2.6 Anxiety, OCD & Trauma/Stressor-Related Disorders

Anxiety, obsessive-compulsive, and trauma/stressor-related disorders were split into three separate DSM-5-TR chapters (they were grouped together in earlier editions), but the PMH-BC exam still tests them as a related cluster because they share overlapping physiological arousal symptoms and require careful differential diagnosis.

Anxiety Disorders

Generalized anxiety disorder (GAD) requires excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities, that the person finds difficult to control, plus at least 3 of 6 associated symptoms: restlessness/feeling on edge, easy fatigability, difficulty concentrating/mind going blank, irritability, muscle tension, and sleep disturbance. The GAD-7 screening tool quantifies severity, with a score of 10 or higher suggesting moderate anxiety warranting further evaluation.

Panic disorder requires recurrent, unexpected panic attacks followed by at least 1 month of persistent concern about additional attacks, worry about their consequences, or a significant maladaptive behavior change related to the attacks (e.g., avoiding exercise for fear of triggering symptoms). A panic attack itself is an abrupt surge of intense fear or discomfort that peaks within minutes, with symptoms such as palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, chills or hot flashes, paresthesias, derealization/depersonalization, and fear of dying, losing control, or "going crazy."

Specific phobia is marked, persistent fear of a specific object or situation (heights, animals, blood) lasting at least 6 months and actively avoided or endured with intense distress. Social anxiety disorder involves marked fear of social or performance situations due to fear of scrutiny, negative evaluation, or embarrassment. Agoraphobia involves marked fear or anxiety about at least 2 of 5 situations: using public transportation, being in open spaces, being in enclosed spaces, standing in a line or crowd, or being outside the home alone — driven by the fear that escape might be difficult or help unavailable if panic-like symptoms occur.

Obsessive-Compulsive Disorder

OCD is defined by obsessions (recurrent, intrusive, unwanted thoughts, urges, or images that cause marked anxiety, which the person attempts to suppress or neutralize) and/or compulsions (repetitive behaviors or mental acts performed to reduce the anxiety triggered by an obsession or according to rigid rules). The obsessions/compulsions must be time-consuming (more than 1 hour per day) or cause clinically significant distress or impairment. Insight varies widely — from good insight (the person recognizes the beliefs are untrue) to absent insight/delusional beliefs. Related disorders in the DSM-5-TR OCD-spectrum chapter include body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling), and excoriation disorder (skin-picking).

Trauma and Stressor-Related Disorders

Posttraumatic stress disorder (PTSD) requires exposure to actual or threatened death, serious injury, or sexual violence (directly, as a witness, or by learning it happened to a close family member/friend), followed by symptoms from 4 clusters, persisting for more than 1 month:

1. Intrusion — recurrent distressing memories, nightmares, flashbacks, or intense psychological/physiological distress at trauma cues.
2. Avoidance — of trauma-related thoughts, feelings, or external reminders.
3. Negative alterations in cognition and mood — distorted blame, persistent negative emotional state, detachment, inability to recall key trauma details.
4. Alterations in arousal and reactivity — hypervigilance, exaggerated startle, irritability/aggression, sleep disturbance, reckless behavior.

Acute stress disorder captures the same general symptom picture but for a shorter window — 3 days to 1 month post-trauma; if symptoms persist beyond 1 month, the diagnosis shifts to PTSD. Adjustment disorders involve emotional or behavioral symptoms developing within 3 months of an identifiable stressor (not necessarily a DSM-5-TR "trauma"-level event), causing marked distress or impairment, and resolving within 6 months after the stressor or its consequences have ended.

Trauma-Informed History Taking

Additional Anxiety Presentations Across the Lifespan

Two further DSM-5-TR anxiety diagnoses round out this chapter's coverage. Separation anxiety disorder involves developmentally inappropriate, excessive fear or anxiety about separation from attachment figures — historically considered a childhood disorder, it is now recognized as occurring in adults as well, who may show excessive worry about a partner's or child's safety when apart. Selective mutism involves a consistent failure to speak in specific social situations (such as school) despite speaking normally in other settings (such as home), persisting for at least 1 month beyond the first month of school, and is classified with the anxiety disorders because it is understood as an anxiety-driven behavior rather than a communication or developmental disorder.

Because assessment itself can retraumatize a patient, trauma history taking should follow trauma-informed principles: establish physical and emotional safety first, offer the patient choice and control over pacing and what is disclosed, build trust through transparency, and avoid pressing for graphic detail the patient is not ready to share. The goal of the initial assessment is to identify the presence and general nature of trauma exposure and its current symptom impact — not to obtain a forensic-level narrative, which can be pursued later in specialized trauma therapy.