Anxiety Disorders
QUESTIONS
1. A 54-year-old male presents for a consultation due to sudden onset of seizures. On examination, the patient is noted to be slightly delirious and is not able to give a coherent history. Collateral information reveals that he was taking diazepam up to 30 mg every day to “calm his nerves.” He bought these pills from someone off the street and has not been able to obtain any pills for the past 2 days. His wife mentions that he has been irritable and agitated over the past 12 hours and then had a sudden onset of “seizures” after which she called 911. Cessation of benzodiazepines after chronic use may cause all of the following except:
A. depersonalization and derealization
B. perceptual disturbances
C. anxiety
D. constipation
E. rhinorrhea
View Answer
1. Answer: E. Benzodiazepine withdrawal symptoms can be serious and sometimes fatal. They last for many days. Apart from anxiety, delirium, depersonalization, and derealization, the withdrawal symptoms can also result in seizures. Both constipation and diarrhea are recognized features of benzodiazepine withdrawal. Rhinorrhea is a feature of opiate withdrawal.
2. A 24-year-old salesperson is referred for an evaluation because of difficulty dealing with customers because she gets “so nervous and anxious that my mind goes blank.” A careful evaluation reveals that she has social phobia. She is motivated to obtain treatment and continue doing her job. All of the following are effective interventions except:
A. selective serotonin reuptake inhibitors (SSRIs)
B. flooding
C. modeling
D. systematic desensitization
E. electroconvulsive therapy (ECT)
View Answer
2. Answer: E. ECT is most commonly indicated for severe depression not responding to medications. Social phobia is an anxiety disorder that responds well to psychological interventions. Flooding, modeling, systematic desensitization, and relaxation techniques have all been found to be effective. The pharmacological treatments that have been found to be effective include SSRIs and MAOIs.
3. Phobia is an anxiety disorder that can be severe and debilitating. All of the following features are noted in phobias except:
A. higher incidence of major depressive disorder
B. patients usually come from stable families
C. patients tend to have anxious and/or dependent traits
D. in general, phobias are more common in women
E. phobias are usually triggered by major life events
View Answer
3. Answer: A. The incidence of major depressive disorder is no more common in phobia patients than in the general population. There is also a known association between phobias and childhood enuresis. Subjects with phobia have anxious/dependent traits, and they usually come from stable families.
4. Anxiety disorders are more common in women compared to men. However, not all phobias (which is an anxiety disorder) are more common in women. All of the following have a higher incidence in women compared to men except:
A. needle phobia
B. social phobia
C. animal phobia
D. hospital phobia
E. claustrophobia
View Answer
4. Answer: B. Although all anxiety spectrum disorders are more common in women, social phobia is equally common in men and women, and in some studies, it was found to be more common in men than in women.
5. Numerous theories have been put forward to explain the pathogenesis of phobias. All of the following theories explain phobias to some extent except:
A. concept of “preparedness”
B. classical conditioning
C. neurodevelopmental theory
D. operant conditioning
E. observational learning
View Answer
5. Answer: C. The theories of classical conditioning, operant conditioning, observational learning, and the concept of “preparedness” try to explain the pathogenesis of phobias. Neurodevelopmental theory was proposed to explain the etiology of schizophrenia.
6. Anxiety is a normal emotional response, and a degree of anxiety is necessary for survival. Pathological anxiety is distinguished from a normal emotional response by all of the following characteristic features except:
A. autonomy
B. physical health status
C. intensity
D. duration
E. behavior
View Answer
6. Answer: B. Certain characteristic features distinguish pathological anxiety from normal emotional response. Pathological anxiety is autonomous (i.e., it may or may not have a trigger). The intensity and duration of anxiety are out of proportion to the real or imagined stressor, and behavior is impaired. Physical health status is not a criterion used to distinguish normal fear from pathological anxiety.
7. Which of the following structures is the main source of the brain’s adrenergic innervations?
A. Nucleus raphe
B. Locus ceruleus
C. Nucleus of Meynert
D. Midbrain
E. Medial temporal lobe
View Answer
7. Answer: B. The locus ceruleus is a small retropontine structure and is the main source of the brain’s adrenergic innervations. In experimental studies, stimulation of the nucleus ceruleus caused severe anxiety and panic attacks, and the blockade of locus ceruleus efferents decreased anxiety and panic attacks. The raphe nucleus is the main source of serotonin.
8. According to the Epidemiologic Catchment Area (ECA) study, which of the following is the most common anxiety disorder in the United States?
A. Panic disorder
B. Simple phobia
C. Agoraphobia
D. Social phobia
E. Generalized anxiety disorder
View Answer
8. Answer: D. The ECA study collected data on the prevalence and incidence of mental disorders and on the use of and need for services by the mentally ill. In this study, social phobia is the most common anxiety disorder with a lifetime prevalence of 13.3%. This is closely followed by simple phobia at 11.3%.
9. A 65-year-old male experiences a panic attack for the first time in his life. He had a stroke recently and has other cardiac problems including angina and atrial fibrillation. The treating physician makes a diagnosis of organic anxiety syndrome. All of the following are the features of organic anxiety syndrome except:
A. onset of symptoms after 35 years of age
B. family history of anxiety disorders
C. no history of childhood anxiety disorders
D. poor response to the usual treatments of panic disorder
E. no avoidance behavior
View Answer
9. Answer: B. Patients with organic anxiety syndrome usually do not have a family history of anxiety disorders. All of the other features above are commonly seen in patients with organic anxiety disorder. One other feature, which helps to distinguish organic anxiety syndrome from primary panic disorder, is the absence of triggering factors for the anxiety syndrome.
10. According to the National Ambulatory Medical Survey, all of the following are true regarding anxiety disorders in primary care settings except:
A. high rates of anxiety symptoms in patients with chest pain, dyspnea, and dizziness
B. presenting problem in 11% of patients visiting primary care physicians
C. a common psychiatric disorder in primary care physicians’ office
D. a majority of these patients have serious medical problems
E. high utilizers of primary care physicians’ time and resources
View Answer
10. Answer: D. The National Ambulatory Medical Care Survey is a national probability sample survey conducted by the National Center for Health Statistics, which annually collects information on the use of ambulatory medical services provided by office-based physicians in the United States. Anxiety disorders are very common in primary care settings. A majority of these patients do not have any serious medical problems.
11. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), patients with generalized anxiety disorder (GAD) have excessive anxiety and worry on more days than not for a period of at least:
A. 2 weeks
B. 2 months
C. 6 weeks
D. 6 months
E. 4 weeks
View Answer
11. Answer: D. According to the DSM-IV, patients with GAD have symptoms of excessive worry and anxiety on most days for at least 6 months. They find it hard to control worrying and must have three out of the following six symptoms to make a diagnosis of GAD: muscle tension, restlessness, easy fatigability, difficulty concentrating, irritability, and insomnia.
12. All of the following are true about specific phobias except:
A. If the patient is under 18 years of age, the phobia should last for longer than 6 months.
B. Natural environment phobias (heights, water) have an onset in childhood.
C. Situational phobias (elevators, airplanes) have an onset in the mid-50s.
D. Lifetime prevalence varies between 10% to 11%.
E. Cognitive behavior therapy (CBT) and other psychological interventions are found to be effective.
View Answer
12. Answer: C. Situational phobia typically has a bimodal onset with one peak in childhood and the other in mid-20s. All of the specific phobias are more common in women, and evidence suggests aggregation within families by the type of phobia. In situational phobias, the phobic situation is avoided or else is endured with intense anxiety or distress.
13. According to the DSM-IV, all of the following are true regarding posttraumatic stress disorder (PTSD) except:
A. symptoms should last for more than 1 month
B. there are four subtypes: acute, subacute, chronic, and delayed onset
C. the individual is exposed to a traumatic event
D. the response to the traumatic event involves intense fear, horror, or helplessness
E. acute stress disorder is a different diagnosis
View Answer
13. Answer: B. There are three subtypes of PTSD based on duration criteria: (1) acute: symptoms last for less than 3 months; (2) chronic: symptoms last for more than 3 months; and (3) delayed onset: symptoms appear more than 6 months after the traumatic event. In acute stress disorder, symptoms occur within 4 weeks of the traumatic event and last for a minimum of 2 days but resolve within 4 weeks.
14. According to the DSM-IV, the diagnostic criteria for acute stress disorder emphasize a group of symptoms that are not included in the criteria for PTSD. These include:
A. dissociative symptoms
B. psychotic symptoms
C. neurotic symptoms
D. depressive symptoms
E. cognitive symptoms
View Answer
14. Answer: A. According to the DSM-IV, the diagnostic criteria for acute stress disorder emphasize dissociative symptoms such as depersonalization, derealization, and dissociative amnesia, while experiencing or after experiencing the distressing event. This set of symptoms is not included in the diagnostic criteria for PTSD. In acute stress disorder, symptoms occur within 4 weeks of the traumatic event and last for a minimum of 2 days but resolve within 4 weeks.
15. A 28-year-old female was diagnosed to have PTSD after she was assaulted and raped 6 months ago. Over the next 2 years, despite extensive therapy and pharmacological treatment, the response was suboptimal. She was later diagnosed to have major depressive disorder and substance abuse problems. Which of the following is the most common comorbid condition in women with PTSD?
A. Substance abuse
B. Depression
C. Obsessive compulsive disorder
D. Psychotic disorders
E. Eating disorders
View Answer
15. Answer: B. PTSD is associated with significant comorbidities. The most common comorbid condition in women is depression (49%), and the most common comorbid condition in men is substance abuse (52%).
16. According to the DSM IV, chronic PTSD cannot be diagnosed unless the patient has PTSD symptoms for a period of at least:
A. 6 months
B. 1 year
C. 2 years
D. 3 months
E. 1 month
View Answer
16. Answer: D. There are three subtypes of PTSD based on duration criteria: (1) acute: symptoms last for less than 3 months; (2) chronic: symptoms last for more than 3 months; and (3) delayed onset: symptoms appear more than 6 months after the traumatic event. In acute stress disorder, symptoms occur within 4 weeks of the traumatic event and last for a minimum of 2 days but resolve within 4 weeks.
17. Which of the following medications have been found to be effective in the treatment of PTSD symptoms?
A. SSRIs
B. Mood stabilizers
C. Beta-blockers
D. Antipsychotics
E. Benzodiazepines
F. All of the above
View Answer
17. Answer: F. Various medications have been tried to treat different groups of symptoms in patients with PTSD, and all of the above have some utility. SSRIs, however, are found to be most effective, and these are often used as first-line treatments. Other medicines that have been tried in PTSD include clonidine, anticonvulsants, and MAOIs.
18. Psychological interventions are considered to be equally, if not more important than pharmacological interventions in the treatment of PTSD. All of the following psychological interventions have been found to be effective in the treatment of PTSD except:
A. supportive psychotherapy
B. psychoanalytic psychotherapy
C. cognitive behavioral therapy
D. group therapy
E. eye movement desensitization and reprocessing therapy
View Answer
18. Answer: B. Psychological interventions are an essential component in the treatment of PTSD. Most of the evidence is for cognitive behavioral therapy. However, group therapy is being increasingly utilized at the present time.
19. According to the DSM-IV, all of the following are included in the diagnostic criteria for somatization disorder except:
A. four pain symptoms
B. two gastrointestinal symptoms other than pain
C. one sexual symptom
D. one pseudoneurologic symptom
E. symptoms beginning after the age of 30 years
View Answer
19. Answer: E. According to the DSM-IV, for the diagnosis of somatization disorder, the onset of symptoms should be before the age of 30 years. The multiple, recurring, physical symptoms usually start in adolescence, and the diagnostic criteria are usually met by 25 years of age. The multiple symptoms can occur at any time during the course of the illness, resulting in treatment-seeking behavior and significant impairment in functioning.
20. A 35-year-old woman is seen by a neurologist for impaired coordination. However, a detailed neurologic examination reveals nothing abnormal. A careful history reveals that starting at the age of 18, she has been having multiple physical symptoms including pain symptoms, gastrointestinal symptoms, and irregular menstruation. Despite extensive tests, however, nothing abnormal was detected. All of the following are more likely suggestive of a somatization disorder except:
A. family history of histrionic personality
B. early onset of symptoms
C. chronic course
D. multiorgan system involvement
E. absence of laboratory, radiologic, and physical abnormalities
View Answer
20. Answer: A. Patients with somatization disorders often have a family history of somatization disorder. In fact, 10% to 20% of first-degree female relatives of female patients with somatization disorder develop somatization disorder. The male relatives of women with somatization disorder show an increased risk of antisocial personality disorder and substance-related disorders.
21. Which of the following is the most common somatoform disorder?
A. Conversion disorder
B. Somatization disorder
C. Pain disorder
D. Hypochondriasis
E. Body dysmorphic disorder
View Answer
21. Answer: C. Pain disorder is relatively more common. The prevalence of conversion disorder varies widely from 11 to 300 out of 100,000. The prevalence of hypochondriasis in general medical practice is reported to be between 4% to 9%.
22. All of the following are recognized subtypes of conversion disorder except:
A. gastrointestinal problems
B. motor symptoms or deficit
C. sensory symptoms or deficit
D. seizures or convulsions
E. mixed presentation
View Answer
22. Answer: A. One of the diagnostic features of conversion disorder is the presence of one or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or general medical condition. The DSM-IV has four subtypes, and they are listed above.
23. All of the following are characteristic features of conversion disorder except:
A. patients are usually suggestible
B. symptoms appear or exacerbated following severe stress
C. patients believe that they have serious underlying illness
D. symptoms are not feigned
E. usually occurs between the age of 10 to 35 years
View Answer
23. Answer: C. Patients with conversion disorder are more focused on the presenting symptom, and there may be la belle indifference. In contrast, patients with hypochondriasis are preoccupied with having serious underlying illness.
24. A 34-year-old female is admitted to the neurology in-patient unit for further assessment and management of “episodes of shaking of whole body followed by drooling of saliva and eyes rolling upward.” An extensive workup including an admission to an epilepsy monitoring unit at an outside hospital did not find anything abnormal. There is no family history of seizure disorder, but one of her neighbors was diagnosed with seizure disorder recently. Collateral information reveals that the patient is under a lot of stress because of a recent divorce and problems at her workplace. The psychiatry consult team believes the patient has conversion disorder. All of the following are true about conversion disorders except:
A. usual age of onset is between 10 to 35 years.
B. the symptoms tend to conform to the patient’s own idea of illness
C. paralysis, aphonia, and blindness are associated with bad prognosis
D. remission is usually noticed within 2 weeks after hospitalization
E. recurrence rate is as high as 20% to 25% within the first year
View Answer
24. Answer: C. Paralysis, aphonia, and blindness are associated with good prognosis, whereas tremors and seizures are associated with a bad prognosis. Onset of conversion disorder is rare after 35 years. The likelihood of occult neurological or general medical condition is high in someone who develops conversion disorder for the first time in middle or old age.
25. According to the DSM-IV, to make a diagnosis of hypochondriasis, the symptoms should last for at least:
A. 2 weeks
B. 2 months
C. 6 weeks
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