Anxiety in children and adolescents — MCQs

10 questions

A 23-year-old man presents to an outpatient psychiatrist complaining of anxiety and a persistent feeling that “something terrible will happen to my family.” He describes 1 year of vague, disturbing thoughts about his family members contracting a “horrible disease” or dying in an accident. He believes that he can prevent these outcomes by washing his hands of “the contaminants” any time that he touches something and by performing praying and counting rituals each time that he has unwanted, disturbing thoughts. The thoughts and rituals have become more frequent recently, making it impossible for him to work, and he expresses feeling deeply embarrassed by them. Which of the following is the most effective treatment for this patient's disorder?

A 14-year-old girl presents to the pediatrician for behavior issues. The girl has been having difficulty in school as a result. Every time the girl enters her classroom, she feels the urge to touch every wall before heading to her seat. When asked why she does this, she responds, "I'm not really sure. I just can't stop thinking about it until I have touched each wall." The parents have noticed this behavior occasionally at home but were not concerned. The girl is otherwise healthy, has many friends, eats a balanced diet, does not smoke, and is not sexually active. Her temperature is 98.2°F (36.8°C), blood pressure is 117/74 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for a healthy young girl. Neurologic exam is unremarkable. There is no observed abnormalities in behavior while the girl is in the office. Which of the following is the most appropriate initial step in management for this patient?

A 7-year-old boy is brought to the physician because of repetitive, involuntary blinking, shrugging, and grunting for the past year. His mother states that his symptoms improve when he is physically active, while tiredness, boredom, and stress aggravate them. He has felt increasingly embarrassed by his symptoms in school, and his grades have been dropping from average levels. He has met all his developmental milestones. Vital signs are within normal limits. Mental status examination shows intact higher mental functioning and thought processes. Excessive blinking, grunting, and jerking of the shoulders and neck occur while at rest. The remainder of the examination shows no abnormalities. This patient's condition is most likely associated with which of the following findings?

A 10-year-old child is sent to the school psychologist in May because he refuses to comply with the class rules. His teacher says this has been going on since school started back in August. He gets upset at the teacher regularly when he is told to complete a homework assignment in class. Sometimes he refuses to complete them altogether. Several of his teachers have reported that he intentionally creates noises in class to interrupt the class. He tells the psychologist that the teacher and his classmates are at fault. What is the most appropriate treatment?

A 7-year-old boy is brought to the physician by his mother for the evaluation of abdominal pain and trouble sleeping for the past 6 months. His mother says he complains of crampy abdominal pain every morning on school days. He started attending a new school 7 months ago and she is concerned because he has missed school frequently due to the abdominal pain. He also has trouble falling asleep at night and asks to sleep in the same room with his parents every night. He has not had fever, vomiting, diarrhea, or weight loss. He sits very close to his mother and starts to cry when she steps out of the room to take a phone call. Abdominal examination shows no abnormalities. Which of the following is the most likely diagnosis?

A 35-year-old man comes to the Veterans Affairs hospital because of a 2-month history of anxiety. He recently returned from his third deployment to Iraq, where he served as a combat medic. He has had difficulty readjusting to civilian life. He works as a taxi driver but had to take a leave of absence because of difficulties with driving. Last week, he hit a stop sign because he swerved out of the way of a grocery bag that was in the street. He has difficulty sleeping because of nightmares about the deaths of some of the other soldiers in his unit and states, “it's my fault, I could have saved them. Please help me.” Mental status examination shows a depressed mood and a restricted affect. There is no evidence of suicidal ideation. Which of the following is the most appropriate initial step in treatment?

An 8-year-old boy is brought to his pediatrician by his mother because she is worried about whether he is becoming ill. Specifically, he has been sent home from school six times in the past month because of headaches and abdominal pain. In fact, he has been in the nurse's office almost every day with various symptoms. These symptoms started when the family moved to an old house in another state about 2 months ago. Furthermore, whenever he is taken care of by a babysitter he also has these symptoms. Despite these occurrences, the boy never seems to have any problems at home with his parents. Which of the following treatments would likely be effective for this patient?

A 5-year-old boy is brought in by his mother with reports of trouble at school. Teachers report that for the last 6 months he has been having difficulty finishing tasks, is easily distracted, frequently does not listen, commonly fails to finish schoolwork, has not been able to complete any of the class projects this year, and frequently loses school books and supplies. Teachers also say that he constantly fidgets, often leaves his seat without permission, has trouble being quiet, talks excessively, frequently interrupts his classmates when trying to answer questions, and has difficulty waiting in line. The mother states that she has also been noticing similar behaviors at home and that his symptoms have been affecting him negatively academically and socially. The patient has no significant past medical history. The patient is in the 90th percentile for height and weight and has been meeting all the developmental milestones. He is afebrile, and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following medications is a first-line treatment for this patient’s most likely diagnosis?

A 35-year-old woman presents to clinic in emotional distress. She states she has been unhappy for the past couple of months and is having problems with her sleep and appetite. Additionally, she reports significant anxiety regarding thoughts of dirtiness around the house. She states that she cleans all of the doorknobs 5-10 times per day and that, despite her actions, the stress related to cleaning is becoming worse. What is this patient's diagnosis?

Q10

A previously healthy 36-year-old man is brought to the physician by a friend because of fatigue and a depressed mood for the past few weeks. During this time, he has not been going to work and did not show up to meet his friends for two bowling nights. The friend is concerned that he may lose his job. He spends most of his time alone at home watching television on the couch. He has been waking up often at night and sometimes takes 20 minutes to go back to sleep. He has also been drinking half a pint of whiskey per day for 1 week. His wife left him 4 weeks ago and moved out of their house. His vital signs are within normal limits. On mental status examination, he is oriented to person, place and time. He displays a flattened affect and says that he “doesn't know how he can live without his wife.” He denies suicidal ideation. Which of the following is the next appropriate step in management?

Anxiety in children and adolescents US Medical PG Practice Questions and MCQs

Question 1: A 23-year-old man presents to an outpatient psychiatrist complaining of anxiety and a persistent feeling that “something terrible will happen to my family.” He describes 1 year of vague, disturbing thoughts about his family members contracting a “horrible disease” or dying in an accident. He believes that he can prevent these outcomes by washing his hands of “the contaminants” any time that he touches something and by performing praying and counting rituals each time that he has unwanted, disturbing thoughts. The thoughts and rituals have become more frequent recently, making it impossible for him to work, and he expresses feeling deeply embarrassed by them. Which of the following is the most effective treatment for this patient's disorder?

A. Psychodynamic psychotherapy and citalopram
B. Cognitive behavioral therapy and haloperidol
C. Cognitive behavioral therapy and clonazepam
D. Cognitive behavioral therapy and fluoxetine (Correct Answer)
E. Psychodynamic psychotherapy and aripiprazole

Explanation: ***Cognitive behavioral therapy and fluoxetine*** - This patient presents with symptoms highly suggestive of **obsessive-compulsive disorder (OCD)**, characterized by intrusive, distressing thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) performed to neutralize the anxiety. - **Cognitive Behavioral Therapy (CBT)**, specifically Exposure and Response Prevention (ERP), is the most effective psychotherapy for OCD, and **SSRIs** like fluoxetine are the first-line pharmacotherapy. *Psychodynamic psychotherapy and citalopram* - While citalopram (an SSRI) is an appropriate pharmacological treatment for OCD, **psychodynamic psychotherapy** is generally not considered first-line or most effective for OCD due to its focus on unconscious conflicts rather than direct symptom reduction. - This approach may not provide the structured, symptom-focused interventions needed to manage obsessions and compulsions effectively. *Cognitive behavioral therapy and haloperidol* - **CBT** is an excellent choice, but **haloperidol**, an antipsychotic, is not a first-line treatment for OCD; it is primarily used for psychotic disorders or as an augmentation strategy in severe, treatment-resistant OCD, which is not indicated here. - Using an antipsychotic as a primary treatment for OCD without a clear indication of psychosis or severe non-response to SSRIs is inappropriate and can lead to unnecessary side effects. *Cognitive behavioral therapy and clonazepam* - **CBT** is appropriate, but **clonazepam**, a benzodiazepine, is generally not recommended as a monotherapy or primary adjunctive treatment for OCD due to its *sedative side effects*, *potential for dependence*, and *lack of efficacy* in addressing the core symptoms of OCD. - Benzodiazepines may be used for short-term anxiety relief but do not treat the underlying obsessive-compulsive processes. *Psychodynamic psychotherapy and aripiprazole* - **Psychodynamic psychotherapy** is not the most effective approach for OCD. - **Aripiprazole**, an atypical antipsychotic, is typically used as an augmentation strategy for *treatment-resistant OCD* when initial SSRI trials have failed, not as a first-line medication, and this patient's case does not describe treatment resistance.

Question 2: A 14-year-old girl presents to the pediatrician for behavior issues. The girl has been having difficulty in school as a result. Every time the girl enters her classroom, she feels the urge to touch every wall before heading to her seat. When asked why she does this, she responds, "I'm not really sure. I just can't stop thinking about it until I have touched each wall." The parents have noticed this behavior occasionally at home but were not concerned. The girl is otherwise healthy, has many friends, eats a balanced diet, does not smoke, and is not sexually active. Her temperature is 98.2°F (36.8°C), blood pressure is 117/74 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for a healthy young girl. Neurologic exam is unremarkable. There is no observed abnormalities in behavior while the girl is in the office. Which of the following is the most appropriate initial step in management for this patient?

A. Cognitive behavioral therapy (Correct Answer)
B. Lorazepam
C. Risperidone
D. Clomipramine
E. Fluoxetine

Explanation: ***Cognitive behavioral therapy*** - This patient exhibits classic symptoms of **obsessive-compulsive disorder (OCD)**, characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions) performed to alleviate anxiety. - **Exposure and response prevention (ERP)**, a component of cognitive behavioral therapy, is the first-line psychosocial treatment for OCD and has strong evidence for its efficacy in both children and adults. *Lorazepam* - **Lorazepam** is a benzodiazepine used for acute anxiety or panic attacks, providing short-term relief. - It is not a primary treatment for OCD and does not address the underlying obsessive-compulsive cycle; long-term use can lead to dependence. *Risperidone* - **Risperidone** is an atypical antipsychotic, primarily used for conditions like schizophrenia, bipolar disorder, or severe behavioral disturbances. - While sometimes used as an augmentation strategy in refractory OCD, it is not a first-line treatment, especially without prior trials of CBT or SSRIs. *Clomipramine* - **Clomipramine** is a tricyclic antidepressant (TCA) with potent serotonin reuptake inhibition, making it effective for OCD. - However, due to its less favorable side effect profile compared to selective serotonin reuptake inhibitors (SSRIs), it is typically reserved for cases where SSRIs are ineffective. *Fluoxetine* - **Fluoxetine** is an SSRI, a first-line pharmacologic treatment for OCD. - While effective, current guidelines recommend starting with **CBT (specifically ERP)** as the initial treatment for mild to moderate OCD, or combining it with medication for more severe cases.

Question 3: A 7-year-old boy is brought to the physician because of repetitive, involuntary blinking, shrugging, and grunting for the past year. His mother states that his symptoms improve when he is physically active, while tiredness, boredom, and stress aggravate them. He has felt increasingly embarrassed by his symptoms in school, and his grades have been dropping from average levels. He has met all his developmental milestones. Vital signs are within normal limits. Mental status examination shows intact higher mental functioning and thought processes. Excessive blinking, grunting, and jerking of the shoulders and neck occur while at rest. The remainder of the examination shows no abnormalities. This patient's condition is most likely associated with which of the following findings?

A. Feelings of persistent sadness and loss of interest
B. Defiant and hostile behavior toward teachers and parents
C. Recurrent episodes of intense fear
D. Chorea and hyperreflexia
E. Excessive impulsivity and inattention (Correct Answer)

Explanation: ***Excessive impulsivity and inattention*** - The patient exhibits features of **Tourette syndrome**, characterized by multiple motor **tics** and at least one vocal tic present for longer than a year, with onset before age 18. - Tourette syndrome is frequently comorbid with **attention-deficit/hyperactivity disorder (ADHD)**, which presents with symptoms of **inattention** and **hyperactivity-impulsivity**. *Feelings of persistent sadness and loss of interest* - These symptoms describe **major depressive disorder**, which is less commonly comorbid with Tourette syndrome in childhood and less directly linked than ADHD. - While depression can occur, the primary associations with Tourette's during childhood are more behavioral and attention-related. *Defiant and hostile behavior toward teachers and parents* - This symptom profile suggests **oppositional defiant disorder (ODD)** or **conduct disorder**, which are less common comorbidities of Tourette syndrome than ADHD. - While behavioral issues can arise from the distress of tics, ODD is not the most direct or prevalent comorbidity. *Recurrent episodes of intense fear* - This symptom describes **panic attacks** or an **anxiety disorder**, which can co-occur with Tourette syndrome, but less frequently than ADHD. - The primary clinical picture presented (tics and academic decline) points more strongly to an attention-related comorbidity. *Chorea and hyperreflexia* - **Chorea** and **hyperreflexia** are neurological signs not typically associated with Tourette syndrome; they are more characteristic of conditions like Huntington's disease or Sydenham chorea. - Tourette syndrome is a **neurological disorder** of tics, not a progressive degenerative disorder with chorea and hyperreflexia.

Question 4: A 10-year-old child is sent to the school psychologist in May because he refuses to comply with the class rules. His teacher says this has been going on since school started back in August. He gets upset at the teacher regularly when he is told to complete a homework assignment in class. Sometimes he refuses to complete them altogether. Several of his teachers have reported that he intentionally creates noises in class to interrupt the class. He tells the psychologist that the teacher and his classmates are at fault. What is the most appropriate treatment?

A. Cognitive-behavioral therapy (Correct Answer)
B. Interpersonal therapy
C. Administration of lithium
D. Motivational interviewing
E. Administration of clozapine

Explanation: ***Cognitive-behavioral therapy*** - This child exhibits symptoms consistent with **Oppositional Defiant Disorder (ODD)**, including persistent refusal to comply with rules, anger outbursts, and blaming others. **CBT** is a highly effective treatment for ODD, teaching children coping skills, anger management, and problem-solving. - CBT helps children identify and change **maladaptive thought patterns** and behaviors, which is crucial for managing the defiant and argumentative behaviors seen in ODD. *Interpersonal therapy* - **Interpersonal therapy (IPT)** primarily focuses on improving interpersonal relationships and communication patterns, often used for depression or eating disorders. - While improved relationships might be a secondary benefit, IPT does not directly target the core **defiant behaviors** and **anger management** issues central to ODD. *Administration of lithium* - **Lithium** is a mood stabilizer primarily used in the treatment of **bipolar disorder** and severe mood dysregulation. - There is no indication from the provided symptoms (defiance, anger, blaming others) that the child is experiencing a mood disorder that would warrant lithium. *Motivational interviewing* - **Motivational interviewing** is a counseling approach that helps individuals resolve ambivalence to change, often used in substance abuse or health behavior change. - While it can be useful in encouraging willingness to engage in therapy, it is not a direct therapeutic modality for addressing the specific **behavioral challenges** and **underlying cognitive distortions** of ODD. *Administration of clozapine* - **Clozapine** is an antipsychotic medication reserved for severe mental illnesses like **treatment-resistant schizophrenia** due to its significant side effects. - The child's symptoms of defiance and rule-breaking are not indicative of a psychotic disorder requiring antipsychotic medication.

Question 5: A 7-year-old boy is brought to the physician by his mother for the evaluation of abdominal pain and trouble sleeping for the past 6 months. His mother says he complains of crampy abdominal pain every morning on school days. He started attending a new school 7 months ago and she is concerned because he has missed school frequently due to the abdominal pain. He also has trouble falling asleep at night and asks to sleep in the same room with his parents every night. He has not had fever, vomiting, diarrhea, or weight loss. He sits very close to his mother and starts to cry when she steps out of the room to take a phone call. Abdominal examination shows no abnormalities. Which of the following is the most likely diagnosis?

A. Acute stress disorder
B. Separation anxiety disorder (Correct Answer)
C. Normal behavior
D. Irritable bowel syndrome
E. Conduct disorder

Explanation: ***Separation anxiety disorder*** - This child exhibits classic symptoms of **separation anxiety disorder**, including **school refusal** due to physical complaints (abdominal pain), **difficulty sleeping alone**, and **excessive distress** when separated from a primary attachment figure (mother). - The symptoms started shortly after attending a new school, a common trigger for separation anxiety, and have persisted for 6 months, meeting the **diagnostic criteria for duration** in children (≥4 weeks). *Acute stress disorder* - **Acute stress disorder** typically occurs within one month of exposure to a **traumatic event** and involves symptoms like intrusive thoughts, negative mood, dissociation, and hypervigilance. - The boy's symptoms are **chronic (6 months)** and are related to separation, not a specific traumatic event, making this diagnosis less likely. *Normal behavior* - While some mild separation anxiety is normal in young children, the **severity**, **duration (6 months)**, and **functional impairment** (missing school, difficulty sleeping alone) in this 7-year-old go beyond what is considered typical developmental behavior. - Normal separation anxiety usually resolves by preschool age or is short-lived without significant impact on daily life. *Irritable bowel syndrome* - **Irritable bowel syndrome (IBS)** is a common cause of recurrent abdominal pain, but it is typically associated with **changes in bowel habits** (constipation or diarrhea), which are absent in this case. - Furthermore, the child's other symptoms, such as **school refusal**, **sleep disturbances**, and **distress upon separation**, are not characteristic of IBS and point towards a psychological rather than purely gastrointestinal etiology. *Conduct disorder* - **Conduct disorder** involves a persistent pattern of **aggressive behavior**, **destruction of property**, **deceitfulness or theft**, and **serious rule violations**, none of which are described in this case. - The child's symptoms are characterized by anxiety and emotional distress related to separation, not defiant or antisocial behavior.

Question 6: A 35-year-old man comes to the Veterans Affairs hospital because of a 2-month history of anxiety. He recently returned from his third deployment to Iraq, where he served as a combat medic. He has had difficulty readjusting to civilian life. He works as a taxi driver but had to take a leave of absence because of difficulties with driving. Last week, he hit a stop sign because he swerved out of the way of a grocery bag that was in the street. He has difficulty sleeping because of nightmares about the deaths of some of the other soldiers in his unit and states, “it's my fault, I could have saved them. Please help me.” Mental status examination shows a depressed mood and a restricted affect. There is no evidence of suicidal ideation. Which of the following is the most appropriate initial step in treatment?

A. Dialectical behavioral therapy
B. Venlafaxine therapy
C. Cognitive behavioral therapy (Correct Answer)
D. Motivational interviewing
E. Prazosin therapy

Explanation: ***Cognitive behavioral therapy*** - **Cognitive Behavioral Therapy (CBT)** is considered a first-line psychological treatment for **Post-Traumatic Stress Disorder (PTSD)**, which the patient's symptoms (deployments, intrusive thoughts, nightmares, avoidance, guilt) strongly suggest. - CBT helps individuals identify and challenge **maladaptive thought patterns** and behaviors related to the trauma, fostering new coping mechanisms. *Dialectical behavioral therapy* - **Dialectical Behavioral Therapy (DBT)** is primarily used for individuals with **Borderline Personality Disorder** or severe emotional dysregulation. - While it can help with emotional regulation, it is not the **first-line therapy** specifically targeting trauma-related cognitive distortions and avoidance behaviors seen in PTSD. *Venlafaxine therapy* - **Venlafaxine**, an SNRI, is an antidepressant that can be effective for PTSD symptoms. However, current guidelines recommend **psychotherapy (like CBT)** as the initial step, especially when feasible. - While pharmacotherapy can be used, it's typically considered **adjunctive** or for cases where psychotherapy alone is insufficient or not preferred. *Motivational interviewing* - **Motivational interviewing** is a patient-centered counseling style used to address ambivalence and enhance a person's **intrinsic motivation** for change. - It is often utilized in substance abuse treatment or when patients are resistant to treatment, but it is not a primary, standalone treatment for the core symptoms of PTSD. *Prazosin therapy* - **Prazosin** is an alpha-1 antagonist used off-label to treat **PTSD-related nightmares** and sleep disturbances. - While it can be helpful for a specific symptom, it does not address the broader spectrum of PTSD symptoms, such as intrusive thoughts, avoidance, or negative cognitions.

Question 7: An 8-year-old boy is brought to his pediatrician by his mother because she is worried about whether he is becoming ill. Specifically, he has been sent home from school six times in the past month because of headaches and abdominal pain. In fact, he has been in the nurse's office almost every day with various symptoms. These symptoms started when the family moved to an old house in another state about 2 months ago. Furthermore, whenever he is taken care of by a babysitter he also has these symptoms. Despite these occurrences, the boy never seems to have any problems at home with his parents. Which of the following treatments would likely be effective for this patient?

A. Play therapy (Correct Answer)
B. Succimer
C. Supportive only
D. Clonidine
E. Methylphenidate

Explanation: ***Play therapy*** - The boy's symptoms are likely **psychosomatic**, triggered by **stressors** like moving and separation from parents, as they resolve at home. - **Play therapy** is an effective treatment for children experiencing emotional or behavioral difficulties due to stress, allowing them to express feelings in a non-threatening environment. *Succimer* - **Succimer** is a chelating agent used to treat **lead poisoning**. - While the family moved to an old house, symptoms like headaches and abdominal pain could be associated with lead exposure, but the **situational nature** of his symptoms (occurring only outside the home or with babysitters) makes lead poisoning less likely. *Supportive only* - While supportive care is generally helpful, the severity and persistence of the symptoms suggest that a **more targeted intervention** like therapy is needed to address the underlying psychological distress. - Simply observing or offering general support would likely not resolve the **situational anxiety** contributing to his somatic complaints. *Clonidine* - **Clonidine** is typically used to treat conditions like **ADHD**, **hypertension**, or tics, and is not a primary treatment for psychosomatic complaints in children. - The patient's symptoms are linked to specific psychological triggers rather than a primary medical or neurological condition usually targeted by clonidine. *Methylphenidate* - **Methylphenidate** is a stimulant medication commonly used to treat **Attention-Deficit/Hyperactivity Disorder (ADHD)**. - There is no indication from the provided symptoms (headaches, abdominal pain, situational nature) that the child has ADHD.

Question 8: A 5-year-old boy is brought in by his mother with reports of trouble at school. Teachers report that for the last 6 months he has been having difficulty finishing tasks, is easily distracted, frequently does not listen, commonly fails to finish schoolwork, has not been able to complete any of the class projects this year, and frequently loses school books and supplies. Teachers also say that he constantly fidgets, often leaves his seat without permission, has trouble being quiet, talks excessively, frequently interrupts his classmates when trying to answer questions, and has difficulty waiting in line. The mother states that she has also been noticing similar behaviors at home and that his symptoms have been affecting him negatively academically and socially. The patient has no significant past medical history. The patient is in the 90th percentile for height and weight and has been meeting all the developmental milestones. He is afebrile, and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following medications is a first-line treatment for this patient’s most likely diagnosis?

A. Clonidine
B. Guanfacine
C. Atomoxetine
D. Methylphenidate (Correct Answer)
E. Haloperidol

Explanation: ***Methylphenidate*** - The patient exhibits core symptoms of **ADHD** (hyperactivity, impulsivity, and inattention) for at least 6 months, across multiple settings, and causing significant impairment. **Methylphenidate** is a **first-line stimulant medication** for treating ADHD. - As a **stimulant**, methylphenidate increases levels of **dopamine** and **norepinephrine** in the brain, improving focus and reducing hyperactivity. *Clonidine* - **Clonidine** is an **alpha-2 adrenergic agonist** that can be used to treat ADHD, particularly for managing **hyperactivity, impulsivity, and tics**. - It is typically considered a **second-line agent** or an adjunct therapy when stimulants are not effective or are contraindicated. *Guanfacine* - **Guanfacine** is another **alpha-2 adrenergic agonist** often used for ADHD, especially for children who cannot tolerate stimulants or have significant **hyperactivity/impulsivity**. - Like clonidine, it is generally considered a **non-stimulant alternative** but not typically the first-line choice over stimulants. *Atomoxetine* - **Atomoxetine** is a **norepinephrine reuptake inhibitor** and a non-stimulant medication for ADHD. - It is a **first-line non-stimulant option** but stimulants like methylphenidate are generally preferred as first-line due to their higher efficacy and faster onset of action. *Haloperidol* - **Haloperidol** is a **first-generation antipsychotic** primarily used to treat **psychotic disorders** like schizophrenia, severe agitation, and Tourette's syndrome. - It is **not indicated** for the treatment of ADHD and would be inappropriate given the patient's symptoms.

Question 9: A 35-year-old woman presents to clinic in emotional distress. She states she has been unhappy for the past couple of months and is having problems with her sleep and appetite. Additionally, she reports significant anxiety regarding thoughts of dirtiness around the house. She states that she cleans all of the doorknobs 5-10 times per day and that, despite her actions, the stress related to cleaning is becoming worse. What is this patient's diagnosis?

A. Panic Disorder (PD)
B. Generalized anxiety disorder (GAD)
C. Obsessive compulsive personality disorder (OCPD)
D. Obsessive compulsive disorder (OCD) (Correct Answer)
E. Tic disorder

Explanation: ***Obsessive compulsive disorder (OCD)*** - The patient's **recurrent distressing thoughts** about dirtiness (obsessions) and **repetitive cleaning behaviors** (compulsions) designed to reduce anxiety are hallmark symptoms of OCD. - The significant **emotional distress**, impact on daily life, and worsening stress despite the compulsions further support this diagnosis. *Panic Disorder (PD)* - Characterized by **recurrent, unexpected panic attacks** and persistent worry about additional attacks or their consequences. - While anxiety is present, the patient's primary distress is driven by specific obsessions and compulsions, not sudden episodes of intense fear. *Generalized anxiety disorder (GAD)* - Involves **excessive, uncontrollable worry** about a variety of events or activities for at least 6 months. - The anxiety symptoms are general, not focused on specific obsessions leading to compulsive behaviors as seen in this case. *Obsessive compulsive personality disorder (OCPD)* - Marked by pervasive patterns of **perfectionism, orderliness, and control** at the expense of flexibility and efficiency. - While there may be a preoccupation with rules, OCPD does not typically involve intrusive, ego-dystonic obsessions or ritualistic compulsions like repetitive cleaning to reduce anxiety. *Tic disorder* - Characterized by **sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations**. - Tics are distinct from the complex, goal-directed, and anxiety-driven compulsive behaviors described by the patient.

Question 10: A previously healthy 36-year-old man is brought to the physician by a friend because of fatigue and a depressed mood for the past few weeks. During this time, he has not been going to work and did not show up to meet his friends for two bowling nights. The friend is concerned that he may lose his job. He spends most of his time alone at home watching television on the couch. He has been waking up often at night and sometimes takes 20 minutes to go back to sleep. He has also been drinking half a pint of whiskey per day for 1 week. His wife left him 4 weeks ago and moved out of their house. His vital signs are within normal limits. On mental status examination, he is oriented to person, place and time. He displays a flattened affect and says that he “doesn't know how he can live without his wife.” He denies suicidal ideation. Which of the following is the next appropriate step in management?

A. Prescribe a short course of alprazolam
B. Hospitalize the patient
C. Initiate cognitive behavioral therapy (Correct Answer)
D. Initiate disulfiram therapy
E. Prescribe a short course of duloxetine

Explanation: ***Initiate cognitive behavioral therapy*** - The patient exhibits features of **adjustment disorder with depressed mood**, characterized by significant distress or impairment in functioning in response to an identifiable stressor (wife leaving). - **Cognitive behavioral therapy (CBT)** is an effective first-line treatment for adjustment disorders, helping patients develop coping strategies and restructure negative thought patterns. *Prescribe a short course of alprazolam* - **Alprazolam**, a benzodiazepine, can provide temporary relief for anxiety but does not address the underlying issues of adjustment disorder and carries risks of **dependence** and withdrawal. - It would be inappropriate as a sole initial treatment and could exacerbate his **alcohol use**. *Hospitalize the patient* - The patient denies **suicidal ideation** and does not present with acute psychosis or severe impairment that would warrant **hospitalization**. - His orientation and ability to engage in conversation further suggest an outpatient approach is safe and appropriate. *Initiate disulfiram therapy* - **Disulfiram** is used for alcohol dependence to deter drinking, but the patient's current alcohol use is a recent development in response to stress, not necessarily full-blown **alcohol dependence** requiring disulfiram. - Addressing the underlying **adjustment disorder** is the priority, which may in turn reduce his alcohol consumption. *Prescribe a short course of duloxetine* - **Duloxetine** is an antidepressant that is not indicated for **adjustment disorder** as a first-line treatment, especially given the short duration and clear precipitating factor. - **Psychotherapy**, like CBT, is generally the preferred initial intervention for adjustment disorders.

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