Anxiety and fear-related disorders together with trauma and stressor-related disorders constitute a significant proportion of general adult psychiatry questions in Paper B. ICD-11 reorganised these conditions into two separate chapters: anxiety and fear-related disorders (GAD, panic disorder, agoraphobia, social anxiety disorder, specific phobia, separation anxiety disorder, selective mutism) and disorders specifically associated with stress (PTSD, complex PTSD, prolonged grief disorder, adjustment disorder, reactive attachment disorder, disinhibited social engagement disorder). This restructuring is examined.
Generalised Anxiety Disorder (GAD)
ICD-11 criteria: Generalised anxiety disorder is characterised by marked symptoms of anxiety that are present most days over a period of at least 6 months. The core feature is generalised and persistent anxiety that is not restricted to any particular environmental circumstance (free-floating anxiety). Symptoms include motor tension (trembling, restlessness, headache), autonomic overactivity (palpitations, sweating, dry mouth, epigastric discomfort, dizziness), apprehensive expectation (worry about future events, excessive worry about everyday matters), and hypervigilance (difficulty concentrating, initial insomnia, irritability). The individual finds it difficult to control the worry.
NICE treatment (CG113): Step 1: Identification and assessment in primary care. Step 2: Low-intensity psychological intervention (guided self-help based on CBT principles, psychoeducation, monitoring). Step 3: High-intensity psychological intervention (CBT or applied relaxation, 12-15 sessions) OR an SSRI (sertraline first-line, then fluoxetine, citalopram, escitalopram or paroxetine). Step 4: If inadequate response, consider specialist review, alternative SSRI, or SNRI (venlafaxine, duloxetine), or pregabalin. Pregabalin has evidence for GAD but carries risk of dependence and is scheduled as a controlled drug under the Misuse of Drugs Act. Buspirone (5-HT1A partial agonist) is a non-sedating alternative but less effective.
GAD vs worry in healthy individuals: The key distinction is the pervasiveness, duration (6 months), and functional impairment. The worry in GAD is difficult to control and accompanied by somatic symptoms. Benzodiazepines are NOT recommended for long-term treatment of GAD beyond 2-4 weeks due to tolerance and dependence.
Panic Disorder and Agoraphobia
ICD-11 criteria: Panic disorder is characterised by recurrent, unexpected panic attacks (discrete episodes of intense fear or discomfort accompanied by autonomic and cognitive symptoms) that are not restricted to specific situations or stimuli. The individual experiences persistent worry about future attacks and the implications of the attacks (e.g., fear of losing control, going mad, having a heart attack, dying). Agoraphobia involves fear and avoidance of situations from which escape might be difficult (crowds, public transport, open spaces, being outside the home alone). The two frequently co-occur but can be diagnosed independently in ICD-11.
Panic attack symptoms (any 4 of the following): Palpitations, sweating, trembling, shortness of breath, choking sensation, chest pain, nausea, dizziness, derealisation, fear of losing control, fear of dying, paraesthesias, chills or hot flushes. Panic attacks reach peak intensity within minutes and typically resolve within 20-30 minutes. They can be expected (cue-related, in response to a phobic stimulus) or unexpected (uncued, out of the blue).
NICE treatment (CG113): First-line psychological intervention: CBT for panic disorder (7-14 hours total). First-line medication: SSRI (sertraline, fluoxetine, or escitalopram). Avoid benzodiazepines beyond short-term crisis management (maximum 2-4 weeks). If no response to SSRI after 12 weeks, consider switching to another SSRI, SNRI (venlafaxine), or tricyclic (clomipramine). The combination of CBT + SSRI is more effective than either alone for moderate-severe panic disorder.
Social Anxiety Disorder (Social Phobia)
ICD-11 criteria: Marked and disproportionate fear or anxiety about one or more social situations where the individual is exposed to possible scrutiny by others (e.g., conversations, meeting unfamiliar people, eating in public, performing). The individual fears that they will act in a way that will be negatively evaluated. The social situations are avoided or endured with intense fear. The symptoms persist for at least several months.
Treatment: First-line: individual CBT specifically for social anxiety (CBT-SA). Medication options: SSRI (escitalopram, sertraline, fluoxetine, paroxetine). SNRI (venlafaxine) is an alternative. The combination of CBT and SSRI is superior to either alone. Beta-blockers (propranolol) are sometimes used for performance anxiety (stage fright) but are not NICE-recommended for generalised social anxiety.
Key distinction — social anxiety vs schizotypal PD: A recall question tested this. Social anxiety involves fear of negative evaluation with desire for social connection. Schizotypal PD involves eccentric behaviour, magical thinking, perceptual distortions, and social anxiety that is more pervasive and accompanied by cognitive/perceptual oddities. Schizoid PD involves no desire for social connection.
Post-Traumatic Stress Disorder (PTSD)
ICD-11 criteria: PTSD requires exposure to an event or situation of an extremely threatening or horrific nature (traumatic event). The core features are: 1) Re-experiencing the traumatic event in the present, involving vivid intrusive memories, flashbacks, or nightmares accompanied by strong emotions of fear or horror. 2) Deliberate avoidance of reminders of the trauma. 3) Persistent perceptions of heightened current threat (hypervigilance, exaggerated startle response). Symptoms must persist for at least several weeks and cause functional impairment. The ICD-11 simplified the PTSD criteria from ICD-10 (which had 6 clusters) to these 3 core clusters.
Complex PTSD (ICD-11 addition): In addition to the core PTSD symptoms, complex PTSD includes severe and pervasive disturbances in affect regulation (emotional dysregulation), negative self-concept (feelings of worthlessness, shame, guilt), and interpersonal difficulties (difficulty sustaining relationships, feeling distant from others). It is associated with prolonged, repeated, or multiple forms of traumatic exposure (childhood abuse, domestic violence, torture, genocide). This is a new ICD-11 category that may appear in the exam.
NICE treatment (NG116, updated 2024): First-line: trauma-focused psychological therapy. Options: trauma-focused CBT (TF-CBT), eye movement desensitisation and reprocessing (EMDR), or prolonged exposure therapy. These are recommended before medication. For adults, TF-CBT or EMDR (8-12 sessions). For children, TF-CBT. Medication: paroxetine or venlafaxine are recommended as second-line (when psychological therapy is declined or unavailable or not effective). Antipsychotics are NOT recommended for PTSD. Benzodiazepines should NOT be used. Early single-session debriefing (psychological debriefing) immediately after trauma is NOT recommended and may be harmful.
Risk factors for PTSD: Greater trauma severity, prior trauma history, prior psychiatric disorder, female sex, low social support, peritraumatic dissociation, and high emotional reactivity during the event.
Adjustment Disorder
ICD-11 criteria: A maladaptive reaction to an identifiable psychosocial stressor (such as divorce, job loss, illness, or bereavement) that emerges within 1 month of the stressor. The reaction is characterised by preoccupation with the stressor and failure to adapt (symptoms of depression, anxiety, or behavioural disturbance). The condition typically resolves within 6 months if the stressor or its consequences are removed. The key distinction from major depression is the temporal relationship to the stressor and the absence of full depressive syndrome. Adjustment disorder can be acute (persists less than 3 months) or prolonged (persists 3-12 months).
High-Yield Recall Patterns
- GAD minimum duration: 6 months of symptoms present most days. Distinguishes it from adjustment disorder (1 month) and mixed anxiety-depression.
- Panic attack physiological peak: Minutes. 20-30 minutes typical duration.
- PTSD core symptom clusters (ICD-11): Re-experiencing, avoidance, hypervigilance (3 clusters, simplified from ICD-10 which had 6)
- Complex PTSD added features: Affect dysregulation, negative self-concept, interpersonal difficulties — from prolonged/repeated trauma
- First-line PTSD treatment: Trauma-focused CBT or EMDR (NOT medication)
- Unhelpful PTSD intervention: Psychological debriefing (single session) — NOT recommended, may be harmful
- Benzodiazepine role in anxiety: Maximum 2-4 weeks. Not for long-term treatment.
- Pregabalin: Evidence for GAD but dependence risk. Controlled drug.
- Beta-blockers: Propranolol for performance anxiety only (not generalised social anxiety)
- Social anxiety vs schizotypal vs schizoid: Social anxiety = fear with desire for connection. Schizotypal = odd/eccentric + social anxiety. Schizoid = no desire for connection.
- Prolonged grief disorder (ICD-11): Persistent and pervasive grief response lasting longer than 6 months, characterised by longing for the deceased, preoccupation with thoughts of the deceased, and intense emotional pain.
PsychStar’s Paper B question bank covers anxiety disorders, PTSD, and trauma-related conditions with questions calibrated to real exam depth. Start with 5 free questions at psychstar.io/try.