CCFP priority topic 6 of 105
Anxiety on the CCFP exam
9 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 9 key features for Anxiety. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 9
Hidden anxiety
When a patient brings many symptoms with no clear cause, consider anxiety as the cause or part of it.
CFPC skill Clinical reasoning, patient-centred approachPhase Hypothesis generation, diagnosis
On the exam
A woman returns a fourth time with headaches, a racing heart and poor sleep, and normal tests. Expect a short menu (pick several from a list).
Pick the questions that find the anxiety.
Common mistakes
Another round of tests for each new complaint. Or calling it stress without asking about worry, spells or avoidance. Both miss the diagnosis.
Approach
- Ask directly about worry, fear, sudden spells of panic and things the patient now avoids.
- Know how anxiety shows in the body: racing heart, short breath, chest tightness, tingling, upset stomach, headaches, poor sleep, tiredness.
- Watch for behaviours too: repeat visits, asking for reassurance, missing school or work, avoiding places.
- In children, stomach aches or headaches on school days, clinging, or refusing school can be anxiety.
- Anxiety can be the whole cause or one part. A physical illness and anxiety can sit side by side.
- Name it kindly. Say the symptoms are real, and explain how worry makes them.
Key feature 2 of 9
Worry or disorder
Tell normal worry, fear or nerves apart from a disorder that needs treatment.
CFPC skill Clinical reasoning, patient-centred approachPhase History, diagnosis
On the exam
A student is nervous and sleeping badly in the week before exams. Expect one best answer.
Pick whether this is stress or a disorder.
Common mistakes
Labelling normal nerves before an exam or after a loss as a disorder, then starting a drug. Waving off months of worry that stops someone working is wrong too.
Approach
- Ask how long it has lasted, how much of the day it fills, and whether it matches the trigger.
- Normal worry fits the size of the trigger and fades when the trigger passes.
- A disorder is out of proportion, lasts weeks to months, is hard to control, and harms work, school, home or friends.
- Distress tied to a recent hard event, that eases as life settles, is a reaction to stress.
- For normal distress, listening, simple coping steps and a follow-up visit are usually enough.
Key feature 3 of 9
Panic or emergency
Before calling sudden panic symptoms anxiety, rule out dangerous causes like a lung clot or heart attack.
CFPC skill Selectivity, clinical reasoningPhase Hypothesis generation, diagnosisSources Choosing Wisely Canada
On the exam
A woman with known panic attacks is breathless, with a pounding heart. Expect a short menu (pick several from a list).
Pick the checks to do before you reassure her.
Common mistakes
Reassuring her because she has panic disorder, before vital signs and an exam. The opposite error: a heart ultrasound or urine tests for a rare adrenal tumour, for brief spells with normal vital signs, exam and ECG.
Approach
- Check pulse, blood pressure, breathing rate and oxygen level. Examine the heart and lungs.
- Ask what is new: chest pain, pain on breathing, fainting, a swollen leg, symptoms on exertion, a spell unlike the usual ones.
- Get an ECG (a tracing of the heart) for chest pain or a racing heart.
- Suspect a lung clot? Score the risk first, with the Wells score or the PERC rule (a short checklist). Add a D-dimer blood test if needed, and image only after that.
- Spells that pass in minutes, recur over weeks, and leave normal vital signs and a normal exam point to panic.
- A known panic disorder does not lower the risk of a clot or a heart attack.
Key feature 4 of 9
Before you diagnose
Before you name a disorder, check for medical causes, other mental illness, abuse, drinking and drug use, suicide risk and harm to daily life.
CFPC skill Selectivity, clinical reasoning, patient-centred approachPhase Hypothesis generation, diagnosis, history
On the exam
A widower of 76 has worried for months and takes a friend's lorazepam at night. Expect a short menu (pick several from a list).
Pick what to ask before you diagnose.
Common mistakes
Questions that feel thorough but change nothing today: family history, a hearing screen, prostate screening, his diet. They skip his suicide risk, mood, drinking and what the worry costs him.
Approach
- Ask about suicide in every patient with anxiety: thoughts, plans, means and past attempts.
- Screen for depression, which often comes with anxiety. Ask about trauma, obsessions, mood swings and eating problems too.
- Ask about alcohol, cannabis, caffeine, stimulants and any sedative, including one borrowed from someone else.
- Ask about abuse and safety at home, in private. In children and frail older adults, ask who cares for them.
- Look for medical causes in the history and exam: thyroid, heart rhythm, lung disease, stimulating drugs, and withdrawal.
- Ask what the worry stops the patient doing: work, school, sleep, driving, seeing friends.
| Area | Ask or look for | Why it matters |
|---|---|---|
| Suicide | Thoughts, plans, means, past attempts | Sets how fast you act today |
| Other mental illness | Low mood, trauma, obsessions, mania | Changes the diagnosis and the treatment |
| Substances | Alcohol, cannabis, caffeine, sedatives, stimulants | Can cause, mimic or worsen anxiety |
| Abuse | Violence or neglect at home, past trauma | Safety comes before treatment |
| Daily life | Work, school, sleep, family, driving | Shows whether it is a disorder |
Key feature 5 of 9
Name the type
Match the picture to a named disorder, because each type is treated differently.
CFPC skill Clinical reasoningPhase Diagnosis
On the exam
A woman of 36 has sudden spells of pounding heart, even from sleep. She avoids the highway but still rides the bus. Expect one best answer.
Pick the diagnosis.
Common mistakes
Agoraphobia or a driving phobia because she avoids one road. She still rides the bus. She fears the spell itself: that is panic disorder.
Approach
- Name the type from the pattern: what is feared, when it comes, how long it lasts, and what the patient avoids.
- Panic disorder: spells out of the blue, then fear of the next one, or changes made to avoid them.
- Generalized anxiety: worry about many everyday things, most days, for months, that is hard to switch off.
- Fear of the spell itself points to panic disorder. Avoiding several kinds of place for fear of a spell with no way out adds agoraphobia. Fear of being judged by others is social anxiety.
- Rule out look-alikes: depression, a trauma-related disorder, obsessive-compulsive disorder, illness anxiety and grief.
| Disorder | Core fear | Clue |
|---|---|---|
| Panic disorder | The next spell | Spells out of the blue, even from sleep |
| Agoraphobia | Being trapped with no help | Avoids several kinds of place: crowds, transit, being out alone |
| Generalized anxiety | Many everyday things | Worry most days, for months, hard to control |
| Social anxiety | Being judged | Avoids speaking, eating or performing in front of others |
| Illness anxiety (a look-alike) | Having a serious disease | Few or mild symptoms, much checking |
Key feature 6 of 9
New symptom, old label
In a patient already known to have anxiety, judge each new symptom on its own merits.
CFPC skill Selectivity, clinical reasoningPhase Hypothesis generation
On the exam
A woman with known panic disorder has more spells since her thyroid dose was raised. Expect a short menu (pick several from a list).
Pick what to check before blaming the anxiety.
Common mistakes
Raising her anxiety drug or adding a sedative because the diagnosis is already known. A new thyroid dose, a new drug or a new illness can cause the change.
Approach
- Treat a new or changed symptom as new. Take the history and do the exam again.
- Ask what changed: a new drug or dose, caffeine, alcohol or drug use, stopping a sedative, a new illness.
- Too much thyroid pill, salbutamol, decongestants, stimulants and steroids can all bring on anxiety.
- Look for signs anxiety does not explain: weight loss, fever, fainting, chest pain on exertion, new nerve signs.
- Watch your own bias. A label in the chart makes it easy to stop looking.
Key feature 7 of 9
Build the plan
Offer a plan the patient helps choose: self-help, follow-up, community supports, therapy, medicine, and care shared with other professionals.
CFPC skill Patient-centred approachPhase Treatment, referralSources Health Canada, Choosing Wisely Canada
On the exam
Generalized anxiety is confirmed in a man of 76 taking a friend's lorazepam. Expect one best answer.
Pick the best plan.
Common mistakes
Prescribing lorazepam to make his supply legal. In older adults, sedatives raise falls, fractures, crashes and confusion. Therapy alone, with no plan to stop the borrowed drug, also falls short.
Approach
- Build the plan with the patient. Ask what they want and can reach: cost, wait times, language.
- Give self-help to everyone: explain how anxiety works, cut caffeine, move daily, practise slow breathing.
- Offer cognitive behavioural therapy (CBT), a structured talking therapy that targets fearful thoughts and avoidance.
- Book regular follow-up. On an antidepressant, watch closely for worse symptoms, agitation and suicidal thoughts.
- Sertraline for panic disorder: start 25 mg once daily. After one week, raise to 50 mg if tolerated. Change the dose no faster than weekly.
- Health Canada has not approved sertraline for anyone under 18. In children, start with therapy that involves the family.
- Refer for shared care when the diagnosis is unclear, suicide risk is high, or first treatments fail. Stay involved.
| Option | Fits when | Know this |
|---|---|---|
| Self-help and follow-up | Every patient, alone or with other treatment | Explain anxiety, cut caffeine, exercise, breathing skills; book the next visit |
| CBT | Any anxiety disorder | Works on avoidance; its skills stay after sessions end |
| SSRI (selective serotonin reuptake inhibitor) antidepressant, such as sertraline | A disorder that harms daily life | Panic disorder: 25 mg daily for a week, then 50 mg. Full effect can take 4 weeks or more. |
| Benzodiazepine (a sedative, such as lorazepam) | Short-term relief; in older adults, only severe generalized anxiety other treatments have not helped | Memory problems, dependence, falls, fractures, crashes. Plan the taper when you start. |
| Community and shared care | Needs beyond the office | Peer groups, school or work supports, a therapist or psychiatrist; you stay involved |
Key feature 8 of 9
Not drugs alone
Never treat anxiety with a drug and nothing else.
CFPC skill Patient-centred approach, clinical reasoningPhase TreatmentSources Health Canada, Choosing Wisely Canada
On the exam
A woman with panic disorder starts sertraline and agrees to cut back her nightly wine. Expect one best answer.
Pick what her plan still needs.
Common mistakes
The plan covers the drug and the wine, so it feels complete. But medicine is still her only treatment. Without therapy, spells tend to return when the drug stops.
Approach
- Pair every drug with therapy, self-help and follow-up.
- Set goals together: places to face again, skills to practise, a date to review.
- Rescue doses of a sedative teach escape from the fear. That feeds the avoidance therapy works on.
- Benzodiazepines bring memory problems and dependence. Review any you inherit, and plan and discuss the taper early.
- Keep sertraline at the lowest dose that works, and review the need for it regularly.
- To stop sertraline, lower the dose over several weeks rather than stopping at once.
Key feature 9 of 9
Alcohol and drugs
Ask about drinking and drug use, and explain that using them to calm nerves makes anxiety worse.
CFPC skill Patient-centred approach, communicationPhase TreatmentSources Health Canada, Choosing Wisely Canada
On the exam
A woman with panic disorder says nightly wine is the only thing that settles her. Expect one best answer.
Pick when and how to raise it.
Common mistakes
Leaving the wine for a later visit so she is not overloaded. Or adding a benzodiazepine on top of it, which stacks sedation and dependence.
Approach
- Ask every anxious patient about alcohol, cannabis, sedatives and other drugs: how much, how often, and when.
- Explain the loop: a drink calms for a short time, then wears off, and the anxiety comes back harder.
- Tell a patient on sertraline that alcohol with it is not recommended.
- Agree on a goal, cutting down or stopping, and offer help to reach it.
- Ask teens alone, in private, about alcohol, cannabis and vaping.
- With an alcohol use disorder, low mood is often from the drinking. Reassess after 2 to 4 weeks sober before an antidepressant.
Flashcards
Answer it first, then check.
KF 3A patient with known panic disorder is newly breathless. Is a lung CT the first test?
No. Score the clot risk first with Wells or PERC, then a D-dimer if needed. Source: Choosing Wisely Canada
KF 4Name four things to check before you diagnose an anxiety disorder.
Any four of: medical causes, suicide risk, other mental illness, drinking or drugs, abuse, harm to daily life.
KF 5Spells from sleep, fear of the next spell, and one road avoided. Which disorder?
Panic disorder. The fear is of the spell itself, not the road or being judged.
KF 7You start sertraline for panic disorder. What dose, and when do you raise it?
25 mg once daily. Raise to 50 mg after one week if tolerated. Source: Health Canada
KF 7Two weeks on sertraline 50 mg and little change. Do you raise it fast?
No. Full benefit can take 4 weeks or more. Fast increases add side effects, not speed. Source: Health Canada
KF 7An older adult with worry asks for lorazepam. When does a benzodiazepine fit?
Only for severe generalized anxiety that other treatments have not helped. Falls, fractures and crashes rise. Source: Choosing Wisely Canada
KF 8Sertraline has worked for a year, and the patient wants to stop. How?
Lower the dose slowly over several weeks. Stopping at once can bring withdrawal symptoms. Source: Health Canada
KF 9A patient on sertraline for panic disorder asks about wine. What do you say?
Alcohol with sertraline is not recommended. Drinking to calm down also makes the anxiety worse. Source: Health Canada
FAQ
Which anxiety guideline does the exam follow?
The CFPC key features name no guideline. Marks go to the approach: rule out danger, check safety, name the type, then pair therapy with any drug.
Do I need the diagnostic criteria by heart?
Know the core fear and the main clue for each disorder, well enough to tell them apart. The exam asks you to pick the type, because treatment changes with it.
Are benzodiazepines ever the right answer?
Rarely, and briefly. They bring memory problems and dependence, and in older adults falls, fractures and crashes. If you start one, plan and discuss the taper at the start.
How does this change in children?
Anxiety often shows as stomach aches, clinging or refusing school. Start with therapy that involves the parents. Health Canada has not approved sertraline for anyone under 18.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada
- Drug Product DatabaseHealth Canada