11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders

ABIM Internal Medicine Exam

Track your progress as you read

Finished sections get a check mark.

1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders

Key Takeaways Explain This Topic AI

Obsessive-compulsive disorder, phobias, post-traumatic stress disorder, generalized anxiety disorder and panic disorder are the enumerated anxiety topics.

Selective serotonin reuptake inhibitors combined with cognitive behavioral therapy are first-line for essentially all anxiety disorders.

Benzodiazepines are avoided for long-term management because of tolerance, dependence, cognitive impairment and fall risk.

Obsessive-compulsive disorder often requires higher antidepressant doses and longer trials than depression.

Medical mimics of anxiety include hyperthyroidism, pheochromocytoma, arrhythmia, hypoglycemia, and stimulant or withdrawal states.

Last updated: August 2026

2. Valproic Acid / Divalproex Sodium

Mechanism: Increases brain GABA concentrations, blocks voltage-gated sodium channels and T-type calcium channels.

Therapeutic Serum Level: 50 to 125 mcg/mL (draw 12-hour trough level).

Key Clinical Utility: Highly effective for acute manic episodes, mixed episodes, and rapid-cycling bipolar disorder.

Adverse Effects & Black Box Warnings:

Hepatotoxicity / Fatal Hepatic Failure: Most common in first 6 months; monitor baseline and periodic Liver Function Tests (LFTs).

Acute Pancreatitis: Can occur at any point in therapy; severe abdominal pain, elevated amylase/lipase; mandates immediate permanent discontinuation.

Thrombocytopenia & Coagulopathy: Dose-dependent bone marrow suppression (especially at levels >100 mcg/mL); monitor baseline and periodic CBC with platelet count.

Hyperammonemic Encephalopathy: Can present with lethargy, vomiting, and cognitive worsening with normal or near-normal LFTs; check serum ammonia; treated with L-Carnitine and Lactulose .

Severe Teratogenicity: High incidence of Neural Tube Defects (Spina Bifida, Anencephaly: 1-2% risk) , craniofacial anomalies, cardiovascular defects, and lower childhood IQ scores. Strongly avoid in women of childbearing potential unless absolutely refractory to other agents.

Weight gain, alopecia, fine tremor, polycystic ovarian syndrome (PCOS).

3. Atypical Antipsychotics in Bipolar Disorder

Bipolar Depression (FDA-Approved First-Line Options):

Quetiapine (Seroquel): 300 mg at bedtime (dual 5-HT2A and D2 antagonism + active metabolite norquetiapine inhibits NE transporter; adverse effects: sedation, weight gain, metabolic syndrome, orthostasis).

Lurasidone (Latuda): 20 to 120 mg/day (high 5-HT7 and D2 affinity; low metabolic risk; MUST be administered with a meal containing at least 350 calories to ensure absorption; minimal weight gain; EPS/akathisia risk).

Cariprazine (Vraylar): 1.5 to 3 mg/day (D3/D2 partial agonist; effective for mania and depression; low metabolic risk; akathisia).

Olanzapine-Fluoxetine Combination (Symbyax): Effective for treatment-resistant bipolar depression; high metabolic risk (weight gain, dyslipidemia, diabetes).

Lumateperone (Caplyta): 42 mg daily.

Acute Manic Episodes: Aripiprazole, Risperidone, Olanzapine, Quetiapine, Ziprasidone, or Haloperidol (rapid onset of antimanic action, often combined with Lithium or Valproate for severe mania).

Lamotrigine (Lamictal): Approved for bipolar maintenance therapy and prevention of depressive relapses (ineffective for acute mania). Black Box Warning for Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) . Mandates strict slow dose titration (25 mg daily for 2 weeks, 50 mg daily for 2 weeks, 100 mg daily for 1 week, target 200 mg daily). Critical Drug-Drug Interaction: Valproate strongly inhibits lamotrigine glucuronidation and doubles lamotrigine blood levels (starting dose must be halved to 12.5-25 mg every other day); Carbamazepine and phenytoin induce glucuronidation and halve lamotrigine blood levels.

1. Anxiety, Stress-Related & Obsessive-Compulsive Disorders

Anxiety disorders represent a spectrum of conditions characterized by excessive, irrational fear, autonomic hyperarousal, and maladaptive avoidance behaviors.

Clinical Comparison of Anxiety & Stress Disorders

Disorder Core Diagnostic Criteria & Duration First-Line Pharmacotherapy First-Line Psychotherapy Second-Line / Adjunctive Options & Contraindications

Generalized Anxiety Disorder (GAD) Excessive, uncontrollable anxiety and worry about multiple daily domains for >= 6 months , accompanied by >=3 of 6 somatic symptoms (restlessness/on edge, easy fatigability, difficulty concentrating, irritability, muscle tension, sleep disturbance); GAD-7 score >=10 SSRIs (Escitalopram, Sertraline, Paroxetine) or SNRIs (Duloxetine, Venlafaxine XR) Cognitive Behavioral Therapy (CBT) (cognitive restructuring, progressive muscle relaxation, worry exposure) Buspirone (5-HT 1A partial agonist; 15-60 mg/day divided BID/TID; no sedation, zero abuse liability, 2-4 week onset; ineffective PRN); Hydroxyzine (antihistaminergic); Pregabalin; Avoid long-term benzodiazepines

Panic Disorder Recurrent, unexpected panic attacks (abrupt surge of intense fear peaking within minutes with >=4 somatic/cognitive symptoms: palpitations, sweating, trembling, SOB, choking sensation, chest pain, nausea, dizziness, chills/heat, paresthesias, derealization, fear of dying) followed by >=1 month of persistent worry about further attacks or maladaptive behavioral changes (avoidance) SSRIs (Sertraline, Paroxetine, Fluoxetine) or SNRIs (Venlafaxine XR); start at half standard dose to avoid initial jitteriness CBT with Interoceptive Exposure (deliberately inducing somatic panic sensations to extinguish catastrophic misinterpretations) Short-term Benzodiazepine bridging (Clonazepam 0.5-1 mg/day or Lorazepam 0.5-1 mg BID) reserved strictly for severe acute disabling distress during initial 2-4 weeks of SSRI titration, then tapered off; avoid chronic use

Social Anxiety Disorder (SAD) Marked, persistent fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others (conversations, eating in public, public speaking) lasting >= 6 months Generalized Subtype: SSRIs (Sertraline, Paroxetine) or SNRIs (Venlafaxine XR); Performance-Only Subtype: Oral Propranolol 10 to 40 mg (or Atenolol 25-50 mg) taken 30 to 60 minutes prior to the performance event CBT with In Vivo Social Exposure and video feedback Propranolol blunts peripheral beta-adrenergic hyperactivity (palpitations, vocal/hand tremors, diaphoresis); Contraindications to Propranolol: Active reactive airway disease / asthma, severe bradycardia, second/third-degree AV block, decompensated HF

Obsessive-Compulsive Disorder (OCD) Presence of Obsessions (recurrent, persistent intrusive thoughts, urges, or images causing marked anxiety) and/or Compulsions (repetitive behaviors [hand washing, checking, ordering] or mental acts [counting, repeating words silently] performed to neutralize anxiety according to rigid rules); time-consuming ( >1 hour/day ) or causing severe impairment High-Dose SSRIs: Sertraline (up to 200 mg/day), Fluoxetine (up to 80 mg/day), Fluvoxamine (up to 300 mg/day), Paroxetine (up to 60 mg/day). (Note: Higher doses and longer durations [10-12 weeks] are required compared to MDD) Exposure and Response Prevention (ERP) (gold-standard specialized behavioral therapy: systematic exposure to obsession-provoking cues while strictly refraining from performing compulsions) Second-line: Clomipramine (potent serotonergic TCA; monitor anticholinergic effects, QTc, and seizure threshold); Augmentation with atypical antipsychotics (Aripiprazole, Risperidone)

Post-Traumatic Stress Disorder (PTSD) Exposure to actual or threatened death, serious injury, or sexual violence. Symptoms persist for > 1 month across 4 clusters:; 1. Intrusion (flashbacks, nightmares, intrusive memories); 2. Avoidance (trauma reminders, thoughts); 3. Negative alterations in mood/cognition (amnesia, emotional detachment, excessive guilt); 4. Hyperarousal (hypervigilance, exaggerated startle, insomnia, irritability) SSRIs (Sertraline, Paroxetine) or SNRI (Venlafaxine XR) Trauma-Focused Psychotherapy: Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR) Prazosin (centrally acting alpha-1 adrenergic antagonist, 1 to 15 mg at bedtime; crosses BBB and inhibits central noradrenergic hyperactivation; proven to reduce trauma-related nightmares and sleep disturbance ; monitor for orthostasis); BENZODIAZEPINES ARE STRICTLY CONTRAINDICATED (worsen PTSD symptoms, prevent trauma processing, high abuse liability)

Sections you finish are checked off in the contents.

• Up Next
• 11.5 Alcohol Use Disorder & Withdrawal
• Continue learning