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When Anxiety Isn’tJust Anxiety: Recognizing OCD, PTSD, and Panic Disorder in Primary Care By: Trae Stewart, PhD, MPH, MSN, MS, MN, PMHNP ‑ BC
Nuanced First ‑ Line Interventions
overlap between panic disorder and trauma histories. Thus, when a patient describes unpredictable surges of terror, clinicians should always probe for developmental trauma.
Therapeutic response hinges on matching the modality to the diagnosis: OCD : High ‑ dose selective serotonin reuptake inhibitors (SSRIs) are required—fluoxetine 60mg or sertraline up to 200mg—maintained for at least 12 weeks before judging efficacy. Simultaneously, refer for exposure and response prevention; medication alone rarely produces remission. PTSD : Trauma ‑ focused cognitive ‑ behavioral therapies (TF ‑ CBT, EMDR) remain first ‑ line. SSRIs (sertraline, paroxetine) offer modest symptom relief; adjunctive prazosin (1–15 mg) targets trauma ‑ related nightmares. Panic disorder : Begin sertraline 25 mg daily and titrate slowly to minimize early jitteriness. Interoceptive exposure exercises and cognitive restructuring can be as critical and effective as pharmacotherapy. Routine benzodiazepine monotherapy is typically discouraged due to dependence and interference with exposure learning. Urgent psychiatric referral is typically indicated for psychotic features, treatment non ‑ response, or active suicidality.
Panic Disorder: Fear of Fear Itself
Panic disorder is characterized by recurrent, unexpected panic attacks accompanied by persistent concern or behavioral change related to the attacks. The episodes peak within minutes and manifest with autonomic storms—palpitations, paresthesia, choking, derealization—and often drive patients to visit emergency departments convinced of catastrophic myocardial infarction. Key differentiators from PTSD include the absence of a specific cue and the presence of nocturnal attacks, which wake the patient from sleep and strongly favor a panic phenotype. Agoraphobia develops in roughly 59% of cases and, left untreated, can culminate in housebound isolation. Because panic disorder frequently co ‑ occurs with major depressive disorder, alcohol misuse, and other anxiety disorders, an integrated treatment plan addressing all conditions is essential. This three-pronged approach can be used to effectively evaluate patients for mental health conditions and co-morbidities. Targeted screening: Incorporate the PC ‑ PTSD ‑ 5 and the 18 ‑ item Obsessive ‑ Compulsive Inventory– Revised (OCI ‑ R; cutoff ≥21) into annual wellness visits or whenever “anxiety” is the chief complaint. A two ‑ item validated screener (PHQ ‑ PD) can flag probable panic disorder in less than one minute. Rule out medical mimics: Thyroid dysfunction, stimulant or cannabis use, arrhythmia, and vestibular disorders can masquerade as anxiety syndromes. A basic work ‑ up of TSH, ECG, and urine toxicology helps narrow the field. Assess lethality: The combination of PTSD and panic disorder can triple suicide risk. Direct, empathetic inquiry into current suicidal ideation is mandatory whenever severe anxiety, trauma, or compulsions are present. A Three ‑ Step Diagnostic Algorithm
Anxious distress is among the most common complaints in primary care, yet the label “anxiety” all too often serves as diagnostic shorthand for phenomena that are, neurobiologically and therapeutically, worlds apart. Misclassification is rampant: up to 71 % of generalized anxiety disorder and fully 86 % of panic disorder cases are first coded incorrectly and the mean delay from obsessive ‑ compulsive disorder (OCD) onset to detection exceeds 17 years. Such errors matter. Patients with unrecognized panic disorder may cycle through costly cardiology evaluations, survivors of trauma who receive generic “stress ‑ reduction” handouts can devolve into dissociative flashbacks, and covert compulsions in OCD flourish when exposure ‑ based therapy is withheld. High comorbidity muddies the water further—98 % of individuals with panic disorder meet criteria for at least one additional psychiatric diagnosis. This article synthesizes practical, high ‑ yield strategies for distinguishing OCD, post ‑ traumatic stress disorder (PTSD), and panic disorder during routine visits, thereby sharpening diagnostic accuracy and improving outcomes.
disturbing thoughts?” Particular vigilance is required in the perinatal period, when nearly 17 % of new parents experience infant ‑ focused intrusive thoughts that respond to maternal ‑ specific exposure and response prevention.
The Hidden Logic of Obsessions and Compulsions
OCD afflicts 1 %–3 % of adults yet remains widely misread as generalized worry. The hallmark is the presence of intrusive, ego ‑ dystonic thoughts— contamination fears, violent images, taboo blasphemies—followed by repetitive rituals enacted to quell the distress. Because patients often feel ashamed, presentations are indirect: recalcitrant hand dermatitis or irritation from excessive washing, interpersonal conflict driven by constant reassurance ‑ seeking, or unexplained lateness due to covert checking routines. Distinguishing features include: Content that is clearly unwanted and resisted, unlike the rational future ‑ oriented worries of generalized anxiety. Time cost—compulsions consume ≥1hour per day or cause marked functional impairment. Insight—most patients recognize the irrational nature, differentiating OCD from psychotic delusions. A single screening question can be revelatory: “Do you find yourself repeating actions until they feel ‘just right’ or avoiding situations because of
Trauma’s After ‑ Echo: PTSD and Its Complex Form
Asking the Right Questions
PTSD is anchored in a history of actual or threatened death, injury, or sexual violence, followed by four major symptom clusters: re ‑ experiencing, avoidance, negative alterations in cognition, mood, and hyperarousal. Presentation is often delayed—symptoms may surface months or even years after the precipitating event—and patients frequently minimize or omit the trauma in initial interviews. The five ‑ item Primary Care PTSD Screen (PC ‑ PTSD ‑ 5) affords brevity and sensitivity; three or more affirmative responses warrant further assessment. Complex PTSD (cPTSD) adds chronic affect dysregulation and relational disturbances, typically rooted in prolonged childhood maltreatment. Emerging data shows that cPTSD markedly predisposes individuals to panic attacks and agoraphobia, accounting in part for the high
One clarifying question— “Does your anxiety have a signature thought, memory, or bodily surge?”— can redirect a patient from diagnostic limbo toward targeted, life ‑ changing care. By unmasking OCD’s hidden rituals, listening for the echo of trauma in PTSD, and recognizing panic’s abrupt autonomic storms, primary care clinicians can transform a vague “anxiety” label into precise treatment pathways that alleviate suffering and restore function.
Want more mental health insights from Dr. Stewart? Check out the Grand Rounds for the PMHNP: Obsessive-Compulsive Related Disorders course, presented by Fitzgerald.
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