Psychiatry: Anxiety, stress and somatic disorders

• Anxiety disorders: Anxiety — Overview | Generalised Anxiety Disorder | Panic Disorder and Agoraphobia | Phobias and Social Anxiety | Obsessive-Compulsive and Related Disorders | Health Anxiety
• Stress and trauma: Acute Stress Reaction and Adjustment Disorder | Post-traumatic Stress Disorder | Dissociative Disorders
• Body and mind: Somatic Symptom and Bodily Distress Disorders | Functional Neurological Disorder | Chronic Fatigue and Chronic Pain | Factitious Disorder and Malingering
• Sleep and sedatives: Insomnia | Other Sleep Disorders | Benzodiazepines and Z-drugs
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

😰 Anxiety, stress and somatic disorders — anxiety disorders are the commonest mental health problems. They respond well to psychological therapy (especially CBT) and SSRIs; benzodiazepines are for short-term crises only. Many patients present with physical symptoms — palpitations, breathlessness, pain, fatigue, or functional neurological symptoms — and deserve a positive diagnosis and explanation rather than "nothing is wrong".
Your four questions for every patient: Is there a physical cause (thyroid, arrhythmia, drugs, alcohol withdrawal)? Which anxiety disorder is it? Is there coexisting depression, substance use or suicide risk? What has the person tried, and what do they want?

Anxiety — Overview

• Normal anxiety is a helpful response to threat. It becomes a disorder when it is excessive, persistent, out of proportion to the situation, and interferes with life.
• Symptoms:
  • Psychological — worry, fear, irritability, poor concentration, restlessness, feeling on edge, sleep problems.
  • Physical (adrenaline) — palpitations, chest tightness, breathlessness, tingling (hyperventilation), dizziness, tremor, sweating, dry mouth, nausea, butterflies, diarrhoea, urinary frequency, muscle tension and aches.
• Physical causes to rule out:
  • Hyperthyroidism.
  • Arrhythmias (SVT, AF), angina.
  • Hypoglycaemia; phaeochromocytoma (rare); carcinoid.
  • Asthma, COPD, pulmonary embolism.
  • Drugs — caffeine, salbutamol, steroids, levothyroxine excess, stimulants (cocaine, amphetamines), cannabis.
  • Withdrawal — alcohol, benzodiazepines, opioids, antidepressants.
  • Menopause; temporal lobe epilepsy.
• Tests (if indicated) — TFTs, FBC, glucose, ECG; others guided by history.
• Screening — GAD-7 (score 10 or more suggests GAD; 15+ severe); GAD-2 (first two questions).
• Common coexisting problems — depression, alcohol and drug misuse (self-medication), other anxiety disorders.

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Generalised Anxiety Disorder

• What it is: Excessive, uncontrollable worry about many everyday things (health, money, family, work) on most days for at least 6 months (DSM; ICD-11 several months), with physical anxiety symptoms; "free-floating" rather than triggered.
• Who — common (about 1 in 20); more in women; often with depression.
• Stepped care (NICE CG113):
  • Step 1 — diagnosis, education about anxiety, active monitoring.
  • Step 2 — low-intensity psychological interventions: individual non-facilitated or guided self-help (CBT-based), psychoeducational groups.
  • Step 3 — marked impairment or no response — high-intensity CBT or applied relaxation, or drug treatment (by preference).
  • Step 4 — complex, treatment-refractory, high risk — specialist services.
• Drug treatment:
  • First-line — sertraline (cost-effective).
  • Then another SSRI or an SNRI (escitalopram, paroxetine, venlafaxine, duloxetine).
  • Pregabalin if SSRIs and SNRIs are unsuitable (a controlled drug — misuse, dependence, respiratory depression with opioids).
  • Warn about early worsening of anxiety (start low), side effects, delay in benefit, and withdrawal.
  • Review every 2–4 weeks for the first 3 months; continue for at least a year if effective (to prevent relapse).
• Don't use — benzodiazepines (except short-term in a crisis), or antipsychotics in primary care.

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Panic Disorder and Agoraphobia

• Panic attack — sudden, intense fear peaking within minutes: palpitations, chest pain, breathlessness, choking, sweating, shaking, dizziness, tingling, feeling of unreality, fear of dying, "going mad" or losing control. Usually settles within 20–30 minutes.
• Panic disorder — recurrent, unexpected panic attacks with persistent worry about further attacks or their consequences, and changes in behaviour (avoidance).
• Agoraphobia — fear and avoidance of situations where escape might be difficult or help unavailable (crowds, public transport, shops, being away from home); can become housebound.
• Assessment — rule out cardiac and respiratory causes (ECG, especially in older people or with risk factors); hyperthyroidism; caffeine and drugs; alcohol withdrawal.
• Treatment (NICE CG113):
  • CBT (first-line; 7–14 hours over 4 months) or guided self-help.
  • SSRI (licensed for panic — e.g. sertraline, citalopram, escitalopram, paroxetine); start low (initial worsening).
  • If no improvement after 12 weeks — imipramine or clomipramine.
  • No benzodiazepines (worse long-term outcome); no sedating antihistamines or antipsychotics.
• Hyperventilation — slow breathing techniques; explain the tingling and light-headedness (low CO2).

💡 Clinical Pearl: A person who has had a panic attack often fears a heart attack. A clear explanation of how adrenaline causes the symptoms — after appropriate tests — is part of treatment. Repeated reassurance-seeking tests, though, can keep anxiety going.

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Phobias and Social Anxiety

• Specific phobia — intense, irrational fear of a specific object or situation (spiders, heights, flying, needles, blood — blood-injury phobia can cause fainting) with avoidance.
  • Treatment — graded exposure (systematic desensitisation) — highly effective; CBT; no medication usually.
  • Needle phobia — matters for vaccination, blood tests and treatment; applied tension (blood-injury type), topical anaesthetic, graded exposure.
• Social anxiety disorder — intense fear of being judged, embarrassed or humiliated in social or performance situations (talking, eating in public, meetings); blushing, sweating, trembling; avoidance; often starts in adolescence; may lead to alcohol misuse.
  • Treatment (NICE CG159) — individual CBT specifically for social anxiety (first-line); SSRI (escitalopram or sertraline) if declined or not effective; combine if partial response.
  • Beta-blockers (propranolol) sometimes used for performance anxiety only (tremor, palpitations) — not for social anxiety disorder.
• Separation anxiety — mainly children (see the Safeguarding and Mental Health chapter).

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Obsessive-Compulsive and Related Disorders

• Obsessive-compulsive disorder (OCD) — about 1–2% of people:
  • Obsessions — unwanted, intrusive thoughts, images or urges that cause distress; recognised as the person's own thoughts (unlike thought insertion in psychosis); often about contamination, harm (to others or self), symmetry, sexual or religious themes.
  • Compulsions — repetitive behaviours or mental acts to reduce anxiety (washing, checking, counting, ordering, praying, seeking reassurance); give short relief but keep the cycle going.
  • Time-consuming (over an hour a day) or distressing; insight usually present (variable).
  • Severity — Y-BOCS scale.
• Treatment (NICE CG31):
  • CBT with exposure and response prevention (ERP) — gradual exposure to the feared situation without doing the compulsion.
  • SSRI (fluoxetine, sertraline, escitalopram, paroxetine, fluvoxamine) — often higher doses and longer (12 weeks) before response; continue at least 12 months if effective.
  • Clomipramine if SSRIs fail.
  • Severe or refractory — specialist services; antipsychotic augmentation (e.g. aripiprazole, risperidone); deep brain stimulation (research).
• Perinatal OCD — intrusive thoughts of harming the baby; distressing but not acted upon — reassure and treat; avoid unnecessary safeguarding alarm.
• Related disorders:
  • Body dysmorphic disorder — preoccupation with a perceived defect in appearance (slight or not visible), with checking, grooming, camouflaging, seeking cosmetic procedures; high suicide risk; CBT with ERP, SSRIs; cosmetic surgery doesn't help.
  • Hoarding disorder — difficulty discarding possessions; clutter; fire and safety risk; often older people; CBT; safeguarding (self-neglect).
  • Trichotillomania (hair pulling) and excoriation (skin picking) disorder — habit reversal therapy.

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Health Anxiety

• What it is: Persistent preoccupation with having or getting a serious illness, despite medical reassurance — checking the body, searching online, seeking repeated tests (or avoiding doctors).
• Management:
  • One consistent clinician; regular planned appointments (not symptom-driven).
  • Take symptoms seriously, examine appropriately, but avoid unnecessary repeated tests (they bring only short-term relief).
  • CBT for health anxiety; SSRIs if severe or with depression.
• Different from somatic symptom disorder (distress focused on the symptoms themselves) — see below.

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Acute Stress Reaction and Adjustment Disorder

• Acute stress reaction — a normal, short-lived response in the hours to days after an exceptionally stressful event: daze, disorientation, anxiety, anger, despair, overactivity or withdrawal; settles within days (by about 1 month).
  • Management — practical and emotional support, information, sleep; don't offer single-session psychological debriefing (may worsen outcomes); watch for PTSD.
  • A short course of a hypnotic may help severe insomnia.
• Adjustment disorder — distress and impaired functioning in reaction to a life change or stressor (divorce, job loss, diagnosis of illness, moving), starting within a month (ICD-11) and usually resolving within 6 months once the stressor ends or the person adapts:
  • Preoccupation with the stressor, worry, low mood, poor sleep and concentration — but not meeting criteria for depression or another disorder.
  • Management — supportive counselling, problem-solving, practical help; review for depression or suicide risk; medication rarely needed.

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Post-traumatic Stress Disorder

• What it is: A disorder after exposure to an extremely threatening or horrific event (assault, rape, war, serious accidents, disasters, traumatic childbirth, ICU stays), with symptoms lasting more than a month. May start months or years later.
• Core symptoms:
  • Re-experiencing — flashbacks, intrusive memories, nightmares, distress at reminders.
  • Avoidance — of reminders, people, places, thoughts; emotional numbing.
  • Hyperarousal — hypervigilance, exaggerated startle, irritability, anger, poor sleep and concentration.
  • Negative thoughts and mood — guilt, shame, detachment, inability to feel positive emotions.
• Complex PTSD (ICD-11) — after prolonged or repeated trauma (childhood abuse, torture, domestic abuse): PTSD plus problems with emotional regulation, negative self-concept and relationships.
• Coexisting problems — depression, substance misuse, suicide risk, physical symptoms.
• Treatment (NICE NG116):
  • Trauma-focused CBT — first-line (usually 8–12 sessions, more for complex PTSD).
  • EMDR (eye movement desensitisation and reprocessing) — for non-combat trauma (from 1 month after the event).
  • Watchful waiting may be appropriate if symptoms are mild and under 4 weeks; active monitoring.
  • Drugs — venlafaxine or an SSRI (e.g. sertraline) if the person prefers or can't engage with therapy; antipsychotics (e.g. risperidone) for severe symptoms such as hyperarousal or psychotic features, specialist use.
  • Don't offer single-session debriefing; avoid benzodiazepines.
• Ask about trauma sensitively in people with depression, substance misuse, self-harm or unexplained physical symptoms — trauma-informed care.

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Dissociative Disorders

• Dissociation — a disruption in the normal integration of memory, identity, perception and movement; often linked to trauma.
• Types:
  • Depersonalisation–derealisation disorder — feeling detached from oneself (like watching from outside) or that the world is unreal; insight preserved.
  • Dissociative amnesia — inability to recall important personal information, usually traumatic (beyond normal forgetting); dissociative fugue — travel away with loss of identity.
  • Dissociative identity disorder — two or more distinct identity states (rare; controversial).
  • Dissociative neurological symptoms (seizures, weakness) — see Functional Neurological Disorder.
• Exclude — epilepsy (temporal lobe), drugs and alcohol, head injury, transient global amnesia, psychosis.
• Treatment — psychological therapy (trauma-focused), grounding techniques; treat coexisting depression and PTSD.

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Somatic Symptom and Bodily Distress Disorders

• What they are: Distressing physical symptoms with excessive thoughts, feelings and behaviours about them (worry, frequent consultations, disability), whether or not a medical cause is found (somatic symptom disorder — DSM-5; bodily distress disorder — ICD-11).
• Common symptoms — pain (back, abdomen, chest, headache), fatigue, dizziness, palpitations, bowel symptoms (IBS), breathlessness.
• Very common in all specialties — about a third of new outpatient referrals have symptoms not explained by disease.
• Management principles:
  • Acknowledge the symptoms are real; avoid "it's all in your head" or "nothing is wrong".
  • Thorough but proportionate assessment — avoid repeated tests and referrals (iatrogenic harm, reinforcement).
  • Give a positive explanation (how stress, attention, sleep and the nervous system amplify symptoms).
  • One coordinating clinician; regular scheduled reviews.
  • Focus on function and goals rather than cure; graded activity.
  • CBT; treat depression and anxiety (antidepressants such as low-dose TCAs or SNRIs can help pain).
• Remember — people with functional symptoms can also develop organic disease; reassess if symptoms change.

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Functional Neurological Disorder

• What it is: Genuine neurological symptoms caused by a problem with how the nervous system functions, not structural disease — one of the commonest reasons for neurology referral. (Previously called "conversion disorder".)
• Symptoms — functional limb weakness, tremor, gait disorder, sensory loss, speech problems, visual loss, and dissociative (non-epileptic) seizures.
• Diagnosis is made on positive signs, not just normal tests:
  • Hoover's sign — weak hip extension becomes normal when the other hip is flexed against resistance.
  • Hip abductor sign; give-way weakness; drift without pronation.
  • Tremor entrainment — the tremor changes to match a rhythm tapped with the other hand; distractibility.
  • Dissociative seizures — eyes closed (resisting opening), long duration, fluctuating, side-to-side head movements, pelvic thrusting, crying afterwards, recall of the episode; video EEG confirms.
• Risk factors — physical injury or illness (common trigger), pain, anxiety, depression, trauma (in some — not all).
• Management:
  • Clear explanation of the diagnosis — it is common, real, and potentially reversible (resources such as neurosymptoms.org).
  • Specialist physiotherapy (retraining movement), occupational therapy, speech therapy.
  • Psychological therapy (CBT-based) — especially for dissociative seizures.
  • Avoid unnecessary antiepileptic drugs and repeated emergency treatments (e.g. intubation for "status").

⚠️ Safety Pearl: Dissociative seizures are often mistaken for status epilepticus, leading to high doses of benzodiazepines and even intubation. Eyes firmly shut, fluctuating movements and long duration with normal oxygen levels suggest a dissociative seizure — but if in doubt, treat as epilepsy and get senior help.

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Chronic Fatigue and Chronic Pain

• ME/chronic fatigue syndrome (NICE NG206):
  • Debilitating fatigue, post-exertional malaise (worsening after activity, often delayed), unrefreshing sleep, cognitive difficulties ("brain fog"), for at least 3 months.
  • Exclude anaemia, thyroid disease, diabetes, coeliac, depression, sleep disorders, long COVID overlap.
  • Energy management (pacing within limits); symptom management; don't offer graded exercise therapy based on fixed increments; CBT can help coping (not as a cure).
• Fibromyalgia — widespread pain, fatigue, poor sleep, tenderness; exercise, CBT, amitriptyline or duloxetine (see the Rheumatology chapters).
• Chronic primary pain (NICE NG193) — exercise programmes, psychological therapy (CBT, ACT), acupuncture; antidepressants (amitriptyline, duloxetine, SSRIs) may be considered; avoid opioids, gabapentinoids, benzodiazepines and NSAIDs for chronic primary pain.

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Factitious Disorder and Malingering

• Factitious disorder (previously Munchausen syndrome) — deliberately faking or inducing symptoms to take on the sick role (no obvious external gain):
  • Clues — dramatic but inconsistent history, many hospitals, healthcare work background, eagerness for invasive tests, unusual lab results (e.g. insulin with low C-peptide), wounds that don't heal.
  • Management — non-confrontational discussion with a senior; one lead clinician; psychiatric input; avoid harmful investigations.
• Factitious disorder imposed on another — see Fabricated or Induced Illness in the Safeguarding chapter.
• Malingering — faking symptoms for external gain (money, avoiding work or prison, obtaining drugs) — not a mental disorder.
• Key difference from functional and somatic disorders — those symptoms are not consciously produced.

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Insomnia

• Insomnia — difficulty getting to sleep, staying asleep, or waking early, with daytime impairment, despite adequate opportunity to sleep; chronic if at least 3 nights a week for 3 months.
• Look for causes — anxiety, depression (early waking), pain, nocturia, breathlessness, menopause, caffeine, alcohol, nicotine, drugs (SSRIs, steroids, beta-blockers, stimulants), shift work, sleep apnoea, restless legs.
• Sleep hygiene — regular wake time (even at weekends), no daytime naps, limit caffeine (after midday), alcohol and nicotine; avoid screens and heavy meals before bed; bedroom dark, quiet, cool; regular exercise (not late evening); don't lie awake — get up after 20 minutes.
• CBT for insomnia (CBT-I) — the first-line treatment for chronic insomnia (sleep restriction, stimulus control, cognitive techniques); digital CBT-I (e.g. Sleepio, NICE-recommended).
• Medication — short-term only:
  • Z-drugs (zopiclone, zolpidem) or short-acting benzodiazepines — for severe acute insomnia, the lowest dose for the shortest time (up to 2 weeks, ideally fewer nights).
  • Melatonin (modified-release) — licensed for adults 55 and over (short term).
  • Daridorexant (orexin receptor antagonist) — NICE TA922 for chronic insomnia if CBT-I has been tried and not worked, or isn't available or suitable; review at 3 months.
  • Sedating antihistamines and antidepressants — not recommended for insomnia alone (except where depression coexists).
• Older people — hypnotics increase falls, fractures and confusion; avoid where possible.

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Other Sleep Disorders

• Obstructive sleep apnoea — snoring, witnessed apnoeas, daytime sleepiness (Epworth score); sleep study; CPAP; DVLA rules (see the Respiratory chapters).
• Narcolepsy — excessive daytime sleepiness with sudden sleep attacks; cataplexy (sudden loss of muscle tone with emotion, e.g. laughing), sleep paralysis, hypnagogic hallucinations; low CSF orexin; modafinil, pitolisant, sodium oxybate; DVLA.
• Restless legs syndrome — uncomfortable urge to move the legs in the evening, relieved by movement; check ferritin (treat iron deficiency), pregnancy, CKD; dopamine agonists (risk of augmentation), gabapentinoids.
• Parasomnias:
  • NREM (first part of the night) — sleepwalking, night terrors, confusional arousals — more common in children.
  • REM sleep behaviour disorder — acting out dreams (punching, kicking); strongly linked to later Parkinson's disease and dementia with Lewy bodies; clonazepam or melatonin; bedroom safety.
• Circadian rhythm disorders — delayed sleep phase (teenagers), shift work, jet lag; light timing and melatonin.

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Benzodiazepines and Z-drugs

• Uses — short-term severe anxiety or insomnia, alcohol withdrawal, seizures (status epilepticus), acute behavioural disturbance, catatonia, sedation for procedures, muscle spasm.
• Problems:
  • Tolerance and dependence — after as little as 2–4 weeks of regular use.
  • Sedation, impaired driving, memory problems, falls and fractures in older people, confusion.
  • Respiratory depression — especially with opioids, alcohol or gabapentinoids (MHRA warning).
  • Paradoxical agitation or disinhibition.
  • Misuse and diversion; street benzodiazepines (etizolam, "fake Valium") cause many deaths.
• Withdrawal — anxiety, insomnia, irritability, tremor, sweating, perceptual disturbance (sensitivity to light and noise), depersonalisation; seizures and delirium if stopped suddenly after high-dose use.
• Stopping long-term benzodiazepines:
  • Agree a plan with the person; never stop suddenly.
  • Often switch to an equivalent dose of diazepam (long half-life), then reduce gradually — e.g. by about 1/8 to 1/10 of the dose every 2–4 weeks; slower near the end; may take months.
  • Support — CBT, anxiety management; treat underlying problems.
• Overdose — usually safe alone (drowsiness, slurred speech, ataxia), dangerous with alcohol or opioids; flumazenil rarely used (seizure risk in dependent users or mixed overdoses with tricyclics).

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 34-year-old teacher has worried constantly about work, money and her children for a year. She sleeps poorly and has tension headaches. GAD-7 is 16. Guided self-help hasn't helped.
Answer: Generalised anxiety disorder with marked impairment (step 3).

• Offer high-intensity CBT or applied relaxation, or sertraline (her choice).
• If sertraline: warn about early worsening and side effects; review at 2–4 weeks.
• Avoid benzodiazepines; check for depression and alcohol use.

2. A 26-year-old man has repeated episodes of sudden chest tightness, palpitations, tingling and fear of dying. ECG and TFTs are normal. He now avoids trains.
Answer: Panic disorder with agoraphobic avoidance.

• Explain the adrenaline response; offer CBT (first-line) or self-help.
• SSRI if preferred or not improving; avoid benzodiazepines.
• Clomipramine or imipramine if no response after 12 weeks.

3. A 40-year-old firefighter has nightmares, flashbacks and irritability 6 months after a fatal fire. He drinks more to sleep.
Answer: PTSD with alcohol misuse.

• Trauma-focused CBT or EMDR.
• Venlafaxine or an SSRI if he prefers medication; assess suicide risk.
• Address alcohol use (brief intervention, AUDIT); occupational health support.

4. A 29-year-old woman has sudden right leg weakness. She can't lift her right leg off the bed, but when she flexes her left hip against resistance, her right hip extends strongly. MRI is normal.
Answer: Functional neurological disorder (positive Hoover's sign).

• Explain the diagnosis positively — a real, common, potentially reversible problem.
• Specialist physiotherapy; psychological therapy if relevant.
• Avoid repeated investigations.

5. A 72-year-old woman has taken temazepam nightly for 10 years. She has had two falls and wants to stop.
Answer: Long-term benzodiazepine dependence with falls.

• Don't stop suddenly (withdrawal, seizures).
• Switch to an equivalent dose of diazepam and taper slowly over months.
• CBT-I and sleep hygiene; falls assessment; review other sedating drugs.

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Key Points

• Exclude physical causes of anxiety: thyroid, arrhythmia, drugs, alcohol and benzodiazepine withdrawal.
• GAD: stepped care — education, self-help, then CBT or sertraline; avoid benzodiazepines.
• Panic disorder: CBT or SSRI; imipramine or clomipramine after 12 weeks if no response; no benzodiazepines.
• Specific phobia: graded exposure. Social anxiety: CBT, then SSRI.
• OCD: ERP and SSRIs (higher dose, 12 weeks); clomipramine next.
• Body dysmorphic disorder has a high suicide risk; cosmetic surgery doesn't help.
• No single-session debriefing after trauma.
• PTSD (over 1 month): trauma-focused CBT or EMDR; venlafaxine or SSRI if preferred.
• Functional disorders are diagnosed on positive signs (Hoover's sign, entrainment); explain positively; physiotherapy.
• Somatic symptoms: acknowledge, avoid repeated tests, one clinician, focus on function.
• Factitious disorder = sick role; malingering = external gain.
• Insomnia: sleep hygiene and CBT-I first; hypnotics for up to 2 weeks only.
• REM sleep behaviour disorder predicts Parkinson's and Lewy body dementia.
• Benzodiazepines: dependence within weeks; respiratory depression with opioids; taper slowly via diazepam.

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Guidelines and Further Reading

• NICE CG113: Generalised anxiety disorder and panic disorder in adults
• NICE CG159: Social anxiety disorder
• NICE CG31: Obsessive-compulsive disorder and body dysmorphic disorder
• NICE NG116: Post-traumatic stress disorder
• NICE NG206: Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome
• NICE NG193: Chronic pain (primary and secondary) in over 16s
• NICE TA922: Daridorexant for treating long-term insomnia
• NICE CKS: Insomnia; Benzodiazepine and z-drug withdrawal
• neurosymptoms.org — functional neurological disorder information
• BNF — for current doses

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