Anxiety Disorders: GAD, Panic & Phobias
A board-focused review of DSM-5 anxiety disorders (GAD, panic disorder, specific phobia, social anxiety, agoraphobia): exact durations and symptom-count criteria, the medical/substance mimics to exclude first, classic vignettes, and first-line SSRI/SNRI-plus-CBT management with next-best-step calls (benzo bridge, buspirone, PRN propranolol).
Overview: How Boards Test Anxiety
Anxiety disorders are the most prevalent psychiatric conditions (~30% lifetime) and are consistently female-predominant (~2:1). The shared theme is excessive, persistent fear or worry that is out of proportion and impairs function. On exams, three things carry the points:
- Memorize the exact durations — they are the fastest way to separate look-alikes.
- In any new somatic presentation, the first move is to exclude medical mimics (hyperthyroidism, arrhythmia, MI, PE, pheochromocytoma) and substances (caffeine, stimulants, alcohol/benzo withdrawal) before labeling it psychiatric.
- The management backbone is identical across GAD, panic disorder, social anxiety, and agoraphobia: an SSRI or SNRI plus CBT.
Note the DSM-5 reshuffle — OCD and PTSD are no longer classified as 'anxiety disorders' (they have their own chapters), a favorite trap. Comorbid major depression is common and worsens prognosis.
- GAD: excessive worry about multiple domains, more days than not, ≥6 months + ≥3 of 6 symptoms (restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance). Children need only 1 symptom.
- Panic disorder: recurrent unexpected panic attacks + ≥1 month of persistent worry about more attacks or maladaptive behavior change. Attack peaks within minutes, needs ≥4 of 13 symptoms.
- Specific phobia: marked, cued fear of a specific object/situation, ≥6 months; immediate anxiety on exposure.
- Social anxiety disorder: fear of scrutiny in social/performance settings, ≥6 months.
- Agoraphobia: fear/avoidance of ≥2 of 5 situations (public transport, open spaces, enclosed spaces, crowds/lines, being outside alone), ≥6 months.
- Contrast the trauma/stress timeline: acute stress disorder 3 days–1 month; PTSD >1 month; adjustment disorder <6 months and within 3 months of an identifiable stressor.
Comparison: Duration · Criteria · First-Line Rx
| Disorder | Duration | Key criteria | First-line treatment |
|---|---|---|---|
| GAD | ≥6 mo | Uncontrollable worry + ≥3 of 6 somatic sx | SSRI/SNRI + CBT; buspirone adjunct |
| Panic disorder | ≥1 mo of worry | Recurrent unexpected attacks, ≥4 of 13 sx, peak in minutes | SSRI/SNRI + CBT; benzo short-term bridge |
| Specific phobia | ≥6 mo | Cued fear, out of proportion | CBT / exposure (meds rarely) |
| Social anxiety | ≥6 mo | Fear of scrutiny/embarrassment | SSRI/SNRI + CBT; propranolol for performance-only |
| Agoraphobia | ≥6 mo | Fear/avoidance of ≥2 of 5 situations | SSRI + CBT |
Vignette: A 24-year-old woman presents to the ED with her 3rd episode this month of abrupt palpitations, chest tightness, dyspnea, tingling in her hands, and a feeling she is 'about to die.' Episodes peak in ~10 minutes and resolve within an hour. Between episodes she now avoids the gym, fearing another spell. ECG, troponin, TSH, and D-dimer are normal.
Diagnosis: Panic disorder — recurrent unexpected attacks + ≥1 month of anticipatory worry/avoidance.
Next best step: After the negative workup, provide reassurance. For an acute attack, a short-acting benzodiazepine (e.g., lorazepam) can abort it; for long-term control, start an SSRI/SNRI and refer for CBT. Do not place her on a standing benzodiazepine as maintenance.
Trap: the perioral/hand paresthesias are driven by hyperventilation → respiratory alkalosis, which transiently lowers ionized calcium — a self-limited part of the attack, not a primary hypocalcemia to work up.
The 13 DSM-5 panic-attack symptoms (need ≥4, peaking within minutes) are most reliably recalled grouped by system — there is no official First Aid/DSM mnemonic for them:
- Cardiopulmonary: palpitations, chest pain, shortness of breath, choking
- Autonomic: sweating, trembling, chills/heat sensations, nausea
- Neurologic: dizziness/unsteadiness, paresthesias (tingling)
- Psychological: derealization/depersonalization, fear of dying, fear of losing control/'going crazy'
An informal study aid some use is 'STUDENTS FEAR the 3 C's' — treat it as a personal memory device, not a validated or official list.
For GAD's 3-of-6 cluster, a commonly used memory aid is WATCHERS — Worry, Anxiety, Tension (muscle), Concentration difficulty, Hyperarousal/irritability, Energy loss/fatigue, Restlessness, Sleep disturbance. Because these overlap heavily with depression, the exam discriminator is prominent, uncontrollable worry (vs MDD's anhedonia/depressed mood).
- First-line meds: SSRIs (sertraline, escitalopram, paroxetine) and SNRIs (venlafaxine, duloxetine) for GAD, panic, social anxiety, agoraphobia. Full effect takes 4–6 weeks.
- Starting an SSRI can transiently worsen panic — start low, go slow; a short benzo bridge is acceptable.
- Buspirone: non-addictive 5-HT1A partial agonist for GAD; no sedation/dependence, no acute relief (~2 wks to work). Favored with a substance-use history.
- Benzodiazepines: fast but risk tolerance/dependence, sedation, falls; avoid long-term and in the elderly, substance abuse, COPD/OSA. Short-term bridge only.
- Beta-blockers (propranolol): performance-only social anxiety / situational autonomic symptoms — not a treatment for generalized anxiety.
- Phobias: CBT with exposure is first-line; blood-injection-injury phobia causes vasovagal syncope → treat with applied muscle tension.
- Paroxetine — most anticholinergic, most weight gain, worst discontinuation syndrome; avoid in pregnancy (cardiac defects).
Vignette: A 30-year-old violinist reports that before solo auditions he develops pounding heart, hand tremor, and sweaty palms that impair his playing. He is completely comfortable in rehearsals and in ordinary social settings and has no symptoms otherwise.
Diagnosis: Social anxiety disorder, performance-only subtype — situational and limited to performance.
Next best step: Propranolol (or a benzodiazepine) taken PRN before performances blunts the autonomic symptoms. A daily SSRI is reserved for the generalized form, not isolated performance anxiety.
Contrast: if he feared and avoided all social interaction for ≥6 months → generalized social anxiety → SSRI + CBT (first-line), not just a PRN beta-blocker.
Medical mimics to exclude before diagnosing anxiety:
- Hyperthyroidism — weight loss, heat intolerance, tremor, low TSH.
- Pheochromocytoma — episodic hypertension, headache, sweating, palpitations.
- Cardiac — arrhythmia (SVT), MI, mitral valve prolapse.
- Pulmonary — PE, asthma; hypoglycemia; carcinoid.
Substance-related: caffeine, stimulants (cocaine, amphetamines), albuterol, excess thyroid hormone; and withdrawal from alcohol/benzodiazepines/opioids.
Psychiatric look-alikes:
- OCD & PTSD — separate DSM-5 chapters, not anxiety disorders (common trap).
- Adjustment disorder — symptoms <6 months after an identifiable stressor.
- Illness anxiety / somatic symptom disorder — worry centered on having a disease.
- GAD vs MDD — overlapping somatic sx; GAD's core is worry, MDD's is anhedonia/depressed mood.
Practice Psychiatry now
Board-style questions, spaced-repetition flashcards, and a Socratic AI tutor — free to start.