CCFP priority topic 93 of 105
Stress on the CCFP exam
5 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 5 key features for Stress. 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 5
Spot the stress
Think of stress behind a headache, tiredness or pain, and raise it with the patient.
CFPC skill Clinical reasoning, communicationPhase Hypothesis generation, historySources Choosing Wisely Canada
On the exam
A 10-year-old girl has had morning headaches on school days for 4 months. She is well on weekends. Expect a short menu (pick several from a list) of questions.
Pick the history that explains the pattern.
Common mistakes
Chasing sinus, diet, dehydration or a tumour. None explains headaches that skip weekends and holidays. Questions about school, friends and home do.
Approach
- Map the pattern first. Symptoms that follow the work or school week point to a stressor there.
- Talk with a child alone as well as with the parent. Ask about school, friends, online life and home.
- In adults, ask the same way about work, money, caregiving and relationships.
- For migraine-type headache, check for red flags: sudden severe onset, fever with a stiff neck, swollen optic discs, unexplained focal signs, unusual triggers, or onset after 50.
- A migraine-type headache with a normal exam and no red flags needs no brain or sinus scan. The yield is very low, and chance findings add worry.
- Reassure with a clear explanation, not a test. Let a finding, not worry, choose each test.
Key feature 2 of 5
Coping or not
Once stress is found, judge how much it is disrupting daily life.
CFPC skill Patient-centred approachPhase History, diagnosis
On the exam
A man caring for a parent with dementia says everything feels like too much. Expect one best answer: the next question to ask.
Pick the question that measures coping.
Common mistakes
Treating the word stress as the answer and moving straight to tips. Or calling him unwell when he still sleeps, works and enjoys things.
Approach
- Ask what the stress has changed: sleep, work or school, family life, and the things the patient enjoys.
- Coping means daily life still works, even when it feels hard. Stress on its own is a normal response.
- Not coping means daily life is breaking down: missed work or school, pulling away from people, constant worry. That is distress.
- Ask how long it has lasted and whether it is getting worse.
- In a child, ask the parent and the child about missed school days, falling marks and dropped activities.
- Ask what the patient has tried, and what helped in the past.
| Coping (stress) | Not coping (distress) | |
|---|---|---|
| Daily life | Work, school and home still run | Missed days, tasks dropped, pulling away |
| Feelings | Tense or worried, but it passes | Worry or low mood most of the time |
| Next step | Name it, support, review | Look for an illness and make a plan |
Key feature 3 of 5
Look for illness
When someone is not managing, check whether depression or an anxiety illness lies underneath.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Choosing Wisely Canada
On the exam
A 10-year-old girl is being bullied and has missed school for weeks. Expect a short menu (pick several from a list) of questions that look for a disorder.
Pick the questions that find depression or anxiety.
Common mistakes
Stopping at the bullying and never asking about mood, sleep, worry or self-harm. Or calling it depression before the criteria are met.
Approach
- Screen everyone who is not coping for low mood, loss of interest, constant worry and panic.
- Ask about thoughts of suicide or self-harm, in children too.
- Diagnose a disorder only when it meets the criteria. Distress alone is not depression.
- Mild or below-threshold low mood: do not routinely start an antidepressant, at any age. Start with talk therapy and lifestyle steps.
- An antidepressant can fit when mild low mood persists, past depression was severe, or other treatment has failed.
Key feature 4 of 5
Stressors and options
Name what is driving the strain, then look for supports and options with the patient.
CFPC skill Patient-centred approach, clinical reasoningPhase History, treatmentSources Choosing Wisely Canada
On the exam
The bullied 10-year-old and her father want it fixed today. Expect a short menu (pick several from a list) of next steps.
Pick the steps that build her plan.
Common mistakes
Taking her phone or keeping her home before you explore. One feels like punishment for telling. The other feeds school avoidance, and online messages follow her home.
Approach
- Name each stressor with the patient. Say that the distress makes sense.
- Ask what the patient sees as the main problem, and what they want to change.
- Ask who can help: family, friends, school staff, an employer, the community.
- Ask what has worked before, and build on it.
- Make a small plan together: one problem, one step, and a date to review it.
- Teach a skill: relaxation, pacing the day, regular meals and regular sleep. These are also part of migraine treatment.
- For a child, bring in the school and keep school going. Staying home makes the return harder.
Key feature 5 of 5
Unhealthy coping
Under strain, check for harmful coping: drinking, drugs, overeating, anger or pills.
CFPC skill Clinical reasoning, communicationPhase Hypothesis generation, historySources Choosing Wisely Canada
On the exam
The bullying has eased, but the 10-year-old girl still takes acetaminophen on most school days. Expect one best answer for the plan.
Pick the safest plan for her headaches.
Common mistakes
Switching to ibuprofen. It keeps a pill as her answer to nerves, and ibuprofen has the same overuse limit. Missing the overuse is the opposite error.
Approach
- Ask everyone under strain about alcohol, cannabis and other drugs, eating changes and gambling.
- Ask about violence both ways: is anyone hurting the patient, or is the patient hurting someone? Ask about children in the home.
- Pain pills taken too often can cause daily headaches of their own. This is medication-overuse headache.
- Ask how often pain pills are taken. Use a headache diary to count the days.
- Count the days, not the doses. Five pill days a week is over 20 a month. Cut back rather than switch drugs.
- Alcohol use disorder with low mood: do not routinely start an antidepressant. Treat the drinking and the low mood together. Keep an antidepressant for moderate to severe depression still there after 2 to 4 weeks sober.
- Older adults: a benzodiazepine or other sleeping pill is not the first choice for poor sleep. They raise the risk of falls, hip fractures, car crashes and memory problems.
| Medicine | Overuse risk from | Know this |
|---|---|---|
| Acetaminophen, or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen | 15 or more days a month | Same limit for both; switching drugs does not help |
| Triptans, ergotamines, or combination pain pills | 10 or more days a month | Track use with a headache diary |
| Opioids | 10 or more days a month | Not a first choice for migraine; can cause dependence |
Flashcards
Answer it first, then check.
KF 1Headaches on school mornings, gone on weekends and holidays. What do you ask about?
School, friends, online life and home. A pattern that follows the school week points to a stressor there.
KF 1Typical migraine, normal exam, no red flags. Does the patient need a brain scan?
No. The yield is very low, and chance findings add worry. Explain the diagnosis instead. Source: Choosing Wisely Canada
KF 2How do you tell stress from distress?
By daily life. With stress, life still runs. With distress, sleep, work, school or relationships break down.
KF 3Mild low mood after a job loss, no history of depression. First treatment?
Talk therapy and lifestyle steps. An antidepressant is not routine first-line care for mild symptoms. Source: Choosing Wisely Canada
KF 4Name three things to explore with a patient who is not coping.
Any three of: the main stressors, what they want to change, who can help, what worked before.
KF 5How many days a month of acetaminophen risks medication-overuse headache?
15 or more. For triptans, opioids and combination pain pills, it is 10 or more. Source: Choosing Wisely Canada
KF 5Alcohol use disorder with low mood. When do you consider an antidepressant?
When moderate to severe depression lasts past 2 to 4 weeks without alcohol. Treat both problems together. Source: Choosing Wisely Canada
FAQ
Which guideline covers stress on the exam?
No Canadian guideline covers stress itself. The key features test an approach: spot it, judge coping, look for illness, plan together, and check how the patient copes.
Is stress a diagnosis?
Not on its own. Stress is a normal response to pressure. The exam wants you to judge coping, and to diagnose depression or anxiety only when the criteria are met.
Should I order a scan to reassure a stressed patient with headaches?
Not by default. With typical migraine, a normal exam and no red flags, a brain or sinus scan has very low yield. Chance findings add worry and tests. Explain the diagnosis instead.
Does this topic cover children and older adults too?
Yes, every age. In a child, ask the parent and the child about school and friends. In an older adult, ask about caregiving, illness, money and loss.
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