ANXIETY DISORDERS

History
Generalised Anxiety Disorder

Chief Presents with:

Complaint ● Persistent fear and worry about everyday problems
and events
● Physical symptoms

History of Persistent fear and worry about everyday problems

Presenting and events:
Illness ● Onset / Duration - “How long have you felt this
way?” (At least 6 months)
● Persistence - “Do you feel like this everyday?”
● Content - “What do you worry about?” (Everyday
problems and events - Family, relationships,
financial difficulties, studies, etc.)
● Difficult to control - “Do you find your fear and
worries difficult to control?”

Physical symptoms:

R Restlessness

I Irritability

DSM-5 M Muscle tension

Criteria
(3/6) S Sleep difficulties

E Easily tired

D Difficulty concentrating

General Heat flashes, chills, sweating

MSK Tremors

Mental Derealisation, depersonalisation,

Others fear of dying / “going crazy’, fear
of losing control

CNS Dizziness

Chest Choking sensation, SOB,

palpitations
 GI Nausea

● Onset / Duration - “How long have you had these

symptoms?” (At least 6 months)
● Associated with persistent fear and worry about
everyday problems and events - “Do you tend to
worry a lot?”

Impact on Functioning:
● Occupational - “How does it affect your
work/studies?”
● Social - “How does it affect your social life?”

Comorbidities:

Major Presence:
Depressive ● “Sometimes when someone feels
Disorder very anxious and is under stress,
they might feel sad and have a
constantly low mood. Have you
experienced that?”

Onset / Duration:
● “When do you start feeling this
way?” (At least 2 weeks)

Symptoms (5/9):
● Anhedonia - “Have you lost
interest in your hobbies?’
● Weight / Appetite change - “Have
there been any changes in your
weight or appetite?”
● Sleep disturbances - “How have
your sleep been lately?”
● Low energy - “Do you feel tired
all day?”
● Difficulty concentrating - “Do you
find it difficult to concentrate?”
● Feeling worthless - “Do you feel
that you are worthless?”
● Suicidal thoughts - “When
someone is under a lot of stress,
they may think of harming
themselves or ending their lives
to get out of their problem. Have
you done that before?”
 Coping Skills:
● “How do you cope with feeling
like this?”

Impact on Functioning:
● “How has it affected your life?”

Panic Presence:
Disorder ● “Do you get panic attacks when
you are outside the house?”

Onset / Duration:
● “When did you start getting panic
attacks?”

Trigger:
● “Do you only get panic attacks
when you are outside the
house?”
● “Is there any trigger for your
panic attacks?”

Symptoms:

General Heat flashes, chills,

sweating

MSK Tremors

Mental Derealisation,
depersonalisation, fear of
dying / ‘going crazy’, fear of
losing control

CNS Dizziness

Chest Choking sensation, SOB,

chest pain / discomfort,
palpitations

GI Abdominal discomfort

Duration:
● “How long does the episode
last?” (Peaks in minutes and
resolves)

Anticipatory Anxiety:
 ● “Do you feel anxious about
having future panic attacks?”
● “How long have you felt this
way?” (At least 1 month)

Substance Presence:
Use ● “Sometimes when someone is
under stress, they might use
alcohol or illicit drugs to help
them cope. Have you done that?”

Onset / Duration:
● “How long have you been doing
so?”
● “How often do you take it?”

Substance Use:
● “What caused you to take it?”
● Substance - “What do you take?”
● Amount - “How much are you
taking?”

Differential Diagnosis:

Organic Causes Hyperthyroidism

Pheochromocytoma

Major Depressive At least 5/9 symptoms (which must

Disorder with include at least 1 core feature)
Anxious Distress for at least 2 weeks that causes
an impairment in functioning
(social / occupational)

At least 5/9 symptoms:

● Low mood for most of the
days (CF)
● Loss of interest or pleasure
in almost all activities (CF)
● Change in weight or
appetite
● Sleep disturbances
● Psychomotor agitation or
retardation
● Low energy nearly
everyday
● Feeling worthless /
 excessive guilt
● Difficulty concentrating
● Suicidal ideations

At least 2/4 symptoms of anxious

distress:
● Restlessness
● Difficulty concentrating
● Fear of losing control
● Worries that something
awful might happen

Adjustment Due to a major life change

Disorder with
Anxiety (+/- Symptoms starts within 3
Depressed Mood) months from onset of trigger
and resolves within 6 months of
removal of trigger

Past Previous Psychiatric Contact:

Psychiatric ● “Have you seeked help from any psychiatrists or
History doctors before?”

Previous Psychiatric Diagnosis:

● “Were you previously diagnosed?”

Previous Treatment:
● “Did you receive any medications or procedures by
the doctor?”
● “What are the medications and the side effects?”
● “Are you compliant to the treatment?”
● “Why are you not compliant to the treatment?”

Previous Psychiatric Hospitalisations:

● “Have you been hospitalised before due to this
problem?”
● “Why were you hospitalised?”
● “What medications or procedures were given?”

Family History Family history of anxiety

Panic Disorder

Chief Presents with:

Complaint ● Panic attacks

History of Panic Attacks:

Presenting
Illness
Onset “When did you start having panic
attacks?”

Frequency “How often do you have panic attacks?”

Trigger “Is there anything that triggered the

panic attacks?”

Symptoms “Can you tell me the symptoms that you

experience during a panic attack?”

General Heat flashes, chills,

sweating

MSK Tremors

Mental Derealisation,
depersonalisation, fear of
dying / ‘going crazy’, fear of
losing control

CNS Dizziness

Chest Chest - Choking sensation,

SOB,chest pain / discomfort,
palpitations

GI Abdominal discomfort

Duration “How long do the episodes last?”

(Peaks within minutes and resolves)

Anticipatory Presence:
Anxiety ● “Do you feel anxious about
future panic attacks?”

Onset / Duration:
● “How long have you felt this
way?” (At least 1 month)

Coping “This sounds like a distressing

Skills experience for you. I am sorry to hear
that. How do you cope with having panic
attacks?”

Impact on Functioning:
 ● Occupational - “How has it affected your work /
school?”
● Social - “How has it affected your social life?”

Comorbidities:

Generalised Presence:
Anxiety ● “Do you find yourself feeling
Disorder anxious everyday about your
problems?”

Onset / Duration:
● “How long have you felt this
way?” (At least 6 months)

Persistence:
● “Do you feel like this
everyday?”

Content:
● “What do you worry about?”
(Everyday problems and
events - Family,
relationships, financial
difficulties, studies, etc.)

Difficult to control:
● “Do you find your fear and
worries difficult to control?”

Agoraphobia Presence:
● “Do you find yourself scared
to leave your home?”

Onset / Duration:
● “How long have you felt this
way?” (At least 6 months)

Trigger:
● “Why do you feel scared to
leave your house?” (Afraid of
being in a situation where
escape is difficult or help is
unavailable)

Location:
● “Are there any specific
situations that you are afraid
 of?” (Being alone outside of
home, public transport, open
spaces, closed spaces, in a
crowd)

Coping Skills:
● “How do you cope with being
outside your home?”

Impact on Functioning:
● “How has it affected your
life?”

Social Anxiety Presence:

Disorder ● “Are you afraid of being in
social situations?”

Onset / Duration:
● “How long have you been
feeling like this?” (At least 6
months)

Trigger:
● “Why are you afraid of being
in social situations?” (Fear of
being negatively judged)

Coping Skills:
● “How do you cope when you
are in social situations?”

Impact on Functioning:
● “How has it affected your
life?”

Major Presence:
Depressive ● “Sometimes when someone
Disorder feels very anxious and is
under stress, they might feel
sad and have a constantly
low mood. Have you
experienced that?”

Onset / Duration:
● “When do you start feeling
this way?” (At least 2 weeks)

Symptoms (5/9):
 ● Anhedonia - “Have you lost
interest in your hobbies?’
● Weight / Appetite change -
“Have there been any
changes in your weight or
appetite?”
● Sleep disturbances - “How
have your sleep been lately?”
● Low energy - “Do you feel
tired all day?”
● Difficulty concentrating - “Do
you find it difficult to
concentrate?”
● Feeling worthless - “Do you
feel that you are worthless?”
● Suicidal thoughts - “When
someone is under a lot of
stress, they may think of
harming themselves or
ending their lives to get out of
their problem. Have you done
that before?”

Coping Skills:
● “How do you cope with
feeling like this?”

Impact on Functioning:
● “How has it affected your
life?”

Substance Use Presence:

● “Sometimes when someone
is under stress, they might
use alcohol or illicit drugs to
help them cope. Have you
done that?”

Onset / Duration:
● “How long have you been
doing so?”
● “How often do you take it?”

Substance Use:
● “What caused you to take it?”
● Substance - “What do you
take?”
● Amount - “How much are you
 taking?”

Differential Diagnosis:

Organic Causes Hyperthyroidism

Pheochromocytoma

Major At least 5/9 symptoms (which must

Depressive include at least 1 core feature) for
Disorder with at least 2 weeks that causes an
Anxious impairment in functioning (social /
Distress occupational)

At least 5/9 symptoms:

● Low mood for most of the
days (CF)
● Loss of interest or pleasure
in almost all activities (CF)
● Change in weight or appetite
● Sleep disturbances
● Psychomotor agitation or
retardation
● Low energy nearly everyday
● Feeling worthless /
excessive guilt
● Difficulty concentrating
● Suicidal ideations

At least 2/4 symptoms of anxious

distress:
● Restlessness
● Difficulty concentrating
● Fear of losing control
● Worries that something
awful might happen

Adjustment Due to a major life change

Disorder with
Anxiety (+/- Symptoms starts within 3 months
Depressed from onset of trigger and
Mood) resolves within 6 months of
removal of trigger

Past Previous Psychiatric Contact:

Psychiatry ● “Have you seeked help from any psychiatrists or
History doctors before?”

Previous Psychiatric Diagnosis:

● “Were you previously diagnosed?”

Previous Treatment:
● “Did you receive any medications or procedures by
the doctor?”
● “What are the medications and the side effects?”
● “Are you compliant to the treatment?”
● “Why are you not compliant to the treatment?”

Previous Psychiatric Hospitalisations:

● “Have you been hospitalised before due to this
problem?”
● “Why were you hospitalised?”
● “What medications or procedures were given?”

Family History Family history of anxiety and panic disorders

Agoraphobia

Chief Presents with:

Complaint ● Becoming increasingly afraid to leave the house

History of Onset / Duration:

Presenting ● “When do you start feeling this way?” (At least 6
Illness months)

Trigger:
● “Why are you afraid to leave the house?” (Afraid of
being in situations that are difficult to escape or
receive help)
● “What situations are you afraid of?” (2/5)
○ Being outside alone
○ Open spaces
○ Close spaces
○ Public transport
○ In a crowd

Symptoms:
● “How do you feel when you are outside the
house?”
○ Extreme fear and anxiety
○ Panic attacks

Coping Skills:
● “How do you cope when you are outside the
house?”
Impact on Functioning:
● Occupational - “How has this affected your work?”
● Social - “How has this affected your social life?”

Comorbidities:

Panic Presence:
Disorder ● “Do you get panic attacks when
you are outside the house?”

Onset / Duration:
● “When did you start getting panic
attacks?”

Trigger:
● “Do you only get panic attacks
when you are outside the
house?”
● “Is there any trigger for your
panic attacks?”

Symptoms:

General Heat flashes, chills,

sweating

MSK Tremors

Mental Derealisation,
depersonalisation, fear of
dying / ‘going crazy’, fear of
losing control

CNS Dizziness

Chest Choking sensation, SOB,

chest pain / discomfort,
palpitations

GI Abdominal discomfort

Duration:
● “How long does the episode
last?” (Peaks in minutes and
resolves)

Anticipatory Anxiety:
● “Do you feel anxious about
 having future panic attacks?”
● “How long have you felt this
way?” (At least 1 month)

Major Presence:
Depressive ● “Sometimes when someone feels
Disorder very anxious and is under stress,
they might feel sad and have a
constantly low mood. Have you
experienced that?”

Onset / Duration:
● “When do you start feeling this
way?” (At least 2 weeks)

Symptoms (5/9):
● Anhedonia - “Have you lost
interest in your hobbies?’
● Weight / Appetite change - “Have
there been any changes in your
weight or appetite?”
● Sleep disturbances - “How have
your sleep been lately?”
● Low energy - “Do you feel tired
all day?”
● Difficulty concentrating - “Do you
find it difficult to concentrate?”
● Feeling worthless - “Do you feel
that you are worthless?”
● Suicidal thoughts - “When
someone is under a lot of stress,
they may think of harming
themselves or ending their lives
to get out of their problem. Have
you done that before?”

Coping Skills:
● “How do you cope with feeling
like this?”

Impact on Functioning:
● “How has it affected your life?”

Substance
Use

Differential Diagnosis:
Organic Causes Hyperthyroidism

Social Anxiety Presence:

Disorder ● “Are you afraid of being in
social situations?”

Onset / Duration:
● “How long have you been
feeling like this?” (At least
6 months)

Trigger:
● “Why are you afraid of
being in social situations?”
(Fear of being negatively
judged)

Coping Skills:
● “How do you cope when
you are in social
situations?”

Impact on Functioning:
● “How has it affected your
life?”

Acute Stress Presence:

Reaction ● “Was there anything
traumatic that happened
that caused you to be
afraid to be outside?”
(Severe / Threatened
death, serious injury,
sexual violence)

Onset / Duration:
● “When did you start to feel
this way?” (3 days to 1
month after stressor)

Symptoms:
● Intrusive symptoms - “Do
you have flashbacks or
nightmares about the
incident?”
● Negative symptoms - “Do
you constantly feel sad and
 low?”
● Avoidance symptoms - “Do
you try to avoid anything
that associates with the
incident?”
● Hyperarousal symptoms -
Sleep difficulties, difficulty
concentrating, restless,
easily startled

PTSD Same as acute stress reaction, but

duration is more than 1 month
after traumatic incident

Schizophrenia Presence of First Rank

Symptoms:
● Auditory hallucinations -
“Can you hear things that
others could not hear?”
● Thought interference -
Thought broadcasting /
insertion / withdrawal
● Delusion of control /
passivity
● Delusional perception

Past Previous Psychiatric Contact:

Psychiatric ● “Have you seeked help from any psychiatrists or
History doctors before?”

Previous Psychiatric Diagnosis:

● “Were you previously diagnosed?”

Previous Treatment:
● “Did you receive any medications or procedures by
the doctor?”
● “What are the medications and the side effects?”
● “Are you compliant to the treatment?”
● “Why are you not compliant to the treatment?”

Previous Psychiatric Hospitalisations:

● “Have you been hospitalised before due to this
problem?”
● “Why were you hospitalised?”
● “What medications or procedures were given?”

Family History Family history of anxiety

 Social Anxiety Disorder

Chief Presents with:

Complaint ● Extreme fear and anxiety being in social situations

History of Onset / Duration:

Presenting ● “When did you start feeling this way?” (At least 6
Illness months)

Trigger:
● “Why are you afraid of being in social situations?”
(Fear of being negatively judged)
● “Was there anything that happened that caused
you to feel this way?”

Types of Social Situations:

● “What type of social situations are you afraid of?”
(At least 1)

Coping Skills:
● “How do you cope when you are in social
situations?”

Impact on Functioning:
● Occupational - “How has it affected your work?”
● Social - “How has it affected your social life?’

Comorbidities:

Panic Presence:
Disorder ● “Do you get panic attacks when
you are outside the house?”

Onset / Duration:
● “When did you start getting panic
attacks?”

Trigger:
● “Do you only get panic attacks
when you are outside the
house?”
● “Is there any trigger for your panic
attacks?”

Symptoms:

General Heat flashes, chills,

sweating
 MSK Tremors

Mental Derealisation,
depersonalisation, fear of
dying / ‘going crazy’, fear of
losing control

CNS Dizziness

Chest Choking sensation, SOB,

chest pain / discomfort,
palpitations

GI Abdominal discomfort

Duration:
● “How long does the episode
last?” (Peaks in minutes and
resolves)

Anticipatory Anxiety:
● “Do you feel anxious about
having future panic attacks?”
● “How long have you felt this
way?” (At least 1 month)

Major Presence:
Depressive ● “Sometimes when someone feels
Disorder very anxious and is under stress,
they might feel sad and have a
constantly low mood. Have you
experienced that?”

Onset / Duration:
● “When do you start feeling this
way?” (At least 2 weeks)

Symptoms (5/9):
● Anhedonia - “Have you lost
interest in your hobbies?’
● Weight / Appetite change - “Have
there been any changes in your
weight or appetite?”
● Sleep disturbances - “How have
your sleep been lately?”
● Low energy - “Do you feel tired all
day?”
 ● Difficulty concentrating - “Do you
find it difficult to concentrate?”
● Feeling worthless - “Do you feel
that you are worthless?”
● Suicidal thoughts - “When
someone is under a lot of stress,
they may think of harming
themselves or ending their lives
to get out of their problem. Have
you done that before?”

Coping Skills:
● “How do you cope with feeling
like this?”

Impact on Functioning:
● “How has it affected your life?

Substance Presence:
Use ● “Sometimes when someone is
under stress, they might use
alcohol or illicit drugs to help
them cope. Have you done that?”

Onset / Duration:
● “How long have you been doing
so?”
● “How often do you take it?”

Substance Use:
● “What caused you to take it?”
● Substance - “What do you take?”
● Amount - “How much are you
taking?”
Differential Diagnosis:

Organic Hyperthyroidism
Causes

Major At least 5/9 symptoms (which must

Depressive include at least 1 core feature) for at
Disorder with least 2 weeks that causes an
Anxious impairment in functioning (social /
Distress occupational)

At least 5/9 symptoms:

● Low mood for most of the days
 (CF)
● Loss of interest or pleasure in
almost all activities (CF)
● Change in weight or appetite
● Sleep disturbances
● Psychomotor agitation or
retardation
● Low energy nearly everyday
● Feeling worthless / excessive
guilt
● Difficulty concentrating
● Suicidal ideations

At least 2/4 symptoms of anxious

distress:
● Restlessness
● Difficulty concentrating
● Fear of losing control
● Worries that something awful
might happen

Adjustment Due to a major life change

Disorder with
Anxiety (+/- Symptoms starts within 3 months
Depressed from onset of trigger and resolves
Mood) within 6 months of removal of
trigger

Past Previous Psychiatric Contact:

Psychiatric ● “Have you seeked help from any psychiatrists or
History doctors before?”

Previous Psychiatric Diagnosis:

● “Were you previously diagnosed?”

Previous Treatment:
● “Did you receive any medications or procedures by
the doctor?”
● “What are the medications and the side effects?”
● “Are you compliant to the treatment?”
● “Why are you not compliant to the treatment?”

Previous Psychiatric Hospitalisations:

● “Have you been hospitalised before due to this
problem?”
● “Why were you hospitalised?”
● “What medications or procedures were given?”
 Family History Family history of anxiety

MSE
General She / He is a body habitus (thin / medium / large) built
Appearance and race (Malay / Chinese / Indian) gender (male / female).
Behaviour
She / He is dressed in casual attire / formal attire /
hospital attire and is grooming (well-groomed).

She / He is rapport (forthcoming / poor rapport) and has

eye contact (good / poor / wandering).

There is presence / no presence of abnormal

movements (psychomotor agitation / retardation).
● Psychomotor agitation - Engagement in
movements that serve no purpose (pacing
around the room, tapping your toes, or rapid
talking)
● Psychomotor retardation - Slowing-down of
thought and a reduction of physical movements
in an individual

There is downward turning of the corners of her / his

mouth. The patient seems to be anxious throughout the
interview as the patient is fidgety and shuffling her /
his feet.

Speech Coherence and Relevance:

● “Her / His speech is / is not coherent and
relevant.”

Tone, Rate and Amount:

● “The tone, rate and amount of her / his speech is
normal / decreased.”

Thought Flow of Thoughts:

● “Regarding the flow of her / his thought, it is
normal.”

Form of Thoughts:
● “Regarding the flow of her / his thought, it is
normal.”

Content of Thoughts:
● “Regarding the content of thoughts, she / he is
preoccupied with thoughts of …”
● Suicidal thoughts
 ○ “She / he is currently having / not having
suicidal thoughts.”

Mood Mood:
● Anxious / Scared

Affect:
● Affect is congruent to the mood

Perception No perceptual disturbances

Cognitive Orientation:
Function ● Orientated to time, place and person

Attention and Concentration:

● Serial 7 test (fails) - “The attention and
concentration is impaired as she / he is
unable to complete the serial 7 test.”

Judgement “Judgement is intact / impaired.”

Insight “The insight is intact / impaired.”

Summary
History In summary, name, age years old race (Maly / Chinese /
Indian) gender (male / female) presented with … since
duration. It is associated with other symptoms. The anxiety and
worry was caused by trigger. There are comorbidities such as
MDD / panic disorder / substance use which started since
duration. She / He copes with the anxiety and worry by … The
symptoms have caused an impact in her / his functioning
whereby …

MSE She / He is a body habitus (thin / medium / large) built race

(Malay / Chinese / Indian) gender (male / female). She / He is
dressed in casual attire / formal attire / hospital attire and is
grooming (well-groomed). She / He is rapport (forthcoming /
poor rapport) and has eye contact (good / poor / wandering).
There is presence / no presence of abnormal movements
(psychomotor agitation / retardation). There is downward
turning of the corners of her / his mouth. The patient seems
to be anxious throughout the interview as the patient is fidgety
and shuffling her / his feet.

Regarding the speech, the speech is coherent and relevant.

The tone, rate and amount is normal / increased / decreased.

Regarding the thought, the form and flow of the thought is

 normal. The content of the thought is regarding anxiety and
worry of … There are no suicidal thoughts.

Regarding the mood, she / he feels anxious / worried. The

affect is congruent to the mood.

Regarding the perception, there are no perceptual

disturbances.

Regarding the cognitive function, the patient is oriented to

time, place and person.

Regarding the judgement, the patient has good / poor

judgement.

Regarding the insight, the patient has good / poor insight.

Diagnosis
Generalised Anxiety Disorder

Provisional Generalised Anxiety Disorder with / without Major

Diagnosis Depressive Disorder, Panic Disorder and Substance
Misuse / Substance Use Disorder:

Generalised Persistent anxiety and worry about

Anxiety everyday events that is difficult to control
Disorder with 3/6 symptoms for at least 6 months
which impacts functioning

Symptoms:
● Restlessness
● Irritability
● Muscle tension
● Sleep disturbances
● Easily tired
● Difficulty concentrating

Major At least 5/9 symptoms (1 of which must be

Depressive a core feature) for at least 2 weeks and
Disorder impacts functioning

Symptoms:
● Persistently low mood
● Loss of interest in most activities
● Weight / Appetite changes
● Sleep difficulties
 ● Low energy
● Difficulty concentrating
● Feeling worthless, excessive guilt
● Psychomotor agitation / retardation
● Suicidal thoughts

Panic Sudden onset of intense fear that peaks

Disorder within minutes and is accompanied by the
following symptoms
● Heat flashes / Chills
● Sweating
● Tremors
● Derealisation
● Depersonalisation
● Fear of dying / ‘going crazy’
● Fear of losing control
● Dizziness
● Choking sensation
● SOB
● Chest pain / discomfort
● Palpitations
● Abdominal discomfort

At least 1 panic attack is accompanied by

1 of the following for at least 1 month
● Fear of future panic attacks
● Marked changes in behaviours in
relation to the attack

Substance Evidence of substance use that is < 12

Misuse months

Substance Problematic usage of substance that

Use caused impaired functioning for at least 12
Disorder months with at least 2 symptoms

Impaired Increased usage of

Control substance or usage for
longer than intended

Large amount of time

spent to obtain, use or
recover from the
substance

Intense desire to use the

substance
 Repeated unsuccessful
attempts to cut down or
control usage despite
efforts to do so

Social Fails to fulfill major roles

Impairment
Gives up important
activities

Continuous use despite

social impairments
caused by substance use

Risky Use Continuous use despite

physical impairment

Continuous use despite of

knowledge of physical or
psychological problems
caused by substance

Tolerance Increased amount needed

to achieve the desired
effect

Usual amount does not

produce desired effect

Withdrawal Withdrawal symptoms

Use of substance to avoid

/ prevent withdrawal
symptoms

Differential Hyperthyroidism:
Diagnosis ● Rule out with a thyroid function test

Substance-Induced Anxiety Disorder:

● Panic attacks or anxiety that develops during or soon
after substance intoxication or withdrawal or after
medication use
● Substances that can cause panic attack or anxiety
includes
 Intoxication Alcohol
Cannabis
Phencyclidine
Hallucinogens
Inhalants
Stimulants

Withdrawal Alcohol
Opioids
Sedatives
Hypnotics
Anxiolytics
Stimulants

Medications Thyroid medications

OCP
Anticholinergics
Antidepressants
Bronchodilators

Major Depressive Disorder with Anxious Distress:

● At least 5/9 symptoms (1 of which must be a core
feature) for at least 2 weeks and impacts functioning
● Symptoms of MDD
○ Persistently low mood
○ Loss of interest in most activities
○ Weight / Appetite changes
○ Sleep difficulties
○ Low energy
○ Difficulty concentrating
○ Feeling worthless, excessive guilt
○ Psychomotor agitation / retardation
○ Suicidal thoughts
● Symptoms of anxious distress
○ Restlessness
○ Difficulty concentrating
○ Fear of losing control
○ Fear of something bad might happen

Adjustment Disorder with Anxiety (+/- Depressed Mood):

● Symptoms occurs at 3 months from the onset of
trigger and resolves within 6 months from removal of
trigger

Panic Disorder

Provisional Panic Disorder with / without Major Depressive Disorder

Diagnosis and Substance Misuse / Substance Use Disorder:
 ● Sudden onset of intense fear that peaks within
minutes and is accompanied by the following
symptoms
○ Heat flashes / Chills
○ Sweating
○ Tremors
○ Derealisation
○ Depersonalisation
○ Fear of dying / ‘going crazy’
○ Fear of losing control
○ Dizziness
○ Choking sensation
○ SOB
○ Chest pain / discomfort
○ Palpitations
○ Abdominal discomfort
● At least 1 panic attack is accompanied by 1 of the
following for at least 1 month
○ Fear of future panic attacks
○ Marked changes in behaviours in relation to
the attack

Differential Organic Causes - Hyperthyroidism:

Diagnosis ● Rule out with a thyroid function test

Substance-Induced Anxiety Disorder:

● Panic attacks or anxiety that develops during or soon
after substance intoxication or withdrawal or after
medication use
● Substances that can cause panic attack or anxiety
includes

Intoxication Alcohol
Cannabis
Phencyclidine
Hallucinogens
Inhalants
Stimulants

Withdrawal Alcohol
Opioids
Sedatives
Hypnotics
Anxiolytics
Stimulants

Medications Thyroid medications

OCP
 Anticholinergics
Antidepressants
Bronchodilators

Major Depressive Disorder with Anxious Distress:

● At least 5/9 symptoms (1 of which must be a core
feature) for at least 2 weeks and impacts functioning
● Symptoms of MDD
○ Persistently low mood
○ Loss of interest in most activities
○ Weight / Appetite changes
○ Sleep difficulties
○ Low energy
○ Difficulty concentrating
○ Feeling worthless, excessive guilt
○ Psychomotor agitation / retardation
○ Suicidal thoughts
● Symptoms of anxious distress
○ Restlessness
○ Difficulty concentrating
○ Fear of losing control
○ Fear of something bad might happen

Adjustment Disorder with Anxiety (+/- Depressed Mood):

● Symptoms occurs at 3 months from the onset of
trigger and resolves within 6 months from removal of
trigger

Agoraphobia

Provisional Agoraphobia with / without Panic Disorder:

Diagnosis ● Intense fear and anxiety in at least 2 situations due to
fear of being in a situation where escape is difficult or
help is not available which impacts functioning for at
least 6 months
○ Being alone outside
○ Open spaces
○ Closed spaces
○ In a crowd
○ In public transport

Differential Organic Causes - Hyperthyroidism:

Diagnosis ● Rule out using a thyroid function test

Social Anxiety Disorder:

● Extreme fear or anxiety being in more than 1 social
situation where the individual is afraid of being
negatively evaluated by others and impacts
 functioning for at least 6 months

Acute Stress Reaction

● Symptoms occurs within 3 days to 1 month from the
traumatic experience
● Symptoms
○ Exposure to a severe / threatened death,
serious injury or sexual violence
○ Intrusion symptoms - Repetitive, intrusive and
distressing memories of the traumatic event
○ Negative mood - Marked inability to feel
positive emotions
○ Dissociative symptoms - Feeling of an altered
sense of reality or selective dissociative
amnesia of the events
○ Avoidance symptoms - Marked efforts to
avoid distressing memories and external
reminders
○ Hyperarousal symptoms - Sleep difficulties,
difficulty concentrating, restless, always on
edge, gets startled easily

PTSD
● Similar to acute stress reaction, but symptoms
persists for > 1 month

Schizophrenia
● Rule out due to absence of first rank symptoms
○ Auditory hallucinations
○ Thought interference
○ Delusion of control / passivity
○ Delusional perception

Social Anxiety Disorder

Provisional Social Anxiety with / without Major Depressive Disorder

Diagnosis and Panic Disorder:
● Extreme fear or anxiety being in more than 1 social
situation where the individual is afraid of being
negatively evaluated by others and impacts
functioning for at least 6 months

Differential Organic Causes - Hyperthyroidism:

Diagnosis ● Rule out using a thyroid function test

Major Depressive Disorder with Anxious Distress:

● At least 5/9 symptoms (1 of which must be a core
feature) for at least 2 weeks and impacts functioning
● Symptoms of MDD
○ Persistently low mood
 ○ Loss of interest in most activities
○ Weight / Appetite changes
○ Sleep difficulties
○ Low energy
○ Difficulty concentrating
○ Feeling worthless, excessive guilt
○ Psychomotor agitation / retardation
○ Suicidal thoughts
● Symptoms of anxious distress
○ Restlessness
○ Difficulty concentrating
○ Fear of losing control
○ Fear of something bad might happen

Adjustment Disorder with Anxiety (+/- Depressed Mood):

● Symptoms occurs at 3 months from the onset of
trigger and resolves within 6 months from removal of
trigger

Investigations
Full Blood Count Anemia (fatigue, easily tired)

Liver Function Test Baseline before starting medications

Renal Profile Baseline before starting medications

Thyroid Function Rule out hyperthyroidism

Test

ECG Palpitations - Rule out cardiac causes such as

arrhythmia

Urine drug test Suspected substance induced anxiety

Management
Risk Assessment Suicidal Risk Assessment:
● Low risk - Manage as outpatient

Pharmacotherapy Antidepressants:
● SSRI - 50-200 mg/day Sertraline / 10-20 mg/day
Escitalopram
● NaSSA - 15-45 mg/day Mirtazapine (if there is
sleep difficulties)

Short-Acting Benzodiazepines:
● Lowest effective dose is used for short term
 symptom relief and is gradually tapered off
● 0.5 mg/day Alprazolam PRN for 2 weeks

Psychoeducation Explain to the patient regarding anxiety disorders,

symptoms, management and side effects of
medications

Psychotherapy Cognitive Behavioural Therapy:

● Challenge the negative thoughts using a logical
approach

Relaxation Techniques:
● Deep breathing techniques
● Progressive muscle relaxation
● Mindfulness

Psychosocial Advise the patient to exercise, eat a healthy diet,

Intervention discover new hobbies and avoid substance use as well
as sleep hygiene

Discussion Benzodiazepines:

Benzodiazepines

Short-Acting Alprazolam (Xanax) 0.5 mg/day

Benzodiazepines
Clonazepam 0.5 mg/day

Midazolam 7.5 mg/day

Intermediate-Acting Lorazepam 1 mg/day

Benzodiazepines

Long-Acting Diazepam (Valium) 10 mg/day

Benzodiazepines

Side Effects

Sedation, dizziness, weakness, unsteadiness, headache, memory

impairment, dependence

Dependence

Short-acting benzodiazepines are associated with a high risk of dependence

as the effect is instantaneous.

Withdrawal Symptoms

Symptoms:
 ● Sleep disturbances
● Anxiety
● Tremors
● Sweating
● Difficulty concentrating
● Nausea
● Irritability
● Seizures
● Psychotic symptoms

Prevention:
● Taper benzodiazepines gradually

Benzodiazepine Overdose

Symptoms:
● Excess sedation
● Lethargy
● Incoordination
● Slurred speech
● Impaired cognitive function

Antidepressants:

What will you do if there is no clinical response to the antidepressant

that is prescribed?
● Check the compliance
● Increase the dose
● Switch to another medication of the same class
● Switch to another class
● Combination therapy - 2 antidepressants
● Augmentation therapy - Antidepressant + Mood stabiliser (Lithium) /
Antipsychotic (Olanzapine / Quetiapine)