8.4 Anxiety Disorders, OCD, PTSD, Eating Disorders, Personality Disorders & Somatic Presentations
Key Takeaways
Generalised anxiety disorder follows NICE CG113 stepped care: psychoeducation, then low-intensity interventions, then CBT or applied relaxation or an SSRI, with sertraline first-line.
Benzodiazepines are not used for generalised anxiety or panic disorder except briefly in a crisis.
NICE NG116 recommends trauma-focused CBT or EMDR for PTSD; psychological debriefing should not be offered after trauma.
Anorexia nervosa causes bradycardia, hypotension, hypothermia and electrolyte disturbance; refeeding syndrome risk is managed with phosphate monitoring and thiamine.
Dialectical behaviour therapy is used for emotionally unstable (borderline) personality disorder with recurrent self-harm; medication is not used for the core disorder.
Anxiety Disorders, OCD, PTSD, Eating Disorders, Personality Disorders & Somatic Presentations
Generalised Anxiety Disorder (GAD)
Excessive, hard-to-control worry about many things on most days for at least 6 months, with restlessness, fatigue, poor concentration, irritability, muscle tension and poor sleep. Exclude physical causes (hyperthyroidism, arrhythmias, phaeochromocytoma, hypoglycaemia, caffeine, alcohol or drug withdrawal) and screen for depression and substance use. The GAD-7 questionnaire measures severity.
Stepped Care (NICE CG113)
- Identification, education and active monitoring.
- Low-intensity psychological interventions: guided or non-facilitated self-help, psychoeducational groups.
- High-intensity psychological therapy (CBT or applied relaxation) or drug treatment: an SSRI, with sertraline first-line; if ineffective, another SSRI or an SNRI (for example venlafaxine); pregabalin if SSRIs and SNRIs are unsuitable.
- Specialist care for complex, treatment-resistant disorders or marked functional impairment.
Caution
Avoid Benzodiazepines: Do not offer benzodiazepines for GAD or panic disorder except as short-term help in a crisis, because of dependence and tolerance. Antipsychotics should not be used for GAD in primary care.
Panic Disorder & Phobias
- Panic disorder: recurrent unexpected panic attacks (palpitations, sweating, chest tightness, breathlessness, fear of dying) with worry about further attacks; often with agoraphobia. Treat with CBT, or an SSRI (clomipramine or imipramine if an SSRI fails).
- Specific phobias respond to graded exposure; social anxiety disorder is treated with CBT designed for social anxiety, then an SSRI.
Obsessive-Compulsive Disorder (OCD)
Obsessions are intrusive, unwanted thoughts, images or urges (contamination, harm, symmetry) recognised as the person's own; compulsions are repetitive acts or mental rituals (washing, checking, counting) that briefly relieve anxiety. Treatment (NICE CG31): CBT including exposure and response prevention (ERP), an SSRI (often at higher doses), or clomipramine; combined treatment for moderate or severe OCD. Body dysmorphic disorder is managed similarly.
Post-Traumatic Stress Disorder (PTSD)
After a traumatic event: re-experiencing (flashbacks, nightmares), avoidance, hyperarousal (hypervigilance, exaggerated startle, poor sleep) and negative changes in mood and beliefs, lasting more than a month. Complex PTSD follows prolonged or repeated trauma such as childhood abuse.
- Treatment (NICE NG116): trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR); an SSRI (such as sertraline) or venlafaxine if the person prefers drug treatment.
- Do not offer psychological debriefing to prevent PTSD, and do not offer drugs to prevent PTSD in adults.
- Acute stress reaction (within days of the event) and adjustment disorder (distress after a life change) are usually managed with support and watchful waiting.
Eating Disorders (NICE NG69)
| Feature | Anorexia Nervosa | Bulimia Nervosa | Binge Eating Disorder |
|---|---|---|---|
| Core features | Restriction, low weight, intense fear of weight gain, distorted body image | Recurrent binges with compensatory purging, laxatives or exercise | Recurrent binges without compensatory behaviour |
| Weight | Low (BMI often below 17.5 in adults) | Usually normal | Often overweight |
| Physical signs | Bradycardia, hypotension, hypothermia, lanugo hair, amenorrhoea, osteoporosis | Russell's sign (knuckle calluses), parotid swelling, dental erosion | Obesity-related problems |
| Biochemistry | Hypokalaemia, hypophosphataemia, low glucose, raised LFTs | Hypokalaemic metabolic alkalosis (vomiting) | Usually normal |
| First-line treatment | Adults: eating-disorder-focused CBT, MANTRA or specialist supportive clinical management; children and young people: anorexia-focused family therapy | Bulimia-focused guided self-help, then individual CBT-ED; family therapy for young people | Binge-eating-focused guided self-help, then group CBT-ED |
Warning
Medical Risk & Refeeding Syndrome: The Royal College of Psychiatrists' Medical Emergencies in Eating Disorders (MEED, 2022) guidance flags high risk with very low or rapidly falling BMI, heart rate below about 40, postural collapse, prolonged QTc, low potassium or phosphate, and hypothermia. Starting nutrition in a starved patient can cause refeeding syndrome (hypophosphataemia, hypokalaemia, hypomagnesaemia, fluid shifts, heart failure). Reintroduce feeding carefully, check electrolytes daily (especially phosphate), replace them, and give thiamine. Eating disorders have the highest mortality of any psychiatric illness.
Personality Disorders
Enduring, inflexible patterns of thinking, feeling and relating that start in adolescence or early adulthood and cause distress or impairment. DSM-5 groups them into three clusters; ICD-11 now uses a single diagnosis of personality disorder graded by severity (mild, moderate, severe) with trait descriptors and a "borderline pattern" specifier.
| Cluster | Types | Description |
|---|---|---|
| A (odd, eccentric) | Paranoid, schizoid, schizotypal | Suspicious, detached, unusual beliefs |
| B (dramatic, emotional) | Emotionally unstable (borderline), antisocial (dissocial), histrionic, narcissistic | Impulsivity, unstable relationships, emotional dysregulation |
| C (anxious, fearful) | Avoidant, dependent, obsessive-compulsive (anankastic) | Anxiety, fear of rejection, perfectionism |
- Borderline personality disorder (NICE CG78): unstable mood and relationships, fear of abandonment, impulsivity, chronic emptiness and recurrent self-harm. Offer structured psychological therapy (dialectical behaviour therapy for women with recurrent self-harm; mentalisation-based therapy), a consistent care team and crisis plans. Do not use drugs for the core disorder; short-term sedation (no more than a week) may help in a crisis.
- Antisocial personality disorder: disregard for others' rights, often with conduct disorder in childhood; group cognitive and behavioural programmes.
Functional, Factitious & Related Presentations
| Presentation | Symptoms Produced Deliberately? | Motivation |
|---|---|---|
| Somatic symptom disorder | No | Distressing physical symptoms with excessive health-related thoughts and behaviour |
| Illness anxiety (health anxiety) | No | Preoccupation with having a serious illness despite reassurance |
| Functional neurological disorder (conversion) | No | Genuine neurological symptoms (weakness, non-epileptic seizures) inconsistent with structural disease; positive signs such as Hoover's sign |
| Factitious disorder (Munchausen syndrome) | Yes | To take on the sick role (internal reward) |
| Malingering | Yes | External gain (money, avoiding work or prosecution); not a mental disorder |
Explain functional diagnoses positively and honestly, avoid unnecessary repeated investigation, and offer physiotherapy, psychological therapy and a single coordinating clinician. Factitious disorder imposed on another (fabricated or induced illness in a child) is a safeguarding concern.
A 29-year-old woman has 8 months of constant worry about work, family and money, with muscle tension, poor sleep and irritability. Thyroid function is normal. Guided self-help has not helped and she prefers medication. According to NICE, what is the most appropriate first-line drug?
Pregabalin
Sertraline
Quetiapine
Diazepam 5 mg three times daily
A 17-year-old girl with anorexia nervosa is admitted with a BMI of 12.8 kg/m². She is started on nasogastric feeding. On day 3 she becomes confused and breathless with ankle swelling. Which blood abnormality is most likely to explain this deterioration?
Hypophosphataemia
Hyperkalaemia
Hypernatraemia
Hypercalcaemia
A 35-year-old firefighter developed nightmares, flashbacks, hypervigilance and avoidance of reminders 3 months after a fatal house fire. He wants treatment. What is the most appropriate first-line intervention?
Single-session psychological debriefing
Long-term diazepam
Trauma-focused CBT or EMDR
Watchful waiting for a further 6 months
Sections you finish are checked off in the contents.