{"id":37196,"date":"2026-07-04T07:13:36","date_gmt":"2026-07-04T01:43:36","guid":{"rendered":"https:\/\/atsixty.com\/?p=37196"},"modified":"2026-07-04T07:38:08","modified_gmt":"2026-07-04T02:08:08","slug":"anxiety-ocd-trauma","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/morning-rounds\/anxiety-ocd-trauma\/","title":{"rendered":"Anxiety, OCD & Trauma"},"content":{"rendered":"\n\n\n\n\nMorning Rounds · Psychiatry · Anxiety, OCD & Trauma<\/title>\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&display=swap\" rel=\"stylesheet\">\n<style>\n#psy02 *,#psy02 *::before,#psy02 *::after{box-sizing:border-box;margin:0;padding:0}\n#psy02{\n --py:#34547A;\n --py-light:#4A6B95;\n --py-pale:#E8EEF5;\n --py-dark:#243C56;\n --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n --wrong:#B83232;--wrong-bg:#FDF0F0;--wrong-border:#E53935;\n 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.mr-retry:hover{background:var(--py);color:#EEF3FA}\n@media(max-width:480px){#psy02 .mr-title{font-size:1.4rem}#psy02 .mr-num{font-size:1.7rem}#psy02 .mr-stem{font-size:0.9rem}#psy02 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<div id=\"psy02\">\n\n <div class=\"mr-header\">\n <div class=\"mr-eyebrow\">Morning Rounds · Psychiatry Series · Round 02<\/div>\n <div class=\"mr-title\">\n Anxiety, OCD & Trauma —<br><em>Worry, Rituals & the Aftermath of Fear<\/em>\n <\/div>\n <div class=\"mr-subtitle\">Five cases · GAD, panic, OCD, PTSD & phobic disorders, with pharmacotherapy throughout · Trust your instinct<\/div>\n <div class=\"mr-chips\">\n <span class=\"mr-chip\">5 Cases<\/span>\n <span class=\"mr-chip\">+4 \/ −1 scoring<\/span>\n <span class=\"mr-chip\">Options reshuffled<\/span>\n <\/div>\n <\/div>\n\n <div class=\"mr-sentinel\" id=\"psy02-sentinel\"><\/div>\n\n <div class=\"mr-progress\" id=\"psy02-progress\">\n <div class=\"mr-prog-inner\">\n <div class=\"mr-pips\" id=\"psy02-pips\"><\/div>\n <\/div>\n <\/div>\n\n <div class=\"mr-body\">\n <div id=\"psy02-cases\"><\/div>\n <div class=\"mr-submit-wrap\">\n <button class=\"mr-btn\" id=\"psy02-submit\">Submit for Debrief<\/button>\n <\/div>\n <div class=\"mr-score\" id=\"psy02-score\">\n <div class=\"mr-score-in\">\n <div class=\"mr-score-ey\">Round Complete<\/div>\n <div class=\"mr-ring\" id=\"psy02-ring\">\n <div class=\"mr-ring-in\">\n <span class=\"mr-ring-pct\" id=\"psy02-pct\">0%<\/span>\n <span class=\"mr-ring-sub\">net<\/span>\n <\/div>\n <\/div>\n <div class=\"mr-score-title\">Your Debrief<\/div>\n <div class=\"mr-score-net\" id=\"psy02-net\"><\/div>\n <div class=\"mr-verdict\" id=\"psy02-verdict\"><\/div>\n <div class=\"mr-bands\">\n <span class=\"mr-band mr-band-c\" id=\"psy02-ct-c\"><\/span>\n <span class=\"mr-band mr-band-w\" id=\"psy02-ct-w\"><\/span>\n <span class=\"mr-band mr-band-s\" id=\"psy02-ct-s\"><\/span>\n <\/div>\n <button class=\"mr-retry\" id=\"psy02-retry\">↻ New Round<\/button>\n <\/div>\n <\/div>\n <\/div>\n\n<\/div><!-- end #psy02 -->\n\n<script>\n(function () {\n 'use strict';\n\n var NS = 'psy02';\n var TOTAL = 5;\n var MAX = 20;\n var LTRS = ['A','B','C','D'];\n\n var QS = [{\"id\": 1, \"tag\": \"Generalised Anxiety Disorder & Pharmacotherapy\", \"stem\": \"A 38-year-old reports excessive worry about work, finances, and her children's health, present most days for the past 8 months, with muscle tension, restlessness, and poor sleep, hard to control even with reassurance. What diagnosis fits, and what first-line medication options exist?\", \"correct\": \"Generalised anxiety disorder — worry across multiple domains for six-plus months; an SSRI or SNRI like escitalopram is first-line therapy.\", \"opts\": [\"Generalised anxiety disorder — worry across multiple domains for six-plus months; an SSRI or SNRI like escitalopram is first-line therapy.\", \"Generalised anxiety disorder — but scheduled long-term alprazolam is preferred first-line, since benzodiazepines carry no dependence risk here.\", \"Adjustment disorder with anxiety, since the worry links to ongoing stressors, and pharmacotherapy isn't indicated for this diagnosis at all.\", \"Panic disorder, since restlessness and poor sleep reflect autonomic arousal, with a fixed daily beta-blocker as the appropriate first-line drug.\"], \"exp\": \"GAD requires excessive, hard-to-control worry across multiple domains for ≥6 months plus associated symptoms (restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance). First-line pharmacotherapy is an SSRI (escitalopram, paroxetine, sertraline) or SNRI (venlafaxine, duloxetine), typically needing 2–4 weeks for effect; buspirone offers a non-sedating, non-dependence-forming alternative; short-term benzodiazepines can bridge the early weeks but aren't a maintenance strategy.<br><br>Long-term scheduled benzodiazepine use carries real dependence and tolerance risk and is not first-line maintenance therapy for GAD — that claim inverts standard practice. Adjustment disorder requires a closer temporal\/causal link to a single identifiable stressor and a generally self-limited course; this chronic, multi-domain 8-month pattern fits GAD better, and pharmacotherapy is certainly used when indicated. And propranolol's role is in situational performance anxiety, not as fixed daily therapy for generalised, multi-domain worry — that's not the established first-line approach for GAD.\", \"imgId\": null}, {\"id\": 2, \"tag\": \"Panic Disorder, Agoraphobia & SSRI\/Benzodiazepine Bridging\", \"stem\": \"A patient has had three sudden episodes over the past month of palpitations, chest tightness, sweating, and fear of dying, each resolving within 10 minutes. She now avoids the mall and public transport, fearing she can't escape if another episode occurs. What diagnosis fits, and how should pharmacotherapy be sequenced given SSRIs' delayed onset?\", \"correct\": \"Panic disorder with agoraphobia — an SSRI is first-line, with a short-term benzodiazepine bridge given the SSRI's two-to-four week delay.\", \"opts\": [\"Panic disorder with agoraphobia — an SSRI is first-line, with a short-term benzodiazepine bridge given the SSRI's two-to-four week delay.\", \"Panic disorder with agoraphobia — but standalone long-term clonazepam is preferred, since an SSRI adds nothing once attacks are controlled.\", \"Specific phobia, situational type — pharmacotherapy should target the avoided locations directly with situational beta-blocker dosing.\", \"Social anxiety disorder — since the settings involve other people, propranolol before any public exposure is the appropriate medication.\"], \"exp\": \"Panic disorder requires recurrent unexpected panic attacks plus ≥1 month of persistent concern about further attacks or related behavioural change; agoraphobia (avoidance of situations where escape might be difficult if symptoms occur) is a separate, frequently co-occurring DSM-5 diagnosis. SSRIs (paroxetine, sertraline) are first-line, but since they take 2–4 weeks to act, a short-term benzodiazepine bridge (clonazepam, often tapered over weeks) is a recognised, practical strategy while waiting for the SSRI to take hold, alongside CBT.<br><br>Long-term benzodiazepine monotherapy carries dependence risk and doesn't address the underlying disorder the way an SSRI does — it's a bridge, not a substitute for definitive pharmacotherapy. The avoidance here developed secondary to panic attacks (fear of being unable to escape one), not as a primary phobia of those locations themselves, so situational beta-blockers targeting a specific phobia framework miss the mechanism. And the fear driving avoidance is of panic recurrence, not social judgment, so propranolol-for-exposure (a social-anxiety\/performance-anxiety strategy) doesn't fit this presentation.\", \"imgId\": null}, {\"id\": 3, \"tag\": \"OCD: SSRI Dosing & Second-Line Clomipramine\", \"stem\": \"A patient washes his hands over 50 times daily due to intrusive contamination fears he recognises as excessive but cannot resist acting on. He has had a partial response to fluoxetine 40mg for 8 weeks. What does this imply about OCD pharmacotherapy dosing, and what is a recognised second-line medication option?\", \"correct\": \"OCD needing a higher SSRI dose and a longer trial before judging response, with clomipramine a recognised second-line option if it fails.\", \"opts\": [\"OCD needing a higher SSRI dose and a longer trial before judging response, with clomipramine a recognised second-line option if it fails.\", \"OCD already adequately dosed at fluoxetine 40mg for eight weeks, meaning a partial response should prompt an immediate switch in drug class.\", \"OCD, but clomipramine is a benzodiazepine and is contraindicated here, leaving further SSRI dose escalation as the only legitimate option.\", \"Not true OCD at all, since a full response to standard depression-equivalent SSRI dosing within this timeframe would be expected otherwise.\"], \"exp\": \"OCD characteristically needs higher SSRI doses than depression (fluoxetine up to 60–80mg, sertraline up to 200mg, for example) and longer adequate trials (8–12 weeks at the higher dose) before concluding a drug has failed. Clomipramine, a TCA with strong serotonin reuptake inhibition, is an established second-line agent for SSRI-refractory OCD, used alongside continued exposure and response prevention.<br><br>Treating fluoxetine 40mg\/8 weeks as already maximised ignores OCD's well-established higher-dose requirement — switching class prematurely risks abandoning a drug that simply hasn't been pushed to an adequate dose yet. Clomipramine is a tricyclic antidepressant, not a benzodiazepine, and has a genuine, guideline-recognised role in OCD, not a contraindication. And a partial response to an inadequately-dosed SSRI says nothing about diagnostic accuracy — it reflects standard OCD pharmacotherapy needing dose escalation, not a signal to reconsider the diagnosis.\", \"imgId\": null}, {\"id\": 4, \"tag\": \"PTSD: SSRIs, Prazosin & Nightmares\", \"stem\": \"A 25-year-old, 6 weeks after a serious road traffic accident, has intrusive memories, nightmares specifically about the crash, avoidance of driving, hypervigilance, and emotional numbness. Pharmacotherapy is being considered. What are the first-line medication options, and is there a specific agent for the nightmares?\", \"correct\": \"PTSD, now past the one-month threshold — sertraline or paroxetine is first-line, with prazosin specifically helpful for the nightmares.\", \"opts\": [\"PTSD, now past the one-month threshold — sertraline or paroxetine is first-line, with prazosin specifically helpful for the nightmares.\", \"Still acute stress disorder regardless of duration, with benzodiazepines as first-line therapy for both hyperarousal and the nightmares.\", \"PTSD, but no SSRI has first-line evidence here, and the nightmares specifically should be targeted with a typical antipsychotic instead.\", \"PTSD, correctly identified, though prazosin helps the nightmares purely through sedation, the same mechanism by which benzodiazepines work.\"], \"exp\": \"At 6 weeks, the diagnosis converts from acute stress disorder to PTSD (the 1-month threshold has passed). Sertraline and paroxetine are the SSRIs with the most robust trial evidence in PTSD and are considered first-line. For nightmares specifically — a distinct, treatable symptom domain — prazosin, an alpha-1 adrenergic blocker more commonly known as an antihypertensive, has specific trial evidence for reducing trauma-related nightmare frequency and intensity, a mechanism separate from its blood-pressure-lowering use.<br><br>Calling this still acute stress disorder ignores the duration criterion that converts the diagnosis to PTSD past 1 month, and benzodiazepines are specifically not recommended as first-line PTSD pharmacotherapy (limited efficacy for core symptoms and dependence\/disinhibition concerns). PTSD does have an established SSRI evidence base (this option denies that outright), and antipsychotics are not first-line nightmare treatment. And prazosin's nightmare-reducing effect is attributed to alpha-1 blockade affecting noradrenergic activity during REM sleep, not generalised sedation — it isn't mechanistically equivalent to a benzodiazepine's action.\", \"imgId\": null}, {\"id\": 5, \"tag\": \"Specific Phobia vs. Social Anxiety: Propranolol's Niche\", \"stem\": \"One patient avoids public speaking and eating in front of others due to fear of being judged, with anticipatory dread for days beforehand. Another patient has an isolated, intense fear of snakes with no broader social-evaluative concern. How do these differ, and where specifically does propranolol fit pharmacologically?\", \"correct\": \"Social anxiety disorder for the first, specific phobia for the second — propranolol's niche is performance-only anxiety, not daily use.\", \"opts\": [\"Social anxiety disorder for the first, specific phobia for the second — propranolol's niche is performance-only anxiety, not daily use.\", \"Both are the same disorder, specific phobia, with propranolol as recommended first-line daily maintenance therapy for both presentations.\", \"Specific phobia for the first, social anxiety disorder for the second — propranolol as daily maintenance for generalised social anxiety.\", \"Social anxiety disorder for the first, specific phobia for the second — propranolol working centrally through serotonin, like an SSRI.\"], \"exp\": \"Social anxiety disorder centres on fear of negative evaluation across social\/performance situations; specific phobia is a discrete, object- or situation-focused fear without that social-evaluative core. CBT with exposure is first-line for both; SSRIs are an option specifically for generalised social anxiety disorder. Propranolol's well-defined niche is performance-only social anxiety — taken as a single dose before a discrete, predictable event (a viva, a public talk) to blunt peripheral autonomic symptoms like tremor and palpitations — it is not used as daily maintenance therapy and isn't a mechanism-matched substitute for SSRIs in generalised cases.<br><br>These are two distinct disorders, not the same one, and propranolol isn't recommended maintenance therapy for either presentation type. The labels are also reversed in the third option, and propranolol is not indicated as daily maintenance for generalised social anxiety disorder — that's precisely the opposite of its actual niche. 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