety disorders,
the anxious individual will often demonstrate safety
behaviours which aim to help minimise the anxiety (eg.
standing away from the social group, volunteering to
be assessed via essay rather than class presentation,
staying away from school on sports days, avoiding social
events and other avoidance strategies). Rather than
constituting coping strategies that are helpful in the long
run, such safety behaviours act to maintain the social
anxiety (ie. the individual never has the opportunity
to learn that such situations are not as dangerous as
they perceive), and can make the person more likely to
experience rejection.
Answer 5
There are a number of possible treatment approaches
for Tom. As with all anxiety disorders, the patient
should be provided with detailed education regarding
what anxiety is, in order to normalise their experience.
10
Breathing control and general relaxation exercises
may be useful. Again, pharmacological treatments,
particularly SSRIs (Table 2), are available and have been
used in adolescents. However, the authors recommend
caution: specialist advice may be needed before these
medications are commenced in this age group.
A referral to a clinical psychologist for a course of CBT
treatment can be considered. Psychological treatments
have been shown to be as effective as medication for
social phobia and CBT have the greatest evidence for
efficacy.
The aim of CBT is to help the patient understand how
and why anxiety symptoms develop, what triggers
them and what unhelpful responses maintain the
symptoms. Also, patients are taught coping strategies
(cognitive and behavioural) to assist them to manage
their symptoms. The main behavioural component of the
treatment is graded exposure to feared social situations,
in which the patient gradually confronts feared or
avoided situations without their usual safety behaviours
until their anxiety reduces.
The cognitive component involves identifying Toms
thoughts about himself which contribute to his fear and
avoidance of social situations. He can then be helped
in challenging these unhelpful thoughts. He can use
these strategies along with relaxation and other anxiety
management strategies when confronting anxiety
situations.
A number of CBT programs, in the form of books and
CDs, have been developed for use with children.17,18
Internet based treatments for childhood and adolescent
anxiety have also been developed.19 Cognitive
behaviour therapy for social phobia can also be
undertaken in a group format. Group treatments can
be particularly effective as they provide a unique
opportunity for exposure to social interaction with other
group members and support from peers in the often
challenging exposure exercises.
Other referrals may be appropriate depending on
Toms needs. He may wish to see a school counsellor
to discuss any ongoing issues with his peers (eg.
bullying, teasing). Some individuals with social phobia
also may require social skills training, either in general
conversation skills, specific skills (eg. public speaking),
or general assertiveness training.
 check Anxiety disorders

Case 3

Amandas panic Question 2

Amanda, aged 26 years, she is a previously well, What is your assessment of Amanda now?
recently divorced mother of a 2 year old son. She
presents complaining that she often feels in a panic
when she is home alone at night.

Question 1
What questions will you ask to find out what Amanda
means when she says panic?

Question 3
What will you do next?

Further history
Amanda describes apprehension, frequent negative
thoughts and increasing anxiety. She has experienced
shortness of breath and palpitations all night over the
last 2 nights and this is what prompted her visit. Her
levels of anxiety have increased over the past week,
particularly in the afternoon in anticipation of putting
her son to bed, with the panic increasing after she puts
him to bed and has her dinner. She cannot recall exactly
when the symptoms started but reports that the feelings
have been gradually getting stronger over the past few
months following the break up of the relationship with
her partner. She says that before the divorce she was an
easy going person and these symptoms are very unusual
for her.
Amanda does not drink alcohol or take any over-the-
counter medications, prescribed medications or illicit
drugs. She does not take excessive caffeine, sugar or
sugar replacements such as aspartame. She denies
symptoms of depression and there are no specific
symptoms suggestive of an organic cause. Basic
investigations (including thyroid function tests and
electrocardiogram) are normal.

11
 check Anxiety disorders
Case 3
Answer 1
It is helpful to start with open questions asking what
Amanda means when she describes panic. Patients who
complain of feeling panic do not necessarily have a panic
attack or panic disorder. The term panic is often used in a
general, exaggerated sense by patients to describe feeling
stressed or overwhelmed. This is a common problem in the
diagnosis of many anxiety disorders because there are so
many lay terms used to describe varying degrees of anxiety
and its accompanying physical symptoms (eg. patients with
preoccupations or minor superstitions may report they have
OCD or refer to their obsessions). Furthermore, patients
may use terms to express their anxiety in a way that is very
different from the way the term is used by clinicians.
The essential feature of a panic attack is the occurrence
of a discrete period of intense fear or discomfort, usually
lasting for several minutes and accompanied by at least
four physiological and/or psychological (eg. palpitations,
sweating, trembling or shaking, shortness of breath,
feelings of choking, chest pain, abdominal discomfort,
derealisation, dizziness, fear of losing control, fear of
dying), which develop abruptly and reach a peak of
intensity within few minutes. It is important to probe Table 4a. Abbreviated DSM-IV criteria for panic attack3
a little further and ask about specific symptoms A discrete period of intense fear or discomfort in which four (or more) of the
such as shortness of breath, heart palpitations, following symptoms developed abruptly and reached a peak within 10 minutes:
chest pain and sweating to determine whether palpitations, pounding heart, or accelerated heart rate
Amanda is having a true panic attack (Table 4).
Self report questionnaires such as the Beck Anxiety
Inventory (BAI) or Depression Anxiety Stress Scales
(DASS) (see Resources) may be helpful.
Answer 2
While some of Amandas symptoms seem
characteristic of a panic attack, they develop
gradually and remain throughout the night, which
is not typical, and they do not seem to meet the
criteria for panic attacks or panic disorder (Table
4). There is no suggestion of specific phobias,
social phobia, OCD, acute and PTSDs, substance
induced anxiety disorder or anxiety disorder
due to general medical condition. Amanda does
not appear to reach the criteria for a disorder.
However, her symptoms are causing significant
distress and need addressing. The main differential
diagnoses are anxiety disorder not otherwise
specified or simply anxiety symptoms secondary
to life stress.
Answer 3
It is important to gather some more details about
Amandas current difficulties. This can help you to
understand what specific stressors precipitated her
symptoms and which strategies might help her to
manage these difficulties.
12
Offering general support may be all that is needed in the
first instance. As with any anxiety symptoms, providing
information about the nature and purpose of anxiety and
fear can be useful. It may help to encourage Amanda
to take part in activities that are either distracting (eg.
hobbies, enjoyable activities), or potentially anxiety
relieving (eg. yoga, exercise, martial arts, tai chi).
Structured problem solving may help Amanda to remove
or deal with some of the difficulties in her life.
General supportive counselling may be useful, either
from the GP if there is sufficient time, or from an
alternative professional (eg. counsellor, social worker,
psychologist). Amanda should be educated about
the impact of the excessive use of caffeine and other
stimulants on anxiety symptoms. Amandas anxiety
should be monitored regularly in order to ensure that her
symptoms do not worsen. At this stage, benzodiazepines
or other psychotropic medications are not indicated.
Sleep problems may develop with increasing anticipatory
anxiety. If this occurs, relaxation techniques or cognitive
behavioural strategies for sleep problems may help.
sweating
trembling or shaking
sensations of shortness of breath or smothering
feeling of choking
chest pain or discomfort
nausea or abdominal distress
feeling dizzy, unsteady, lightheaded, or faint
derealisation (feelings of unreality) or depersonalisation (being detached from
oneself)
fear of losing control or going crazy
fear of dying
paresthesias (numbness or tingling sensations)
chills or hot flushes.
Note that panic attacks are common across several anxiety disorders, and also
occur occasionally in up to 50% of the population at times of stress, illness or
under the influence of a substance. In addition, if fewer than four symptoms
occur, it can be termed a limited symptom attack
Table 4b. Abbreviated DSM-IV criteria for panic disorder3
Both (1) recurrent, unexpected panic attacks; (2) at least one of the attacks has
been followed by one month or more of:
(a) persistent concern about having additional attacks
(b) worry about the implications of the attack or its consequences (eg. losing
control, having a heart attack, going crazy)
(c) a significant change in behaviour related to the attacks.
Note: Panic disorder must be coded as either panic disorder with agoraphobia
(where the person avoids or tolerates with extreme anxiety places or situations
where escape may be difficult in the event of a panic attack, or where help might
not be forthcoming), or panic disorder without agoraphobia (where there is no
agoraphobic avoidance or anxiety).

Jims distressing thoughts
Jim is a construction worker who is 36 years of age.
He presents looking very distressed and explains that
over the past 23 months he has been having awful
thoughts about something bad happening to his wife
and children. He said that he has tried to stop thinking
the thoughts to get rid of them but he keeps checking to
make sure that the dreaded events have not occurred.
The thoughts are becoming more frequent and more
distressing. He reports severe sleep disturbance over
the past few weeks, accompanied by a significant
decrease in appetite and frequent absences from work.
He described experiencing strong feelings of anxiety (eg.
rapid breathing, choking sensations, heart palpitations,
sweating and headaches).
Question 1
Based on this brief description, what do you think might
be happening to Jim?
Question 2
What differential diagnoses would you consider?
check Anxiety disorders
Case 4
Further history
You enquire further about the nature of Jims thoughts.
He reluctantly reveals that they involve him causing
unwanted harm to his family. He starts crying saying
that he loves his family and that he would rather die
before causing his family any harm. The thoughts firstly
occurred while watching a television program which
involved a brutal murder. He said that the image kept
playing on his mind the whole evening and somehow
he started thinking about whether he may lose control
and harm his wife or children. He was repulsed by the
thought and tried to reassure himself that he was being
silly, but in the evening while helping with the dinner,
he found himself having the thought as he was holding
a knife. He said that he immediately left the room and
has not held a knife in the presence of his family since.
He said that he could not sleep that night and as the
days went on, he became more concerned that he was
going crazy. As the thoughts became more frequent,
he is now at the point where he finds it very difficult to
be around his family and not feel anxious. He has not
told his family about the thoughts. However, they have
noticed his increasing agitation around them and are
very concerned about him.
Question 3
What is your assessment of Jim now?
Further history
Jim is relieved that you can explain his symptoms in
terms of a treatable anxiety disorder. He describes
mild to moderate depressive symptoms but no suicidal
thoughts. Your risk assessment is that he is currently not
at risk of harming himself or others. He denies further
obsessions and compulsions.
13
 check Anxiety disorders

Case 4

Question 4 Answer 1

What will you do next? Jims symptoms are characterised by persistent,

unwanted, distressing thoughts which he finds difficult to
control and seem to be associated with strong anxiety.
As such, they are consistent with the DSM-IV definition
of obsessions. Furthermore, Jim reports checking that the
dreaded events that he anticipates have not occurred.
The checking behaviours are consistent with the DSM-IV
definition of compulsions. The presence of obsessions
and/or compulsions is indicative of OCD (Table 5).
In Australia, OCD has a 12 month prevalence of 1.6% in men
and 2.2% in women.1 Onset is typically in late adolescence
to early adulthood, although subclinical symptoms typically
predate the disorder. It has a waxing and waning course
if left untreated. It is associated with a great level of
impairment to quality of life, greater than that in panic
disorder, social phobia or diabetes.20,21 It often leads to role
limitations, unemployment and problems in relationships.

Question 5 Table 5. Abbreviated DSM-IV criteria for OCD3

What are your management options?
A. Obsessions
Recurrent and persistent thoughts, impulses, or images that are
experienced, at some time during the disturbance, as intrusive
and inappropriate and that cause marked anxiety or distress
The thoughts, impulses, or images are not simply excessive
worries about real life problems
The person attempts to ignore or suppress such thoughts,
impulses or images, or to neutralise them with some other
thought or action
The person recognises that the obsessional thoughts, impulses
or images are a product of his or her own mind (not imposed
from without as in thought insertion)
B. Compulsions
Repetitive behaviours (eg. hand washing, ordering, checking)
or mental acts (eg. praying, counting, repeating words silently)
that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly
The behaviours or mental acts are aimed at preventing
or reducing distress or preventing some dreaded event or
situation; however, these behaviours or mental acts either are
not connected in a realistic way with what they are designed to
neutralise or prevent or are clearly excessive
Except in children, the person must recognise at some point in
the disorder that the obsessions or compulsions are excessive or
unreasonable.The obsessions or compulsions must also cause
marked distress, be time consuming (take more than 1 hour a day), or
significantly interfere with the persons normal routine, occupational/
academic functioning or usual social activities or relationships

Answer 2
Other disorders that should be considered include GAD
and MDD. Generalised anxiety disorder shares some
similarities with OCD, particularly if the individual reports
that they cannot control their worrisome thoughts.
However, worries differ from obsessions in that they
are more verbal, less often in the form of an urge or an
image, often an apprehension about a more reality based

14

future concern, and more acceptable to the person.
The most common worries are about competence at
work, academic performance, health issues, financial
circumstances, and intimate relationships. By contrast
common OCD themes include:
contamination concerns and cleaning obsessions
o
 bsessive doubts and overt or covert checking
compulsions (includes compulsively asking for
reassurance this can be a common way that people
check through others, ie. they ask: Is it clean? Are you
sure its clean? Is it okay?)
c
 oncerns about moral matters and an inflated sense of
personal responsibility for preventing harm to oneself
or others
u
 nacceptable thoughts and covert compulsions (eg.
suppressing thoughts, compulsive praying, self criticism)
a
 dysfunctional need for symmetry and order; and
compulsive hoarding.
Obsessive compulsive disorder also tends to be
distinguishable due to the occurrence of obsession which
is followed by a compulsion to undo or in some way put
right or avoid the obsession (eg. washing after a cleaning
obsession, checking after a doubt, thought suppression
after a personally unacceptable intrusive thought), which
typically does not occur in other disorders.
Obsessive compulsive disorder frequently presents
with other comorbid mental health problems (eg. other
anxiety disorders, depression, impulse control disorders),
neurological conditions (eg. Tourette syndrome) or health
problems (eg. dermatological conditions due to excessive
washing). With OCD and other anxiety disorders, the
individual should also be screened for the occurrence of
MDD. At least half of patients presenting with OCD will
also experience significant depression at some time in
their lives. While MDD tends to have a common element
of rumination, it is distinguished by the loss of ones ability
to experience pleasure or increased negative mood. In
particular, the sleep and appetite reported by Jim may
indicate that there is also a mood disorder present, which
could potentially worsen the obsessive symptoms.
Answer 3
Jims description of his symptoms provides further evidence
that he is experiencing obsessions; his thoughts are
unwanted, repugnant and have a sudden, intrusive quality.
They are accompanied by strong anxiety and persistent
unsuccessful attempts to eliminate them, mental checking
of events over the day to feel certain he has not harmed
any family members, reassurance seeking (eg. persistent
telephone calls to make sure family members are well), as
well as avoidance of potential triggers (ie. knives).
Jims thoughts are egodystonic, which means alien to the
individuals sense of self. This is evident from the obvious
check Anxiety disorders
Case 4
discomfort caused to Jim by the thoughts and this is
characteristic of obsessions. Importantly, Jim is aware that
the thoughts are the product of his own mind (however
distressing they may be), distinguishing them from thought
insertion delusions characteristic of psychotic disorders
such as schizophrenia or, if the criteria for schizophrenia
are not met, overvalued ideas and a schizotypal
personality, which constitute negative prognostic factors.
Answer 4
It is important to educate Jim about the possible diagnosis
of OCD and describe to him the symptoms, onset and
treatment of the condition. It is now well established that
the symptoms of OCD (obsessions and compulsions) exist
on a continuum in the population. Specifically, studies have
repeatedly shown that the type of thoughts experienced
by OCD patients are experienced by the majority of the
population, but may differ in the frequency and distress
they cause. This information may serve to normalise
Jims experience and provide him with reassurance that
he is not losing his mind but is rather experiencing an
anxiety problem, which is treatable. In addition, there is
now considerable empirical and clinical evidence that
the way people react to such thoughts impacts on their
frequency and intensity. That is, if such thoughts are
associated with great anxiety and specific behaviours (ie.
compulsions, thought suppression, avoidance), they are
more likely to increase in frequency and intensity, and
become obsessions. Providing Jim with a list of commonly
experienced intrusive thoughts could also help reduce the
anxiety associated with the thoughts. For example, Clark22
reported endorsement of thoughts by nonclinical student
and community samples (Table 6). Such information can
be very anxiety relieving for individuals experiencing OCD.
It is important to ascertain whether Jim is experiencing
comorbid symptoms of depression, and the severity
of these symptoms, given the common co-occurrence
of OCD and depression. While the depression is likely
to be secondary to his OCD (and will thus resolve with
successful treatment), it may be useful to treat this
separately if the depression precludes successful
treatment of the OCD, or if it is associated with significant
suicide risk. If suicidal ideation is present, then the usual
risk management strategies should be put in place.
Given the nature of Jims obsessions, it is also important
to determine that there is no history of psychosis or of
violence of the type that he describes. However, such
enquiries should be done sensitively, as generally in OCD
the fear is that I may be violent. In Jims case, there is no
real risk of the behaviours being carried out so you should
take care not to reinforce such fears.
The presence of some symptoms of OCD may be
indicative that other OCD symptoms are also present.
While individuals with OCD tend to present with some
15
 check Anxiety disorders
Case 4
specific concerns, it is often useful to assess for the
full range of OCD symptoms. While Jim readily reports
intrusive thoughts and some compulsions relating to his
family, there may be other intrusive symptoms that cause
him great shame. While he has insight into the intrusive
nature of the thoughts relating to his family, there may be
less insight with respect to other symptoms. Treatment
outcome is often associated with greater insight by
affected individuals into the intrusiveness of obsessions
and compulsions.
As it is less common for the first onset of OCD to be
experienced after the age of 2530 years, it is useful to get
a lifetime history of OCD symptoms in affected individuals,
although the presentation of OCD may wax and wane over
the lifetime with stressful life events, as may the type of
symptoms that the individual might experience.
Table 6. Common intrusive thoughts in people
without OCD22
Thought % %
women
Did I leave heat, stove, lights on that could cause 79
a fire?
Left the door unlocked, an intruder could be inside 77
While driving, impulse to run the car off the road 64
I could get a sexually transmissible infection from 60
touching a toilet seat or handle
Even though the house is tidy, an impulse to check 52
that absolutely everything is put away
Feel sudden impulse to say something rude or 59
insulting to a friend even though Im not angry at
him
Impulse to say something rude or insulting to a 50
stranger
While driving, the impulse to swerve the car into 55
oncoming traffic
The thought of having sex in a public place 55
The thought of having sex with an authority figure 51
(eg. minister, boss, teacher)
While driving, the thought of running over 46
pedestrians or animals
When talking to people, intrusive thought of their 44
being naked
Impulse to indecently expose myself by lifting my 14
skirt or slipping down my pants
Impulse to masturbate in public 11
When I see a sharp knife, the thought of slitting 20
my wrist or throat
When in a public place, the thought of becoming 35
dirty or contaminated from touching doorknobs
Answer 5
Your management options include the following:
f urther education about OCD and anxiety disorders in
general. As with every anxiety disorder, it is important to
provide the patient with general information regarding
16
what anxiety is, along with specific patient support
materials about OCD (see Resources)
r elaxation: some general stress reduction or anxiety
control strategies may help Jim with his symptoms
p
 sychological approaches: there is good evidence for
the efficacy of psychological approaches (ie. CBT). The
UK National Institute of Health and Clinical Excellence
(NICE) recommend CBT as a first line treatment.23 If
the OCD is severe, then it is probably advisable to
refer the patient for specialist treatment by a clinical
psychologist or psychiatrist who is experienced with
the disorder. The CBT treatment uses graded exposure
and response prevention (ERP) as the cornerstone of
treatment, augmented by psychoeducation on anxiety
and OCD, and techniques targeting beliefs within the
disorder (Table 7). In ERP, the patients obsessions are
provoked in a graded fashion and then they are asked
to refrain from using compulsions to neutralise the
obsession. For example, for Jim he may first be asked
to watch the news, then violent films, then to be in a
men room with knives, then to hold a knife, then to hold a
62 knife while the therapist is in the room, and so forth, all
while refraining from performing any compulsions. In
65 this way, he will learn that his obsessive fear that he is
53 dangerous is unfounded and the intensity of his OCD
40 related anxiety will diminish
40 p
 harmacological approaches (ie. SSRIs): NICE
recommends SSRIs as a second line treatment for OCD
55 if CBT is initially unsuccessful23 (Table 2)
o
 ther: while specialist treatment is advisable for any
OCD of moderate severity, other treatment modalities
55
could include co-treatment of the patient by GP and
49
psychologist, referral to a group treatment program, or
guided internet based interventions. Australian research
67 with GPs has indicated a preference for referral to a
62 specialist who understands OCD.24 Furthermore, the
National e-Therapy Centre for Anxiety Disorders includes
51 a diagnostic tool and a 12 week treatment for OCD that
can be self directed, assisted by an online therapist, or
63 monitored by a GP or other mental health professional
(see Resources).
24
18 Table 7. Beliefs within OCD that may be targeted
22 by CBT
Inflated sense of responsibility for causing or preventing harm or
23 danger
Overestimation of threat in situations
Beliefs about the importance of thoughts in evaluations of the
individuals sense of worth
Unrealistic beliefs about the degree of control one should have
over ones thoughts
An intolerance of uncertainty
An inflated need for perfectionism
 check Anxiety disorders

Case 5

Pauls nightmares and anxiety Question 2

Paul is 55 years of age and a father of four children. He What differential and/or comorbid diagnoses do you
presents with difficulties sleeping and concentrating. He need to consider?
says that he wakes up in a cold sweat every night after a
nightmare and he finds it difficult to fall asleep because
of anxiety. The nightmare is always the same: a car
accident like the one he experienced 10 years ago.
Paul was driving from the hardware shop with his then
8 year old son and was suddenly hit on the side of the
car and swerved onto the side road. He remembers
time slowing down as the car was sliding off the road,
thinking this is it and turning to see his son leaning
toward the window. He had wanted to reach out and
grab him but had to keep his hands on the wheel and
regain control of the car. He said that it was probably
the most intense and scariest few seconds of his life.
Question 3
No-one was injured and at the time Paul felt relieved,
thinking for some time later how lucky they were that the What further history do you want to take from Paul?
car stopped before crashing into a nearby tree.
Paul says he has not thought much about the accident
until 2 months ago when his son came home with
his new drivers licence. He says he felt anxious and
worried about his son driving, despite telling himself
that his son is a safe driver. Every time his son goes out
with the car, he has difficulty concentrating on anything
else and is generally jumpy and on edge. Then about
a month ago the nightmares started. In the nightmares
he sees the accident, feels time slowing down and sees
his sons head smash into the window. He wakes up
sweating, his heart palpitating, breathing heavily and in
complete panic. He describes the whole experience as
so real that often in the morning he is overcome with a Further history
strong sense of grief. Paul denies symptoms of other anxiety disorders,
He is not sure whether it is the lack of sleep or the dreams, complains of moderate depressive symptoms but denies
but he has been walking around home like a zombie and suicidal thoughts. He admits to drinking a fair bit most
not really feeling quite there. He finds it difficult to feel nights sometimes he gets through three-quarters of a
positive about any activities and feels numb toward his bottle of wine on his own. He denies other substance use.
wife. He describes the situation as unbearable.

Question 4
Question 1 What is your management plan?
What is your provisional diagnosis?

17
 check Anxiety disorders

Case 5

Answer 1 Answer 2
Pauls symptoms appear to meet the criteria for PTSD The main differential diagnoses to consider for PTSD
(Table 8). He was exposed to a life threatening event are adjustment disorder and acute stress disorder.
that involved intense fear. While not experiencing Adjustment disorder is characterised by distress and
symptoms at the time, his symptoms have recently emotional disturbance following a significant stressor
emerged, consistent with PTSD, with delayed onset or life event, lasting up to 3 months. However, as Paul is
(where over 6 months pass between the event and PTSD reporting that he experienced a life threatening event
symptoms).3 He has been re-experiencing the event in and is currently feeling numb, has increased arousal
the form of nightmares, numbing (detachment from his and is re-experiencing the event, PTSD is a more
life, lack of interest in activities, lack of affect) and has appropriate diagnosis. Acute stress disorder is similar to
had increased arousal (difficulty falling asleep, being PTSD, except that symptoms must occur within 1 month
jumpy or increased startle response). In Australia in of a stressor and can last for up to 1 month. However, as
2007, 4.6% of men and 8.3% of women will report having Pauls symptoms began over a month after the stressor,
PTSD within a 12 month period, making it the most a diagnosis of acute stress disorder is not appropriate.
common anxiety disorder in Australia.1 Some level of stress symptoms is common after a life
threatening event or situation, but
3 tends to spontaneously resolve, or
Table 8. Abbreviated DSM-IV diagnostic criteria PTSD
resolve with support and general
A. The person has been exposed to a traumatic event in which: stress management. However, if
the person experienced, witnessed or was confronted with an event or events that involved the symptoms do persist into PTSD,
actual or threatened death or serious injury, or a threat to the physical integrity of self or
others, and specialist referral and treatment is
the persons response involved intense fear, helplessness, or horror. recommended.
Note: in children, this may be expressed instead by disorganised or agitated behaviour Comorbidity is common in PTSD.
B. The traumatic event is persistently re-experienced in one (or more) of the following ways: Rates of alcohol use are similar in
recurrent and intrusive distressing recollections of the event, including images, thoughts, or individuals with PTSD and those
perceptions. with other anxiety disorders (odds
Note:in young children, repetitive play may occur in which themes or aspects of the trauma ratio of 3.3). However, rates of
are expressed substance use are higher (odds
recurrent distressing dreams of the event. ratio of 8.3). In addition, rates of
Note: in children, there may be frightening dreams without recognisable content depression are especially high
acting or feeling as if the traumatic event were recurring (includes reliving the (odds ratio of 29.3). Individuals
experience,illusions,hallucinations, and dissociativeflashbackepisodes, including those that
occur on awakening or whenintoxicated). with PTSD are also more likely to
Note:in young children, trauma specific re-enactment may occur experience other anxiety disorders
intense psychological distress at exposure to internal or external cues that symbolise or (panic disorder, social phobia, GAD,
resemble an aspect of the traumatic event and OCD odds ratios of 20.8 to
physiological reactivity on exposure to internal or external cues that symbolise or resemble 37.5).4
an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma andnumbingof general Feedback
responsiveness, as indicated by three or more of the following: When an individual presents with
efforts to avoid thoughts, feelings, or conversations associated with the trauma a mental illness, it is important
efforts to avoid activities, places, or people that arouse recollections of the trauma to keep in mind that psychiatric
inability to recall an important aspect of the trauma comorbidity is the norm, not the
markedly diminished interest or participation in significant activities exception. In the 1997 national
feeling of detachment or estrangement from others survey, Andrews, et al4 noted
restricted range ofaffect(eg. unable to have loving feelings) that 13.2% of the sample had
sense of a foreshortened future (eg. does not expect to have a career, marriage, children, or a one disorder, while 4.4% had
normal life span) two and 3.8% had three or more.
D. Persistentsymptomsof increased arousal, as indicated by two or more of the following: However, those individuals with
difficulty falling or staying asleep two disorders were almost three
irritabilityor outbursts of anger times as likely to seek help as those
difficulty concentrating with a single disorder, and those
hypervigilance with three mental illnesses were
exaggerated startle response over six times as likely; with the
E. The disturbance must last at least 1 month result that the majority of those

18
 check Anxiety disorders

Case 5

seeking a mental health consultation are experiencing should be addressed together in specialist treatment.
psychiatric comorbidity (60%). Furthermore, psychiatric For the GP, it is probably also useful to provide some
comorbidity leads to a substantial rise in the disease general education regarding alcohol or drugs and
burden, and treatment of one mental disorder may not to implement basic risk monitoring and/or reduction
necessarily impact on the other. Finally, three-quarters strategies. Problem solving and motivational interviewing
of those consulting anyone for their mental health approaches may also be helpful.
problem will see their GP, with half only seeing their
GP for their problem, although this may have changed
since the introduction in 2007 of Medicare rebates for
psychological consultations with allied health providers
(psychologists, social workers, occupational therapists).4

Answer 3
Given the likelihood of comorbidity, it is important to
screen for other anxiety disorders, depression and
substance use when an individual presents with PTSD.
In particular, suicidal risk should be assessed, as the
depression and substance abuse sometimes associated
with PTSD can increase risk.

Answer 4
Patients with PTSD should be referred to a specialist
who is knowledgeable about the disorder, and has
experience treating it.
Medication (usually with SSRIs Table 2) and CBT are
often used simultaneously. Cognitive behaviour therapy
for PTSD involves confronting memories, experiences
and situations associated with the traumatic event:
real life or imaginary, and targeting beliefs about
safety, competence and control in order to develop a
more rational view of dealing with possible threats.25
Eye movement desensitisation and reprogramming
(EMDR) is a specialised technique that has yet to find
definitive evidence for its efficacy, but remains popular.
More recent treatment approaches have incorporated
acceptance techniques and promoting post-traumatic
personal growth.
Meanwhile, as with all the anxiety disorders, supportive
counselling and a safe and trusting doctor-patient
relationship is important. It would be useful to inform
Paul about the nature of anxiety in general, and PTSD
specifically. It can be anxiety relieving for patients to
know that they are facing a real problem, that they are
not going crazy, that their experiences (eg. a sense of
a foreshortened future, dissociative feelings) are part of
the diagnostic picture of PTSD, and effective treatment is
available. Practical strategies include general relaxation
exercises to deal with heightened arousal, planning
activities that may be anxiety relieving and/or distracting,
and focussing on the possible positive aspects of the
traumatic event (eg. developing a closer relationship with
his son, opportunity for personal growth).
Concomitant use of substances (termed dual diagnosis)
usually indicates a more severe case of PTSD. Both

19
 check Anxiety disorders

References

1. Australian Bureau of Statistics. National survey of mental health and wellbeing:

summary of results. ABS Cat. no. 4326.0. Canberra: ABS, 2007.
2. C ollaborating Centre for Evidence in Mental Health Policy: World Health
Organization. Management of mental disorders: Treatment Protocol Project. 4th
edn. Darlinghurst: WHO, 2004.
3. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders 4th text revision edn. Washington, DC: APA, 2000.
4. Andrews G, Slade T, Issakidis C. Deconstructing current comorbidity: data from
the Australian National Study of Mental Health and Well-Being. Br J Psychiatry
2002;181:30614.
5. Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. 2nd
edn. Sydney: Psychology Foundation of Australia, 1995.
6. Meyer TJ, Miller ML, Metzger RL, et al. Development and validation of the Penn
State Worry Questionnaire. Behav Res Ther 1990;28:48795.
7. Kyrios M, Hegarty K. Self monitoring and psychometric tools. In: Blashki G, Judd
F, Piterman, editors. Common problems in general practice psychiatry. North Ryde:
McGraw-Hill, 2007;35672.
8. Wells A. Cognitive therapy of anxiety disorders: a practice manual and conceptual
guide. Chichester: John Wiley & Sons, 1997.
9. Pierce D, Gunn J. Using problem solving therapy in general practice. Aust Fam
Physician 2007;36:2303.
10. Siev J, Chambless DL. Specificity of treatment effects: cognitive therapy and
relaxation for generalized anxiety and panic disorders. J Consult Clinl Psych
2007;75:51322.
11. Kagan J, Reznick S, Snidman N. Biological bases of childhood shyness. Science
1988;240:16771.
12. Kagan J, Snidman N. Infant predictors of inhibited and uninhibited profiles.
Psychological Science 1991;2:404.
13. Heimberg RG, Dodge CS, Becker RE. Social phobia. In: Michelson L, Ascher M,
editors. Cognitive behavioral assessment and treatment of anxiety. New York:
Plenum, 1987;280309.
14. Leary MR. A brief version of the fear of negative evaluation scale. Pers Soc Psychol
Bull 1983;9:3715.
15. Liebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry 1992;22:14173.
16. Spence SH, Barrett PM, Turner CM. Psychometric properties of the Spence
Childrens Anxiety Scale with young adolescents. J Anxiety Disord 2003;17:60525.
17. Cunningham MJ, Wuthrich VM, Rapee RM, et al. The cool teens CD-ROM for
anxiety disorders in adolescents: A pilot case series. Eur Child Adolesc Psychiatry
2009;18:1259.
18. Rapee RM, Wignall A, Hudson JL, et al. Treating anxiety in children and
adolescents: an evidence based approach. California: New Harbinger, 2000.
19. March S, Spence SH, Donovan CL. The efficacy of an internet-based cognitive-
behavioral therapy intervention for child anxiety disorders. J Pediatric Psychology
2009;34:47487.
20. Lochner C, Mogotsi M, du Toit PL, et al. Quality of life in anxiety disorders: a
comparison of obsessive-compulsive disorder, social anxiety disorder, and panic
disorder. Psychopathology 2003;36:25562.
21. Koran LM, Thienemann ML, Davenport R. Quality of life for patients with
obsessive-compulsive disorder. Am J Psychiatry 1996;53:7838.
22. Clark DA. Cognitive-behavioral therapy for OCD. New York: Guilford Press, 2004.
23. National Institute for Health and Clinical Excellence. Core interventions in the
treatment of OCD and BDD. London: BPS/Royal College of Psychiatrists, 2006.
24. Kyrios M, Jones B, Moulding R. Obsessive-compulsive disorder: integration of
cognitive-behaviour therapy and clinical psychology care into the primary care
context. Aust J Public Health. In press 2010.
25. Tiller J, Kyrios, M, Bennett P. Post-traumatic stress disorder. Aust Fam Physician
1996;25;156973.

20

Professional
Books
Andrews G, Creamer M, Crino, et al. The treatment of anxiety
disorders. Cambridge: Cambridge University Press, 2003. A useful
book that includes chapters for both clinicians and patients.
Bourne EJ. The anxiety and phobia workbook. Oakland, CA: New
Harbinger Pub, 1990. A useful workbook for patients that presents
information about anxiety disorders and treatment strategies.
Burns DD. Feeling good: The new mood therapy. Victoria:
McPhersons Printing Group, 1980. A useful workbook for patients
that presents strategies for dealing with unhelpful thinking styles
and behaviour related to depression and anxiety.
Collaborating Centre for Evidence in Mental Health Policy: World
Health Organization. Management of mental disorders: Treatment
Protocol Project. 4th edn. Darlinghurst: WHO, 2004.
GPs who have undertaken the Better Outcomes in Mental Health
Care level two training were provided with copies of Management
of mental disorders, a resource developed by the World Health
Organization Collaborating Centre as part of the Treatment Protocol
Project. The resource was developed for use by GPs and generalist
mental health clinicians working in community mental health services.
Blashki G, Judd F, Piterman L, editors. General practice psychiatry.
North Ryde: McGraw-Hill, 2006. This publication includes chapters
on tools for assessing depression and anxiety, self monitoring and
psychometric tools and anxiety as it presents commonly in general
practice.
Online assessment and treatment for anxiety disorders
Anxiety Online is funded by the Australian governments Department
of Health & Ageing, Anxiety Online is an initiative of the National
e-Therapy Centre at Swinburne University of Technology available at
www.anxietyonline.org.au and includes:
high quality information and resources to enable patients to gain a
comprehensive understanding of anxiety generally, and of anxiety
disorders specifically
clinical assessment: the online Psychological Assessment
Program (e-PASS) enables patients to complete a comprehensive
psychological assessment online, and providing feedbackas to the
type and severity of anxiety, andappropriate recommendations for
addressing anxiety problems
treatment programs: comprehensive evidence based treatment
programs are available for each of the specific anxiety disorders
(GAD, OCD, panic disorder, PTSD and social anxiety disorder). The
programs are available in two versions:
self help programs for individuals with mild symptoms, offered
free of charge
therapist assisted programs for individuals with moderate to
severe symptoms, offered at a low cost. Therapist assistance is
in the form of weekly email communication and has been shown
to be more effective than purely self help programs.
check Anxiety disorders
Resources
Clinical Research Unit for Anxiety and Depression (CRUfAD).
Available at www.crufad.com this website offers:
patient services that include self help and a virtual clinic providing
free internet based education and treatment programs for people
with anxiety and depression
clinician services to help GPs/doctors improve access and
outcomes in mental health:
GP Care (www.gpcare.org)
a series of web based courses to teach patients about managing
their health better (CRUfAD Clinic www.crufadclinic.org)
an interactive e-learning environment for health professionals
(CRUfAD Mental Health www.crufadmh.org).
Beacon (Australian National University Centre for Mental Health
Research). Beacon is a portal to health online applications for
mental and physical disorders, including anxiety disorders. Specific
programs are reviewed and rated. Users can also submit their
own ratings and comments about each online health application.
Available at www.beacon.anu.edu.au.
Spence Childrens Anxiety Scale. An appropriate scale to assess
anxiety in adolescents has been developed by Spence and associates
in Australia. Available at www.scaswebsite.com.
Depression Anxiety Stress Scales (DASS). Information is available at
www2.psy.unsw.edu.au/groups/dass/.
Beck Anxiety Inventory (BAI). The BAI manual and answer sheets are
available for purchase at www.psychcorp.co.uk/product.aspx?n=1316
&s=1322&cat=1426&skey=2644.
Better Access to Mental Health Services scheme. Information is
available at www.racgp.org.au/mentalhealth/betteraccess
Therapeutic Goods Administration (TGA). Information is available at
www.tga.gov.au.
Pharmaceutical Benefits Scheme (PBS). Information is available at
www.pbs.org.au.
Patient information
The Clinical Research Unit for Anxiety and Depression (CRUfAD)
Offers patient services that include self help and a virtual clinic
providing free internet based education and treatment programs for
people with anxiety and depression. Available at www.crufad.com.
Anxiety Online
Provides high quality information and resources to enable patients
to gain a comprehensive understanding of anxiety generally, and of
anxiety disorders specifically. Available at www.anxietyonline.org.au.
21
 check Anxiety disorders
qa&cpd Program requirements (20082010 triennium)
Active learning module
In order to qualify for 40 Category 1 QA&CPD points for this ALM:
Step 1. Undertake this predisposing activity
Write answers to the following questions. How common are anxiety
disorders in Australia? How would you diagnose the following
conditions in the general practice setting: generalised anxiety
disorder (GAD), social anxiety disorder, panic disorder, anxiety
disorder not otherwise specified, obsessive compulsive disorder
(OCD), and post-traumatic stress disorder (PTSD)? What clinical
tools do you know that could help you in the diagnosis, assessment
and management of anxiety disorders? How would you explain to
a patient about the nature of anxiety, its purpose and how it can
present? Outline a management plan for the following conditions
in the general practice setting: GAD, social anxiety disorder, panic
disorder, anxiety disorder not otherwise specified, OCD and PTSD?
Develop a list of at least three personal learning goals for this ALM.
It may be helpful to consider the following questions: Why did I
choose this topic at this time? What would I like to do differently as
a result of undertaking this ALM? What would I like to understand
or appreciate more fully about this topic? What skills or knowledge
would I like to gain?
Step 2. Read and complete this unit of check. You do not need
to send in the completed check unit. Please retain your check
unit and answers for your future reference.
Expected time commitment is approximately 2 hours.
Step 3. Undertake one practice based activity and one
community based activity from the list of suggested activities
below.
Choose one practice based activity from the following:
Summarise what you have learned from this unit of check and
give a presentation at a lunchtime practice meeting or journal club.
Facilitate a discussion on the clinical features or management of
one or more of the following: GAD, social anxiety disorder, panic
disorder, anxiety disorder not otherwise specified, OCD and PTSD.
Give a presentation at a lunchtime practice meeting on relaxation
techniques that can be taught to patients to help them to manage
anxiety symptoms.
With a GP colleague from your practice, review the clinical tools
presented in this unit for diagnosis, assessment and management
of anxiety disorders. Which of these tools would be useful in your
own practice? Download files or links to any tools you think would
be useful onto your practice desktop and educate other general
practitioners in the practice about their use.
Write a patient education article for your practice newsletter on
any topic relating to this unit such as the nature and purpose of
anxiety and how it can present, or about specific disorders such as
GAD, social anxiety disorder, panic disorder, anxiety disorder not
otherwise specified, OCD and PTSD.
Review patient education material you have in your practice on any
topic relating to this unit and make up a resource folder of quality
information and useful referral contacts in your local community.
Devise your own activity that utilises the knowledge and skills you
have obtained from this unit of check within your practice and
address your personal learning needs.
SGL and SCA kits are available with instructions on the
RACGP website at www.racgp.org.au or by contacting
a professional development officer at your state QA&CPD unit.
22
This activity must involve at least 2 hours time commitment and details must
be submitted with your evaluation.
Choose one community based activity from the following:
Facilitate a QA&CPD meeting for your local division on anxiety disorders.
Invite local psychologists and/or psychiatrists with experience in
management of anxiety disorders. Discuss best practice management
approaches and how communication between GPs and psychologists and/
or psychiatrists may be improved. Discuss relaxation techniques that can be
taught to patients to help them manage anxiety symptoms.
Attend supervision with a local clinical psychologist to discuss your
management approaches to patients you have seen with anxiety disorders.
Contact your local community health service and local allied health providers
and find out what services are available for patients to aid in the treatment
of anxiety. Are there any local centres offering yoga, meditation or
relaxation classes?
Give a presentation at a local sporting club, community organisation, school
or workplace on a topic relating to this unit such as the nature and purpose
of anxiety and how it can present, relaxation exercises or specific anxiety
disorders.
Write a patient education article for local newspaper on any topic relating
to this unit, eg. the nature and purpose of anxiety and how it can present, or
about specific disorders such as GAD, social anxiety disorder, panic disorder,
anxiety disorder not otherwise specified, OCD and PTSD.
Devise your own activity that utilises the knowledge and skills you have
obtained from this unit of check within your local community and addresses
your personal learning needs.
The activity must involve at least 2 hours time commitment and details must be
submitted with your evaluation.
Step 4. Fill in the reinforcing activity and evaluation summary
Report on the activities you have undertaken and send to the coordinator who
will coordinate the approval and point allocation process. We encourage you to
electronically fill in the evaluation summary and email to check@racgp.org.au.
A check Program ALM evaluation summary form can be downloaded from the
RACGP website at www.racgp.org.au/check. Alternatively, you can photocopy
and fill in the evaluation summary included in this unit and post it. Please
allow up to 6 weeks upon receipt of your evaluation summary to receive your
certificate of participation.
check Category 2 QA&CPD activity
In order to qualify for 6 Category 2 points for this activity in this unit:
read and complete this unit of check, and
log onto the gplearning website at www.gplearning.com.au and answer the
10 multiple choice questions (MCQ) online.
Expected time to complete this activity is 3 hours.
We encourage you to also complete the online evaluation for this activity.
Participants can be awarded QA&CPD points for both the ALM and Category
2 activity.
Other activities to consider for the QA&CPD Program
Small group learning (40 Category 1 points)
Is this topic one you would like to learn more about with your peers? You could
use this unit of check and the resources listed as the basis for a small group
learning (SGL). Ask other GPs in your practice or contact your division of general
practice to find others interested in the same topic.
Facilitator training is run regularly by RACGP faculties and will equip you to run
the small group process effectively.
Supervised clinical attachment (40 Category 1 points)
Consider arranging a supervised clinical attachment (SCA) with a clinical
psychologist.
 check Anxiety disorders

check Program 2010

Activity report and reinforcing activity

Active learning module on anxiety disorders (unit 457)
Eligible for 40 Category 1 points in the RACGP QA&CPD Program. A minimum of 6 hours is required to complete this ALM excluding the time
taken for predisposing and reinforcing activities. Please complete all sections. Upon completion, email to check@racgp.org.au or post to The
RACGP, 1 Palmerston Crescent, South Melbourne, Victoria, 3205, Australia. Please retain a copy for your records.

QA no. _________________ Name ___________________________________________ Contact telephone no. ________________________

Address ________________________________________________________________________________________________________

Have you completed this unit of check? Yes / No Time taken to complete the unit: __________________________________________

1. Activity report
Practice activity
Write a brief description and attach evidence of the activity undertaken within your practice. Evidence includes minutes of meeting, photo of
events, practice newsletter, proformas/guidelines/protocols developed and/or diary entries.

Community activity
Write a brief description and attach evidence of the activity undertaken within your community. Evidence includes a letter of attendance from
the community organisation that you visited, copy of newspaper article, flyer from community talk, diary entries of appointments and/or notes
made of meetings.

2. Reinforcing activity
Refer to your initial answers from the predisposing activity. What differences are there in your answers now that you have completed this unit of check?

What did you learn from this activity?

What will you do differently in your practice as a result of this activity?

continued overleaf

23
 check Anxiety disorders

check Program 2010 ALM

Evaluation
1. Learning objectives
Please indicate to what extent after completing this activity you are able to meet the stated learning objectives.
Not Partially Entirely
met met met
Learning objective
Recognise the clinical features of GAD, social anxiety disorder, panic disorder, anxiety
disorder not otherwise specified, OCD and PTSD.

Appreciate that a number of clinical tools are available to help in the diagnosis and
assessment of anxiety disorders.

Recognise the importance of asking patients wit h anxiety disorders about depressive
symptoms and risk of harm to self or others.

Understand the importance of psychoeducation and relaxation strategies in the

management of anxiety disorders.

Appropriately manage and/or refer patients for management of GAD, social phobia,
panic disorder, anxiety disorder not otherwise specified, OCD and PTSD.

Appreciate that a number of clinical tools, including online tools, are available to aid in
the treatment of anxiety disorders.

2. Learning needs and relevance to practice

O v erall e v aluat i on

Not Partially Entirely

met met met

Rate the degree to which your own learning needs were met.
Not Partially Entirely
relevant relevant relevant

Rate the degree to which this activity was relevant to your own practice.
3. Other information
Please rate the extent to which you agree with the following statements.
Statement Strongly Strongly
disagree Disagree Agree agree
There was sufficient information and resources for me to complete
this activity well.
The writing and case histories were of a high standard.
This activity increased my knowledge/understanding of this topic.
I am likely to change my clinical practice as a result of this activity.
This activity was of benefit to other members of my practice.
4. What other topics would you like to see covered in check?

5. Do you have any additional comments?

Signed by participant ________________________________________________________________________________ Date __________________________

Office use only Approved Signed __________________________________________________________ Date __________________________

Attendance forwarded to the National QA&CPD Unit Date _______________________________

24

Anxiety disorders
In order to qualify for 6 Category 2 points for this activity
in this unit:
read and complete the unit
log onto the gplearning website at www.gplearning.
com.au and answer the following 10 multiple choice
questions (MCQs) online. If you are not an racgp
member, please contact the gplearning helpdesk on
1800 284 789 to register in the first instance. You will be
provided with a username and password that will allow
you access to the test
complete the online evaluation.
Expected time to complete this activity is 3 hours.
Please do not send answers to the MCQs into the check
office. This activity can only be completed online at
www.gplearning.com.au.
If you have any queries or technical issues accessing
the test online, please contact the gplearning helpdesk
on 1800 284 789.
Question 1
Wendy, aged 26 years, is a previously well woman
who works full time as an accountant. She is also
doing further study to gain certification as a certified
practising accountant (CPA). She says she is having
trouble with anxiety symptoms, particularly when she
thinks about the exam. She complains that she often
feels in a panic.
Which of the following historical features would MOST
make you suspect that Wendy is having panic attacks?
A. Nightmares
B. Symptoms that develop gradually
C. Symptoms that reach a peak within 10 minutes
D. Repetitive behaviours (eg. hand washing, ordering,
checking)
E. Concerns about going mad.
Question 2
Bill, aged 55 years, presents complaining that he feels
overwhelmed by life. He says he has always been a
worrier but since his younger brother had a heart
attack 9 months ago, the symptoms have worsened. His
brother is fine but Bill now worries constantly about his
own health and ability to keep working if he gets sick.
He complains that on most days he feels tense and on
edge, with intermittent palpitations and shortness of
breath. He describes difficulty falling or staying asleep,
generalised aches and pains, irritability and persistent
worries about his health, work and his family. He saw
a cardiologist who has given him the all clear and told
him that his symptoms are related to anxiety. Bill says, I
must be going mad. I spend all my time worrying about
any minor symptom I have and what it might mean. I
worry constantly about my work and whether I will be
sacked, and I also worry about how much worry I have!
check Anxiety disorders
Check Category 2 QA&CPD activity
This history is MOST consistent with:
A. post-traumatic stress disorder
B. social phobia
C. panic disorder
D. obsessive compulsive disorder (OCD)
E. generalised anxiety disorder (GAD).
Question 3
Further assessment confirms a diagnosis of GAD in Bill.
Which of the following is TRUE regarding treatment of
GAD?
A. Psychoeducation is unhelpful, as knowing more about
the nature of anxiety will encourage Bill to focus
more on his symptoms
B. Selective serotonin reuptake inhibitor (SSRIs) are
first line treatment if pharmacological treatment is
required
C. A benzodiazepine should be prescribed for daily use
D. Cognitive behaviour therapy (CBT) is an effective
treatment
E. B and D.
Question 4
Miroslav, aged 15 years, has recently been diagnosed
with social anxiety disorder (social phobia) and is
seeing a psychologist for CBT. In a letter, Miroslavs
psychologist explains that Miroslav exhibits safety
behaviours, including sitting in the library at lunchtime,
staying away from school on sports days and avoiding
social events. Safety behaviours in social anxiety
disorder:
A. aim to help minimise anxiety in specific situations
B. are useful long term strategies for coping with
anxiety
C. aim to rid patients of recurrent and persistent
thoughts
D. provide individuals the opportunity to learn that social
situations are not as dangerous as they perceive
E. usually involve excessive cleaning and tidying.
Question 5
Cognitive behaviour therapy to treat social phobia
involves:
A. provoking the patients obsessions in a graded
fashion
B. teaching the patient how to ignore others and enjoy
their isolation
C. helping the patient to understand how and why
anxiety symptoms develop, what triggers them and
what unhelpful responses maintain them
D. exposure to feared social situations starting with the
most fearful situation
E. All of the above.
25
 check Anxiety disorders

Check Category 2 QA&CPD activity

Question 6
Paul is 55 years of age and a father of four children. He
presents with difficulties in sleeping and concentrating.
He says that he wakes up in a cold sweat every night
after a nightmare about an incident that occurred 6
months ago in which he was attacked with a knife at an
automatic teller machine (ATM). In the nightmares he
relives the incident and each time it feels real. He then
finds it difficult to fall asleep because of anxiety.
According to the DSM-IV, one of the requirements for
the diagnosis of PTSD is that the person:
A. experienced, witnessed, or was confronted with a
traumatic event
B. did not feel frightened at the time that the event
occurred
C. seeks stimuli associated with the trauma
D. has persistently decreased arousal
E. has symptoms for more than a year.
Question 7
Paul is diagnosed with PTSD. Regarding the treatment of
PTSD, which of the following is true?
A. Specialist referral is usually required
B. Eye movement desensitisation and reprogramming
(EMDR) is a specialised technique with well
established efficacy
C. SSRIs have no place in treatment
D. Substance use requires a separate referral to a
specialist in treatment of drug and alcohol problems
as this is unlikely to be related to the PTSD
E. All of the above.
Question 9
As you assess Sam you consider the difference between
obsessions and worries.
Which of the following is TRUE?
A. Worries are usually about more reality based
concerns about the future
B. Unlike worries, the type of thoughts experienced
by OCD patients are rarely experienced by the
nonclinical population
C. Worries tend to be in the form of an urge or an image;
obsessions tend to be more verbal
D. Worries are typical of anxiety disorders; obsessions
are typical of psychotic disorders
E. Benzodiazepines are helpful for worries but not
obsessions.
Question 10
Sam is diagnosed with OCD. Regarding treatment of
OCD, which of the following is TRUE?
A. SSRIs are first line treatment
B. CBT should be used if pharmacological treatment
fails
C. Relaxation approaches are not helpful as they
give the patient time and space to focus on their
obsessions
D. Patients should be encouraged to increase their use
of compulsions to neutralise the obsession
E. Psychoeducation about anxiety and about OCD is
helpful.

Question 8
Sam, aged 22 years, presents saying, Im worried I might
have obsessive compulsive disorder (OCD)!
Which of the following is NOT a common presentation of
OCD?
A. Contamination fears and washing or cleaning
compulsions
B. Attachment to objects and compulsive hoarding
C. Unacceptable moral doubts and thought suppression
D. Concerns about appearing anxious and losing control
in front of others
E. Obsessive doubts and overt or covert checking
compulsions.

26
check Anxiety disorders

Notes
check Anxiety disorders

Notes