Answers / review sheet for Anxiety Disorders

Reasons behind answers for :   Anxiety Disorders - Flashcards.      Question  1:    (Test 1, Question 77)      A patient presents to your office with a complaint of intense fear of going to social functions at her child’s school. On further examination you note that she has fears that she will act in a way that will be humiliating or embarrassing. She is also made anxious by having to meet new people that she does not know. Your differential diagnosis of this patient should include which one of the following Axis II disorders? A. Borderline personality disorder B. Obsessive–compulsive personality disorder C. Narcissistic personality disorder D. Avoidant personality disorder E. Dependent personality disorder     Question 77. D.    The case described in this question is consistent with social anxiety disorder (social phobia). It involves certain specific social situations that provoke intense anxiety because of fear of embarrassment or humiliation. An important differential to consider would be avoidant personality disorder. In this disorder there is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. It leads to the avoidance of other people unless the sufferer is sure that he or she is going to be liked. Avoidant personality disorder leads to restraint of intimate relationships for fear of being shamed or ridiculed. These patients often view themselves as socially inept or personally unappealing. They avoid jobs with significant interpersonal contact. Very importantly, they desire the closeness and warmth of relationships but avoid them for fear of rejection. Borderline personality disorder is characterized by a pattern of instability of interpersonal relationships, self-image, and affect, as well as marked impulsivity. OCD is defined by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. Narcissistic personality disorder is defined by a pattern of grandiosity, need for admiration, and lack of empathy. Dependent personality disorder is defined by a pervasive need to be taken care of that leads to submissive and clinging behavior and fears of separation.   119. Which one of the following conditions has the highest prevalence? A. Depressive disorders B. Anxiety disorders C. Schizophrenia D. Dementia E. Substance abuse   Question 119. B.    Of the choices given, the highest prevalence is for anxiety disorders. Over 30 million people in the United States have an anxiety disorder. About 17.5 million have depression. About 2 million have schizophrenia. About 5 million have dementia. About 12.8 million use illicit drugs.     57. A young woman presents to the emergency room with complaints of palpitations, sweating, shortness of breath, chest pain, and nausea. She thinks that she is having a heart attack. Electrocardiogram (ECG) reveals normal sinus rhythm with no ischemic changes. Cardiac enzymes are not elevated. Given her symptoms, an alternative diagnosis would be: A. Manic episode B. Myxedema madness C. Mad Hatter syndrome D. Psychotic disorder not otherwise specified (NOS) E. Panic attack   Question 57. E.    This question includes common symptoms found in a panic attack. Others include trembling, choking sensations, dizziness, fear of losing control, fear of death, paresthesias, chills, or hot flushes. The patient in question does not present with the characteristic signs and symptoms of a manic episode. Myxedema madness is a depressed and psychotic state found in some patients with hypothyroidism. Mad Hatter syndrome presents as manic symptoms resulting from chronic mercury intoxication. The patient describes no psychotic symptoms, so psychotic disorder NOS is clearly the wrong choice. 69. A patient describes feeling anxious about being in places or situations from which escape may be difficult or in which help may not be available should the patient begin to panic. The patient avoids various situations because of these fears. The term that best describes this patient’s symptoms is: A. Agonothete B. Agoniada C. Agoraphobia D. Agora E. Agouara   Question 69. C.    The question stem accurately describes agoraphobia. The other answer choices are distractors. Agonothete is the judge of games in ancient Greece. Agoniada is the bark of a South American shrub. Agora is the market place in ancient Greece. Agouara is a South American wild dog or a crab-eating raccoon. Needless to say, the only one that will show up on the boards is agoraphobia.   15. A construction worker is brought to the emergency room immediately after an accident on a job site. He was standing very near a three-story scaffold that fell and missed crushing him by inches. He reports feeling anxiety, a sense of numbing, detachment, and difficulty remembering the accident and states that he feels like he is in a daze. The most likely diagnosis is: A. Generalized anxiety disorder B. Major depression C. Delirium D. Dissociative amnesia E. Acute stress disorder   Question 15. E.    This is a clear case of acute stress disorder. Acute stress disorder occurs after a person is exposed to a traumatic event. The patient then feels anxiety, detachment, derealization, feelings of being “in a daze,” dissociative amnesia, and numbing. Flashbacks and avoidance of stimuli can occur. The symptoms do not last longer than 4 weeks, and occur within 4 weeks of the traumatic event (as opposed to posttraumatic stress disorder [PTSD] in which symptoms must last more than 1 month). In dissociative amnesia the patient has one or more episodes of inability to recall important personal information usually of a traumatic or stressful nature. The patient maintains intact memory for other information. The prepared test-taker should be able to distinguish this from TGA, which is a reversible anterograde and retrograde memory loss with retention of basic biographic information, which usually occurs in elderly or middle-aged men, lasting several hours, and is likely to be related to a transient ischemic attack.     31. What is the difference between posttraumatic stress disorder and acute stress disorder? A. The nature of the trauma B. The symptoms that follow the trauma C. The impairment resulting from the symptoms D. The duration of the symptoms E. The age of the patient   Question 31. D.    In case Question 15 didn’t solidify acute stress disorder and PTSD in your mind, take advantage of this question to clarify your understanding. Acute stress disorder occurs when a person is exposed to a traumatic event. The patient then feels anxiety, detachment, derealization, feelings of being “in a daze,” dissociative amnesia, and numbing. Flashbacks and avoidance of stimuli can occur. The symptoms do not last longer than 4 weeks and occur within 4 weeks of the traumatic event (as opposed to PTSD, of which symptoms must last more than 1 month).   15. A physician examines a female patient in the emergency room who has recently been diagnosed with a social phobia. Which one of the following answer choices would most likely be the greatest fear for this patient? A. Having to take responsibility for planning a dinner with her husband B. Being in a relationship with a new boyfriend C. Going to a state fair and being around thousands of people D. Being scrutinized by others E. Competing for a new position that just opened up in her company   Question 15. D.    Social phobia is characterized by a fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others. The individual is afraid of acting in a way that would be embarrassing. Exposure to the situation almost always causes anxiety, and the person is aware that the fear is excessive. In this question, fear of scrutiny is the most definitive symptom of social phobia. The other choices could provoke anxiety in someone with some type of anxiety disorder but are neither necessarily limited to nor considered major diagnostic criteria for social phobia.   31. Which one of the following medical conditions should not be considered when evaluating patients with anxiety disorders? A. Carcinoid syndrome B. Hyperventilation syndrome C. Hypoglycemia D. Hyperthyroidism E. Central serous chorioretinopathy   Question 31. E.    Central serous chorioretinopathy is a disease leading to detachment of the retina and has nothing to do with anxiety. Carcinoid syndrome can mimic anxiety disorders and is accompanied by hypertension and elevated urinary 5-hydroxyindoleacetic acid (5-HIAA). Hyperthyroidism presents with anxiety in the context of elevated T3 and T4 and exophthalmos. Hypoglycemia presents with anxiety and fasting blood sugar under 50mg/dL. Signs and symptoms of diabetes may also be present with hypoglycemia (polyuria, polydipsia, and polyphagia). Hyperventilation syndrome presents with a history of rapid deep respirations, circumoral pallor, and anxiety. It responds well to breathing into a paper bag.   111. What is the most important step in treating separation-anxiety disorder in an 11-year-old? A. Give methylphenidate B. Give risperidone C. Rapidly send the child back to school D. Thorough psychoanalysis of the mother E. High-dose benzodiazepine treatment   Question 111. C.    Treatment of children with separation-anxiety disorder should be multimodal. It should involve individual therapy for the child, medication to reduce anxiety, family therapy and education, and return to school, which is graded if necessary (i.e., start with 1 hour per day, then increase to 2 hours, then to 3 hours, etc.). The parental education should focus on giving the child consistent support but maintaining clear boundaries about the child’s avoidant behaviors toward anxiety-provoking situations.   95. A patient comes to you 3 weeks after witnessing a child hit by a car. Since then she has been having feelings of detachment and feels “in a daze.” She has recurrent thoughts and dreams about the event. She describes depersonalization. She has avoided discussing the event with friends and family and her sleep has been poor. What is the most appropriate diagnosis? A. Posttraumatic stress disorder B. Major depressive disorder C. Acute stress disorder D. Panic disorder E. Primary insomnia   Question 95. C.    This patient has acute stress disorder. Acute stress disorder lasts for 2 days to 4 weeks, whereas PTSD must last for 4 weeks or more. Major symptom clusters for both disorders include intrusion symptoms, avoidance symptoms, negative alterations in cognition and mood, and alterations in arousal and reactivity.     110. Which of the following anxiety disorders has equal rates in both males and females? A. Panic disorder B. Generalized anxiety disorder C. Social phobia D. Obsessive–compulsive disorder E. Specific phobia   Question 110. D.    For most anxiety disorders the rates are higher for women than for men. The only anxiety disorder with equal rates between men and women is obsessive–compulsive disorder.   137. Which of the following is the most significant risk factor for posttraumatic stress disorder and the best predictor of symptom development following exposure to trauma? A. A family history of anxiety or depression B. The availability of psychiatric care immediately following the trauma C. Low socioeconomic status D. Being single, divorced, or widowed E. The nature, severity, and duration of exposure to the trauma   Question 137. E.    Most people do not experience PTSD symptoms, even when faced with severe trauma. The lifetime prevalence of PTSD is about 6.7%, as per the National Comorbidity Study. As per that same study about 60% of males and 50% of females had experienced some significant trauma. Evidence points to a “dose–response” relationship between the degree of trauma and the likelihood of symptoms. The subjective meaning of the trauma to the individual is also extremely important. The predisposing vulnerability factors in PTSD are as follows: 1. Presence of childhood trauma. 2. Borderline, paranoid, dependent, or antisocial personality disorder traits. 3. Inadequate family or peer supports. 4. Female gender. 5. Genetic predisposition to mental illness. 6. Recent life stressors. 7. Perception of an external locus of control to the trauma (natural cause) as opposed to an internal one (human cause). 8. Recent alcohol abuse.   17. Which of the following anxiety disorders is most common? A. Panic disorder B. Obsessive–compulsive disorder C. Posttraumatic stress disorder D. Specific phobia E. Generalized anxiety disorder   Question 17. D.    Specific phobia is the most common anxiety disorder. It is the most common mental disorder among women and the second most common among men (after substance abuse). This fact takes many psychiatrists by surprise, however, because most patients with specific phobia do not seek medical attention.   39. Which one of the following is an appropriate Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5), specifier used for substance-induced anxiety disorder? A. With generalized anxiety B. With panic attacks C. With obsessive–compulsive symptoms D. With onset during withdrawal E. With delayed onset   Question 39. D.    Appropriate specifiers for substance-induced anxiety disorder in DSM 5 include “with onset during intoxication,” “with onset during withdrawal,” and “with onset after medication use.” Though some may think this question is picky or unfair, the details of the DSM are indeed fair game for a test of general psychiatric knowledge. The small details of the DSM give the test writer ample opportunity to form tricky questions. Know your DSM well!   95. A 25-year-old female comes to the psychiatrist complaining of irritability, poor concentration, and poor sleep. Which one of the following should not be included in the differential diagnosis? A. Generalized anxiety disorder B. Major depressive disorder C. Premenstrual dysphoric disorder D. Posttraumatic stress disorder E. Social anxiety disorder     Question 95. E.    Irritability, poor concentration, and poor sleep are common to generalized anxiety disorder, MDD, premenstrual dysphoric disorder, and PTSD. Social anxiety disorder is characterized by a fear or anxiety surrounding social situations in which individuals are exposed to possible scrutiny by others. The criteria center around the patient’s anxiety or fear in specific social situations and does not include other specific symptoms such as irritability, decreased concentration, or sleep disturbance. Symptoms in generalized anxiety disorder include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance. MDD and premenstrual dysphoric disorder contain depressed or irritable mood, decreased interest in activities, poor concentration, sleep disturbance, and changes in appetite. In PTSD the patient has experienced actual or threatened death or serious injury, which leads to symptoms of intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. “Alterations in arousal and reactivity” include irritability, poor concentration, and sleep disturbance.   107. A patient with severe panic disorder comes to you for help. Which of the following is the most effective treatment you can offer her? A. Psychodynamic psychotherapy B. An SSRI C. Cognitive behavioral therapy D. A TCA E. Cognitive behavioral therapy plus an SSRI   Question 107. E.    Studies support CBT as the best therapy for panic disorder. SSRIs are also considered first line because of their effectiveness, safety, and low side effect profile. Studies also support the fact that CBT plus an SSRI will deliver better results than either treatment given alone.   108. Which of the following is not a common comorbidity associated with social phobia? A. Drug abuse B. Conversion disorder C. Alcohol abuse D. Other anxiety disorders E. Major depressive disorder   Question 108. B.    Disorders that are frequently comorbid with social phobia include other anxiety disorders, affective disorders, and substance abuse disorders. About one-third of patients with social phobia will meet criteria for MDD. There is no significant comorbidity with the somatoform disorders in general and conversion disorder in particular.   109. You start a patient in your practice on an SSRI for treatment of panic disorder. Which of the following medications can you add that will be effective, is FDA-approved for panic disorder, and will lead to a more rapid response? A. Buspirone B. Gabapentin C. Propranolol D. Topiramate E. Clonazepam   Question 109. E.    The addition of a benzodiazepine to a patient on an SSRI for panic disorder will lead to a more rapid resolution of the anxiety. The SSRI will take 2 to 4 weeks to work in most cases. The benzodiazepine can effectively control the patient’s symptoms until the SSRI is fully working. The other choices will take longer to titrate or become effective and are not good choices for rapid resolution of panic symptoms. Propranolol is indicated only for performance anxiety and should not be used in other anxiety disorders.   132. A patient has a panic attack and then worries significantly about having more attacks. How long must the patient worry to meet DSM criteria for panic disorder? A. 1 week B. 2 weeks C. 1 month D. 3 months E. 6 months   Question 132. C.    DSM criteria for panic disorder state that the patient must have recurrent attacks of which at least one attack is followed by 1 month or more of persistent concern about having more attacks, or worry about the implications of the attack or its consequences, or a significant change in behavior related to the attacks   133. How long must a 42-year-old man have excessive anxiety to meet DSM 5 criteria for generalized anxiety disorder? A. 6 weeks B. 2 weeks C. 6 months D. 2 months E. 5 days   Question 133. C.    DSM 5 states that to meet criteria for generalized anxiety disorder, excessive anxiety and worry must occur more days than not, for at least 6 months, about a number of events or activities. The individual finds it difficult to control the worry. The worry is associated with symptoms such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance. It causes impairment in social or occupational functioning. It is not attributable to substance abuse or another mental disorder.   135. Giving a patient cognitive behavioral therapy (CBT) plus an SSRI for social anxiety disorder will most likely result in which of the following? A. Better results than an SSRI alone B. Better results than CBT alone C. Poor results for refractory cases D. No initial benefit over monotherapy with either an SSRI or CBT in most cases E. Poorer response than psychodynamic psychotherapy alone   Question 135. D.    When treating social anxiety disorder, combining CBT and pharmacotherapy does not show a clear benefit over using just one or the other for most initial treatments. There is evidence, however, that there are some refractory cases that do respond better to a combination of both.   145. Which of the following could be expected for a patient with social phobia compared to the general population? A. Increased number of friendships B. Higher level of education C. Lower rates of suicide D. Poorer marital function E. Increased success in career advancement   Question 145. D.    Compared to the general population patients with social phobia tend to have fewer friendships, lower levels of education, higher rates of suicide, and less success in career advancement. They also have poorer marital function.     Vignette Ten     Lisa is a 22-year-old barista at a local coffee shop who comes to your office seeking help after feeling that she did not get any better with her primary care physician. She gives a long history of anxiety around other people dating back to childhood. At one point, while in high school, her mother pressured her to become a camp counselor to “overcome shyness.” Lisa was able to force herself to do it for a few weeks but then became overwhelmed by the anxiety and quit. She also went through a period of time during her school years when she wouldn’t use public restrooms or would use them only if they were completely empty. She got into trouble for leaving class to go to the restroom all of the time. When the restroom was empty during classes she felt the most comfortable using it. Now she reports being very anxious at work and at parties.    She snuck out of the holiday party for her job because she was so uncomfortable. She worries that other people are judging her and won’t like her. She says that she feels stupid interacting with others, especially at work. She had quit a previous job because there were weekly meetings, which she had to attend and during which she had to speak in front of 30 people. Her anxiety about these meetings led her to quit the job. When you ask about her personal life she tells you “I’ve gone on dates once or twice but have never had any long-term relationships. Dates are excruciating for me. Making conversation with new people makes me so uncomfortable and anxious.” Lisa’s primary care physician had tried her on sertraline in the past. She comes to you to see if there is anything else you can offer her   1. Which of the following should be included in Lisa’s differential diagnosis? (Choose three of four) A. Panic disorder B. Schizoaffective disorder C. Social phobia D. Generalized anxiety disorder 2. Given Lisa’s medication history, which other medications may be worth trying? (Choose three of four) A. Paroxetine B. Clonazepam C. Citalopram D. Bupropion Psychiatry Test Preparation & Review Manual 3. Which of the following has the best evidence to support its use for Lisa’s condition? A. Cognitive behavioral therapy B. Supportive psychotherapy C. Motivational interviewing D. Psychodynamic psychotherapy 4. Lisa is most likely to be misdiagnosed with which of the following? (Choose two of four) A. Schizoid personality disorder B. Avoidant personality disorder C. Schizotypal personality disorder D. Dependent personality disorder 5. Which diagnosis best explains Lisa’s avoidance of public restrooms during her school years? A. Specific phobia B. Panic disorder C. Social phobia D. Agoraphobia 6. The performance-only subtype of social phobia is most successfully treated by which one of the following? A. Benztropine B. Olanzapine C. Propranolol D. Lorazepam 7. The major concern of patients with social phobia is which one of the following? A. Avoidance of relationships B. The need for someone to be with them in stressful situations C. Fear of rejection D. Fear of embarrassment 8. How long does Lisa need to have symptoms to meet DSM criteria for social phobia? A. 2 weeks B. 2 months C. 6 weeks D. 6 months 9. Which of the following are common side effects of Lisa’s condition? (Choose three of four) A. Blushing B. Dry mouth C. Sweating D. Fear of dying  10. As many as one-third of patients with Lisa’s condition also meet criteria for which one of the following disorders? A. Major depressive disorder B. Agoraphobia C. Cocaine abuse D. Body dysmorphic disorder   Vignette Ten 1. ACD. Lisa clearly has some form of anxiety disorder based on the symptoms given in the vignette. As such, panic disorder, social phobia, and generalized anxiety disorder (GAD) should be included in a differential diagnosis and more questions should be asked to better determine the correct diagnosis. There is no mention of psychosis in the vignette, so schizoaffective disorder should not be included. K&S Chapter 9 2. ABC. Based on Lisa’s history the most likely diagnosis is social anxiety disorder. First-line pharmacotherapy consists of SSRIs and SNRIs. Benzodiazepines can also be very effective at decreasing anxiety when the patient has to function in a specific social situation. Lisa has already been tried on sertraline with poor results. However, we don’t know what dosage was tried and for how long she was on the medication. She has also tried bupropion, which tends to be very activating and can make anxiety worse. Our best bet would be to return to first-line treatments and make sure they are given adequate therapeutic trials. Paroxetine and citalopram would both be considered first-line. Clonazepam is a very reasonable add-on to one of these medications to control acute anxiety in specific social situations. Bupropion should be avoided for its potential to make anxiety worse. K&S Chapter 9 3. A. CBT has solid evidence behind its use in social anxiety disorder as well as other anxiety disorders. The other answer choices do not. CBT should be considered the first-line psychotherapy for social anxiety disorder. K&S Chapter 9 4. AB. Social anxiety disorder can overlap with or easily be misdiagnosed as schizoid personality disorder or avoidant personality disorder. Important to keep in mind is that in social phobia the patient fears embarrassment in social situations. In avoidant personality disorder the person fears rejection in relationships. In schizoid personality disorder the patient does not desire close relationships and is very happy without them. K&S Chapter 9 5. C. Patients with social phobia can demonstrate avoidance of public restrooms. Their fear is not a specific phobia of the sink, toilet, or room. Their fear is of being embarrassed if someone hears, sees, or smells them using the bathroom. As such it is a form of social phobia. K&S Chapter 9 6. C. The performance-only subtype of social phobia is performance anxiety. Successful treatment consists of β-adrenergic antagonists such as propranolol. These will decrease the physical manifestations of the anxiety. Always keep in mind that β-blockers are contraindicated in asthma because of their ability to cause bronchoconstriction. As such, if given an asthmatic with performance anxiety one could choose a low-dose benzodiazepine or SSRI (which would be considered second-line agents for social phobia), but don’t give them a β-blocker. Also be careful with benzodiazepine doses if the patient has to speak publicly because of cognitive impairment. K&S Chapter 9 7. D. Fear of embarrassment or scrutiny by others is the major fear of those with social phobia. It is present in all situations that they fear, whether it is using a public restroom or talking at a party. Fear of rejection is found most prominently in those with avoidant personality disorder. They often don’t form relationships for fear of rejection. The need for someone to be with the patient in stressful or anxiety-producing situations is a part of agoraphobia. The example is the person who won’t leave his or her front gate without a friend or family member with him or her. Having someone with them doesn’t help avoidant or social phobia patients. Avoidance of relationships is most characteristic of the schizoid personality disorder patient, who neither has nor seeks close relationships. He or she is a loner and is happy that way. One could argue that avoiding relationships could also describe the avoidant patient, but the underlying motivation is different. The avoidant patient wants relationships but is afraid of rejection. The schizoid patient doesn’t want them at all. K&S Chapter 9 8. D. According to DSM criteria the symptoms of social anxiety disorder must last for 6 months before the diagnosis is made. K&S Chapter 9 9. ABC. Blushing, dry mouth, and sweating are all commonly seen in social phobia, as are muscle twitching and anxiety over scrutiny and embarrassment. Fear of dying is a more severe symptom, which is seen in panic attacks, as would be dizziness and a sense of suffocation. Panic attacks can co-occur with social phobia but should be diagnosed as such if present. They are not a necessary part of the social phobia picture. K&S Chapter 9 10. A. As many as one-third of patients with social anxiety disorder also meet criteria for MDD. Many social phobia patients also have alcohol problems. This makes sense when you think about the availability of alcohol in social situations and its ability to take the edge off their anxiety and allow them to better tolerate social interaction. K&S Chapter 9     Video Vinette 6  is not included in  the textbook.