An 88-year-old man presents to his primary care physician due to insomnia. The patient's wife states that she often sees him sitting awake at night, seems visibly irritated. This has persisted for years but worsened recently when the patient attended a funeral for one of his friends in the military. The patient states that he has trouble sleeping and finds that any slight sound causes him to feel very alarmed. Recently, the patient has been having what he describes as strong memories of events that occurred with his fellow soldiers while at war. At times he awakes in a cold sweat and has not been able to get quality sleep in weeks. The patient has a past medical history of anxiety, obesity, and type II diabetes mellitus. His current medications include insulin, metformin, lisinopril, sodium docusate, and fish oil. Which of the following is the best initial medical therapy for this patient?
Q82
A 5-year-old boy is brought to the physician by his parents because of 2 episodes of screaming in the night over the past week. The parents report that their son woke up suddenly screaming, crying, and aggressively kicking his legs around both times. The episodes lasted several minutes and were accompanied by sweating and fast breathing. The parents state that they were unable to stop the episodes and that their son simply went back to sleep when the episodes were over. The patient cannot recall any details of these incidents. He has a history of obstructive sleep apnea. He takes no medications. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
Q83
A 4-year-old boy presents to the pediatrician's office for a well child checkup. He does not speak during the visit and will not make eye contact. The father explains that the child has always been shy with strangers. However, the child speaks a lot at home and with friends. He can speak in 4 word sentences, tells stories, and parents understand 100% of what he says. He names colors and is starting to recognize letters. However, his pre-kindergarten teachers are concerned that even after 5 months in their class, he does not speak during school at all. The father notes that he is equally as shy in church, which he has been going to his entire life. Which of the following is most likely?
Q84
A 35-year-old woman presents to her family doctor worried that she might have a heart condition. For the past 7 months, she has been having short panic attacks where she feels short of breath, sweaty, and feels like her heart wants to jump out her chest. During these attacks, she feels like she ‘is going crazy’. She has now mapped out all of the places she has had an attack such as the subway, the crowded pharmacy near her house, and an elevator at her work that is especially slow and poorly lit. She actively avoids these areas to prevent an additional episode. She is afraid that during these attacks she may not be able to get the help she needs or escape if needed. No significant past medical history. The patient takes no current medications. Her grandfather died of a heart attack at the age of 70 and she is worried that it might run in the family. The patient is afebrile and vital signs are within normal limits. Laboratory results are unremarkable. Which of the following is the most likely diagnosis for this patient’s condition?
Q85
A 29-year-old woman presents with convulsions. The patient’s brother says that he found her like that an hour ago and immediately called an ambulance. He also says that she has been extremely distraught and receiving supportive care from a social worker following a sexual assault by a coworker a few days ago. He says that the patient has no history of seizures. She has no significant past medical history and takes no medications. The patient’s vital signs include: temperature 37.0°C (98.6°F), pulse 101/min, blood pressure 135/99 mm Hg, and respiratory rate 25/min. On physical examination, the patient is rolling from side to side, arrhythmically thrashing around, and muttering strangely. Her eyes are closed, and there is resistance to opening them. Which of the following is the most likely diagnosis in this patient?
Q86
A 41-year-old man comes to the physician because of a 7-month history of sleep disturbances, restlessness, and difficulty acquiring erections. He started a new job as a project coordinator 8 months ago. He has difficulty falling asleep and lies awake worrying about his family, next day's meetings, and finances. He can no longer concentrate on his tasks at work. He feels tense most days and avoids socializing with his friends. He worries that he has an underlying medical condition that is causing his symptoms. Previous diagnostic evaluations were unremarkable. He has a history of drinking alcohol excessively during his early 20s, but he has not consumed alcohol for the past 10 years. He appears anxious. Physical examination shows no abnormalities. In addition to psychotherapy, treatment with which of the following drugs is most appropriate in this patient?
Q87
A 16-year-old girl comes to the physician because she is worried about gaining weight. She reports that at least twice a week, she eats excessive amounts of food but feels ashamed about losing control soon after. She is very active in her high school's tennis team and goes running daily to lose weight. She has a history of cutting her forearms with the metal tab from a soda can. Her last menstrual period was 3 weeks ago. She is 165 cm (5 ft 5 in) tall and weighs 57 kg (125 lb); BMI is 21 kg/m2. Physical examination shows enlarged, firm parotid glands bilaterally. There are erosions of the enamel on the lingual surfaces of the teeth. Which of the following is the most likely diagnosis?
Q88
A 28-year-old man comes to the physician because of a 9-month history of sleep disturbances, restlessness, and difficulty acquiring erections. He has difficulty falling asleep and wakes up at least 3 times per night. He worries about paying his bills, failing law school, and disappointing his parents. He can no longer concentrate in class and failed the last exam. He feels on edge most days and avoids socializing with his classmates. He worries that he has an underlying medical condition that is causing his symptoms. Previous diagnostic evaluations were unremarkable. There is no personal or family history of serious illness. He is sexually active with his girlfriend. He has a history of drinking alcohol excessively during his early 20s, but he has not consumed alcohol for the past 3 years. He appears anxious. Vital signs are within normal limits. On mental status examination, he is oriented to person, place, and time. Physical examination shows no abnormalities. In addition to psychotherapy, treatment with which of the following drugs is most appropriate in this patient?
Q89
Which of the following situations calls for treatment with alprazolam?
Q90
A 39-year-old man presents to the emergency department for severe abdominal pain. His pain is located in the epigastric region of his abdomen, which he describes as sharp and persistent. His symptoms began approximately 2 days prior to presentation, and he has tried acetaminophen and ibuprofen, which did not improve his symptoms. He feels nauseated and has had 2 episodes of non-bloody, non-bilious emesis. He has a medical history of hypertension and hyperlipidemia for which he is on chlorthalidone and simvastatin. He has smoked 1 pack of cigarettes per day for the last 20 years and drinks 1 pint of vodka per day. On physical exam, there is tenderness to palpation of the upper abdomen, and the patient is noted to have tender hepatomegaly. Serum studies demonstrate:
Amylase: 350 U/L (25-125 U/L)
Lipase: 150 U/L (12-53 U/L)
AST: 305 U/L (8-20 U/L)
ALT: 152 U/L (8-20 U/L)
He is admitted to the hospital and started on intravenous fluids and morphine. Approximately 18 hours after admission the patient reports to feeling anxious, tremulous, and having trouble falling asleep. His blood pressure is 165/105 mmHg and pulse is 140/min. On exam, the patient appears restless and diaphoretic. Which of the following will most likely improve this patient's symptoms?
Anxiety US Medical PG Practice Questions and MCQs
Question 81: An 88-year-old man presents to his primary care physician due to insomnia. The patient's wife states that she often sees him sitting awake at night, seems visibly irritated. This has persisted for years but worsened recently when the patient attended a funeral for one of his friends in the military. The patient states that he has trouble sleeping and finds that any slight sound causes him to feel very alarmed. Recently, the patient has been having what he describes as strong memories of events that occurred with his fellow soldiers while at war. At times he awakes in a cold sweat and has not been able to get quality sleep in weeks. The patient has a past medical history of anxiety, obesity, and type II diabetes mellitus. His current medications include insulin, metformin, lisinopril, sodium docusate, and fish oil. Which of the following is the best initial medical therapy for this patient?
A. Escitalopram
B. Clonazepam
C. Trazodone (Correct Answer)
D. Buspirone
E. Bupropion
Explanation: ***Trazodone***
- This patient presents with symptoms highly suggestive of **post-traumatic stress disorder (PTSD)**, including insomnia, hypervigilance, and intrusive memories, potentially exacerbated by attending a friend's funeral. **Trazodone** is an antidepressant with prominent sedating effects that can be particularly useful for managing **insomnia and nightmares associated with PTSD**, especially in elderly patients, without the highly addictive properties of benzodiazepines.
- Given the patient's age and multiple comorbidities, a medication with a favorable side effect profile for sleep is preferred. Trazodone is generally well-tolerated at lower doses for sleep and avoids the cognitive and dependence risks of other sleep aids like benzodiazepines.
*Escitalopram*
- While **SSRIs like escitalopram** are first-line treatments for the core symptoms of PTSD, they often take several weeks to achieve their full therapeutic effect and do not provide immediate relief for the severe insomnia and nightmares that are most distressing to this patient.
- Escitalopram can sometimes initially worsen sleep disturbances, making it less ideal as a rapid initial therapy for severe insomnia in an elderly patient.
*Clonazepam*
- **Benzodiazepines like clonazepam** can provide quick relief for anxiety and insomnia, but they are generally discouraged in elderly patients due to the high risk of **sedation, cognitive impairment, falls, and potential for dependence and withdrawal symptoms**.
- In a patient with PTSD, benzodiazepines may also **interfere with fear extinction** and proper processing of traumatic memories, potentially hindering long-term recovery.
*Buspirone*
- **Buspirone** is an anxiolytic that can be used to treat generalized anxiety disorder, but it has no significant hypnotic or sedative effects and would not adequately address the patient's primary complaint of severe insomnia and nightmares.
- Its onset of action is also slow, typically taking 2-4 weeks to show noticeable anxiolytic effects, making it unsuitable for acute management of severe sleep disturbance.
*Bupropion*
- **Bupropion** is an antidepressant that works via dopamine and norepinephrine reuptake inhibition. It is generally considered an **activating antidepressant** and can frequently cause or worsen insomnia, rather than alleviating it.
- Bupropion is not effective for PTSD and is contraindicated in patients with a history of seizures or eating disorders.
Question 82: A 5-year-old boy is brought to the physician by his parents because of 2 episodes of screaming in the night over the past week. The parents report that their son woke up suddenly screaming, crying, and aggressively kicking his legs around both times. The episodes lasted several minutes and were accompanied by sweating and fast breathing. The parents state that they were unable to stop the episodes and that their son simply went back to sleep when the episodes were over. The patient cannot recall any details of these incidents. He has a history of obstructive sleep apnea. He takes no medications. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Restless legs syndrome
B. Nightmare disorder
C. Sleepwalking disorder
D. Insomnia disorder
E. Sleep terror disorder (Correct Answer)
Explanation: ***Sleep terror disorder***
- This patient's presentation with sudden nocturnal screaming, agitation, autonomic arousal (sweating, fast breathing), and subsequent **amnesia** for the event is classic for **sleep terror disorder**.
- The inability of parents to awaken or comfort the child, followed by the child returning to sleep and having **no recall**, are key diagnostic features.
*Restless legs syndrome*
- Characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations, typically occurring or worsening during periods of **rest** or **inactivity**, and partially or totally relieved by movement.
- This condition does not involve screaming, intense fear, or amnesia for a sleep event.
*Nightmare disorder*
- Nightmares are typically **vivid, frightening dreams** from which the individual awakens fully alert and often recalls the dream in detail.
- Unlike sleep terrors, nightmares occur during **REM sleep** (usually later in the night), and the child is usually consolable after waking.
*Sleepwalking disorder*
- Involves complex motor behaviors, such as walking, while still asleep, without full consciousness.
- While it can occur during NREM sleep and involves partial amnesia, it typically **does not feature screaming, intense fear, or significant autonomic arousal** as the predominant symptom.
*Insomnia disorder*
- Defined by persistent difficulty with **sleep initiation, duration, consolidation, or quality**, despite adequate opportunity for sleep, leading to daytime impairment.
- It does not involve acute episodes of screaming or terror during sleep as described.
Question 83: A 4-year-old boy presents to the pediatrician's office for a well child checkup. He does not speak during the visit and will not make eye contact. The father explains that the child has always been shy with strangers. However, the child speaks a lot at home and with friends. He can speak in 4 word sentences, tells stories, and parents understand 100% of what he says. He names colors and is starting to recognize letters. However, his pre-kindergarten teachers are concerned that even after 5 months in their class, he does not speak during school at all. The father notes that he is equally as shy in church, which he has been going to his entire life. Which of the following is most likely?
A. Normal development
B. Child abuse at school
C. Expressive speech delay
D. Autism spectrum disorder
E. Selective mutism (Correct Answer)
Explanation: ***Selective mutism***
- This condition is characterized by a **consistent failure to speak** in specific social situations where speaking is expected (e.g., school, church) despite speaking in other situations (e.g., home, with friends).
- The child's excellent speech and language skills at home, coupled with significant anxiety-driven silence in public settings, are classic signs of **selective mutism**, not a general developmental delay.
*Normal development*
- While shyness is common in children, the complete lack of speech in specific, ongoing social settings like school and church, despite fluent speech at home, goes beyond typical shyness and indicates a **clinical concern**.
- A child who refuses to speak to teachers after 5 months, even with fluent home speech, suggests a **pattern inconsistent with normal social-emotional development**.
*Child abuse at school*
- While abuse can cause behavioral changes, the child’s continued silence and shyness in other settings like church, where abuse is unlikely, makes **abuse at school less probable** as the primary explanation.
- The child's ability to speak fluently at home also makes a specific school-related trauma less likely to be the **sole cause** of his mutism in other public settings.
*Expressive speech delay*
- The child's ability to speak in **4-word sentences**, tell stories, be 100% understood by parents, name colors, and recognize letters indicates **age-appropriate or advanced expressive language skills** in familiar settings.
- An expressive speech delay would imply difficulty with *producing* speech or vocabulary regardless of the setting, which is not the case here.
*Autism spectrum disorder*
- While individuals with ASD may avoid eye contact and have social communication challenges, the child's fluent and complex speech at home and with friends makes **ASD less likely**, as pervasive communication deficits across all environments are characteristic.
- The **situational specificity** of the mutism, rather than a global communication impairment, points away from ASD.
Question 84: A 35-year-old woman presents to her family doctor worried that she might have a heart condition. For the past 7 months, she has been having short panic attacks where she feels short of breath, sweaty, and feels like her heart wants to jump out her chest. During these attacks, she feels like she ‘is going crazy’. She has now mapped out all of the places she has had an attack such as the subway, the crowded pharmacy near her house, and an elevator at her work that is especially slow and poorly lit. She actively avoids these areas to prevent an additional episode. She is afraid that during these attacks she may not be able to get the help she needs or escape if needed. No significant past medical history. The patient takes no current medications. Her grandfather died of a heart attack at the age of 70 and she is worried that it might run in the family. The patient is afebrile and vital signs are within normal limits. Laboratory results are unremarkable. Which of the following is the most likely diagnosis for this patient’s condition?
A. Panic disorder
B. Agoraphobia
C. Generalized anxiety disorder
D. Social anxiety disorder
E. Panic disorder and agoraphobia (Correct Answer)
Explanation: ***Panic disorder and agoraphobia***
- The patient experiences **recurrent unexpected panic attacks** ("feels short of breath, sweaty, feels like her heart wants to jump out her chest") and persistent worry about additional attacks or their consequences, consistent with **panic disorder**.
- Her active avoidance of specific places ("subway, crowded pharmacy, slow and poorly lit elevator") and fear that she "may not be able to get the help she needs or escape if needed" in these situations is characteristic of **agoraphobia**.
*Panic disorder*
- While the patient clearly has panic attacks and associated worry, this option is incomplete as it does not account for the prominent **agoraphobic avoidance behaviors** described.
- The patient's **fear of being trapped or unable to escape** in specific situations points beyond just panic disorder.
*Agoraphobia*
- This diagnosis focuses solely on the **fear of situations from which escape might be difficult or help unavailable**, leading to avoidance.
- However, it does not fully encompass the initial presentation of **sudden, unexpected panic attacks** and the "going crazy" feeling that precedes the avoidance.
*Generalized anxiety disorder*
- This disorder involves **persistent, excessive worry** about various aspects of life for at least six months, often accompanied by symptoms like muscle tension and difficulty concentrating.
- The patient's symptoms are specifically tied to discrete panic attacks and avoidance behaviors, rather than diffuse, generalized worry.
*Social anxiety disorder*
- This condition is characterized by **intense fear or anxiety about social situations** where one might be scrutinized or judged negatively.
- The patient's fear is related to being in places where escape might be difficult or help unavailable during a panic attack, not primarily about social evaluation.
Question 85: A 29-year-old woman presents with convulsions. The patient’s brother says that he found her like that an hour ago and immediately called an ambulance. He also says that she has been extremely distraught and receiving supportive care from a social worker following a sexual assault by a coworker a few days ago. He says that the patient has no history of seizures. She has no significant past medical history and takes no medications. The patient’s vital signs include: temperature 37.0°C (98.6°F), pulse 101/min, blood pressure 135/99 mm Hg, and respiratory rate 25/min. On physical examination, the patient is rolling from side to side, arrhythmically thrashing around, and muttering strangely. Her eyes are closed, and there is resistance to opening them. Which of the following is the most likely diagnosis in this patient?
A. Body dysmorphic disorder
B. Somatic symptom disorder
C. Illness anxiety disorder
D. Somatic symptom disorder with predominant pain
E. Functional neurological symptom disorder (Conversion disorder) (Correct Answer)
Explanation: ***Functional neurological symptom disorder (Conversion disorder)***
- This patient presents with **neurological symptoms (pseudoseizures)** inconsistent with known neurological conditions, following a significant **psychological stressor (sexual assault).**
- Key features like **resistance to eye opening**, **arrhythmic thrashing**, **eyes closed during episode**, and general atypical presentation for a true seizure strongly suggest functional neurological symptom disorder (conversion disorder), as these are classic features of *psychogenic non-epileptic seizures (PNES)*.
- The temporal relationship to trauma and absence of prior seizure history further support this diagnosis.
*Body dysmorphic disorder*
- This disorder involves a **preoccupation with perceived flaws in physical appearance**, which are often minor or not observable to others.
- The patient's symptoms of pseudoseizures and thrashing are **neurological manifestations** and do not align with concerns about physical appearance.
*Somatic symptom disorder*
- This diagnosis involves **one or more somatic symptoms that are distressing or result in significant disruption** of daily life, with **excessive thoughts, feelings, or behaviors** related to the somatic symptoms.
- While somatic symptom disorder can include neurological complaints, the acute presentation of pseudoseizures with specific neurological signs (eye closure resistance, arrhythmic movements) directly linked to recent severe trauma makes functional neurological symptom disorder the more precise diagnosis.
*Illness anxiety disorder*
- Characterized by a **preoccupation with having or acquiring a serious illness** based on misinterpretation of bodily symptoms, with minimal or no somatic symptoms present.
- The patient is experiencing active neurological symptoms (pseudoseizures), not health anxiety or unfounded fear of having an illness.
*Somatic symptom disorder with predominant pain*
- In this specifier, the primary symptom is **pain**, which is distressing and associated with excessive thoughts, feelings, or behaviors related to the pain.
- The patient's primary presentation is **pseudoseizures with motor symptoms**, not pain, making this diagnosis inconsistent with her clinical picture.
Question 86: A 41-year-old man comes to the physician because of a 7-month history of sleep disturbances, restlessness, and difficulty acquiring erections. He started a new job as a project coordinator 8 months ago. He has difficulty falling asleep and lies awake worrying about his family, next day's meetings, and finances. He can no longer concentrate on his tasks at work. He feels tense most days and avoids socializing with his friends. He worries that he has an underlying medical condition that is causing his symptoms. Previous diagnostic evaluations were unremarkable. He has a history of drinking alcohol excessively during his early 20s, but he has not consumed alcohol for the past 10 years. He appears anxious. Physical examination shows no abnormalities. In addition to psychotherapy, treatment with which of the following drugs is most appropriate in this patient?
A. Clonazepam
B. Amitriptyline
C. Propranolol
D. Buspirone
E. Escitalopram (Correct Answer)
Explanation: **Escitalopram**
- The patient presents with **generalized anxiety disorder (GAD)** symptoms, including excessive worry, restlessness, sleep disturbances, difficulty concentrating, and somatic symptoms, for over 6 months; **selective serotonin reuptake inhibitors (SSRIs)** like escitalopram are first-line pharmacotherapy.
- SSRIs are effective in reducing both psychological and physical symptoms of GAD and have a favorable side effect profile compared to other antidepressant classes.
*Clonazepam*
- Clonazepam, a **benzodiazepine**, provides rapid symptom relief for acute anxiety but is associated with risks of **dependence, tolerance, and withdrawal** with long-term use.
- It is generally reserved for short-term use during the initial phase of treatment or for acute exacerbations, not as monotherapy for chronic GAD due to its side effects and risk profile.
*Amitriptyline*
- Amitriptyline is a **tricyclic antidepressant (TCA)** that can be used for anxiety but has a less favorable side effect profile (e.g., **anticholinergic effects, cardiac toxicity**) compared to SSRIs.
- Given the availability of safer and equally effective alternatives like SSRIs, TCAs are not typically considered first-line for GAD.
*Propranolol*
- Propranolol is a **beta-blocker** that primarily targets the physical symptoms of anxiety, such as **tremor, palpitations, and sweating**.
- It is effective for **performance anxiety** or specific phobias but does not address the cognitive and psychological symptoms of generalized anxiety disorder.
*Buspirone*
- Buspirone is an **anxiolytic** that acts on 5-HT1A serotonin receptors and is effective for GAD, but its **onset of action is slow** (several weeks), making it less suitable for initial monotherapy when rapid symptom control is desired.
- It lacks the antidepressant properties of SSRIs, which may be beneficial given the patient's general distress and possible co-existing depressive symptoms.
Question 87: A 16-year-old girl comes to the physician because she is worried about gaining weight. She reports that at least twice a week, she eats excessive amounts of food but feels ashamed about losing control soon after. She is very active in her high school's tennis team and goes running daily to lose weight. She has a history of cutting her forearms with the metal tab from a soda can. Her last menstrual period was 3 weeks ago. She is 165 cm (5 ft 5 in) tall and weighs 57 kg (125 lb); BMI is 21 kg/m2. Physical examination shows enlarged, firm parotid glands bilaterally. There are erosions of the enamel on the lingual surfaces of the teeth. Which of the following is the most likely diagnosis?
A. Borderline personality disorder
B. Bulimia nervosa (Correct Answer)
C. Body dysmorphic disorder
D. Anorexia nervosa
E. Obsessive-compulsive disorder
Explanation: ***Bulimia nervosa***
- This patient exhibits characteristic features of bulimia nervosa, including recurrent episodes of **binge eating** (at least twice weekly) followed by inappropriate **compensatory behaviors**.
- The **bilateral parotid gland enlargement** and **lingual enamel erosion** are **pathognomonic physical signs of chronic self-induced vomiting** (purging behavior), combined with excessive exercise as additional compensation.
- Her normal BMI of 21 kg/m² is highly consistent with bulimia nervosa, as individuals with this condition typically maintain a **normal weight or are overweight**, unlike those with anorexia nervosa.
- The sense of **loss of control** and **shame** about eating episodes are core features of this disorder.
*Borderline personality disorder*
- While **self-harm** (cutting) can be associated with borderline personality disorder, the primary concern in this patient is the prominent eating disorder symptoms with pathognomonic physical findings.
- Borderline personality disorder is characterized by a pervasive pattern of **instability in interpersonal relationships**, self-image, affects, and marked impulsivity; these are not the main presenting complaints here.
- Self-harm behavior can occur in multiple psychiatric conditions and does not alone establish this diagnosis.
*Body dysmorphic disorder*
- This disorder involves a **preoccupation with perceived flaws in physical appearance** that are minimal or unobservable to others, leading to significant distress or impairment.
- While the patient is concerned about gaining weight, her primary symptoms revolve around **binge-purge cycles** with physical evidence of purging behavior, rather than a sole preoccupation with a specific body defect.
*Anorexia nervosa*
- Anorexia nervosa is characterized by **restriction of energy intake** leading to a significantly low body weight (BMI usually <17.5 kg/m²) and intense fear of gaining weight despite being underweight.
- This patient has a **normal BMI (21 kg/m²)** and engages in binge-eating followed by compensatory behaviors (purging and exercise), which represents bulimia nervosa rather than anorexia nervosa.
- Additionally, she has **regular menses** (last period 3 weeks ago), whereas amenorrhea is common in anorexia nervosa due to low body weight.
*Obsessive-compulsive disorder*
- OCD involves recurrent, persistent, **intrusive thoughts (obsessions)** and/or repetitive behaviors or mental acts that an individual feels driven to perform **(compulsions)** to reduce anxiety.
- While some of the patient's behaviors might seem ritualistic, the core symptoms are clearly related to **eating disorder pathology with binge-purge cycles**, not typical OCD themes like contamination, symmetry, or checking behaviors.
- The physical signs of chronic purging behavior definitively point to an eating disorder diagnosis.
Question 88: A 28-year-old man comes to the physician because of a 9-month history of sleep disturbances, restlessness, and difficulty acquiring erections. He has difficulty falling asleep and wakes up at least 3 times per night. He worries about paying his bills, failing law school, and disappointing his parents. He can no longer concentrate in class and failed the last exam. He feels on edge most days and avoids socializing with his classmates. He worries that he has an underlying medical condition that is causing his symptoms. Previous diagnostic evaluations were unremarkable. There is no personal or family history of serious illness. He is sexually active with his girlfriend. He has a history of drinking alcohol excessively during his early 20s, but he has not consumed alcohol for the past 3 years. He appears anxious. Vital signs are within normal limits. On mental status examination, he is oriented to person, place, and time. Physical examination shows no abnormalities. In addition to psychotherapy, treatment with which of the following drugs is most appropriate in this patient?
A. Valerian
B. Buspirone (Correct Answer)
C. Doxepin
D. Propranolol
E. Lorazepam
Explanation: ***Buspirone***
- This patient's symptoms of **generalized anxiety, sleep disturbances**, and **difficulty concentrating** suggest **generalized anxiety disorder (GAD)**. Buspirone is an **anxiolytic** that is often used for GAD, particularly when there is a risk of substance abuse or a need to avoid sedation.
- It works by agonizing **serotonin type 1A receptors (5-HT1A)** and lacks the sedative and dependence potential of benzodiazepines, making it a good choice for long-term treatment.
*Valerian*
- **Valerian root** is an herbal supplement sometimes used for **insomnia** and anxiety.
- However, there is **limited scientific evidence** to support its efficacy for generalized anxiety disorder, and it is not a first-line pharmacological treatment.
*Doxepin*
- **Doxepin** is a **tricyclic antidepressant (TCA)** with significant **sedating and anticholinergic side effects**.
- While it can be used for anxiety, it is generally **not preferred** due to its side effect profile, especially in a young patient where a less sedating option like buspirone is available.
*Propranolol*
- **Propranolol** is a **beta-blocker** primarily used to treat the **physical symptoms of anxiety**, such as palpitations and tremors, often in performance anxiety.
- It does **not address the cognitive and psychological symptoms** of generalized anxiety disorder, such as worry and restlessness.
*Lorazepam*
- **Lorazepam** is a **benzodiazepine** that provides rapid relief of anxiety symptoms.
- However, due to the **risk of dependence, sedation, and withdrawal symptoms**, and the patient's history of excessive alcohol use, it is generally **not preferred for long-term management of GAD**, especially as a first-line agent.
Question 89: Which of the following situations calls for treatment with alprazolam?
A. A 19-year-old male that saw his sibling murdered, and has had flashbacks and hypervigilance for more than one month
B. A 28-year-old female that gets irritated or worried about everyday things out of proportion to the actual source of worry
C. A 42-year-old female with extreme mood changes ranging from mania to severe depression
D. A 65-year-old male with narrow angle glaucoma that complains of excessive worry, rumination, and uneasiness about future uncertainties
E. A 35-year-old male that gets tachycardic, tachypneic, and diaphoretic every time he rides a plane (Correct Answer)
Explanation: ***A 35-year-old male that gets tachycardic, tachypnic, and diaphoretic every time he rides a plane***
- Alprazolam is a **benzodiazepine** commonly used for the acute, short-term management of **panic attacks** and specific phobias due to its rapid onset of action. The symptoms described (tachycardia, tachypnea, diaphoresis) are classic signs of a panic attack triggered by a specific phobia (fear of flying).
- For **acute anxiety** or panic related to specific phobic situations, alprazolam can be prescribed for use **as needed** to alleviate intense symptoms.
*A 19-year-old male that saw his sibling murdered, and has had flashbacks and hypervigilance for more than one month*
- This presentation suggests **post-traumatic stress disorder (PTSD)** due to the nature of the trauma and the duration of symptoms. Benzodiazepines like alprazolam are generally **contraindicated for long-term use in PTSD** because they can interfere with trauma processing and have a high risk of dependence and abuse.
- First-line treatments for PTSD typically involve **selective serotonin reuptake inhibitors (SSRIs)** and **trauma-focused psychotherapy**.
*A 28-year-old female that gets irritated or worried about everyday things out of proportion to the actual source of worry*
- This describes symptoms consistent with **generalized anxiety disorder (GAD)**. While alprazolam can provide short-term relief, it is **not recommended for long-term management of GAD** due to the risk of tolerance and dependence.
- **SSRIs/SNRIs** and **cognitive-behavioral therapy (CBT)** are the preferred long-term treatments for GAD.
*A 42-year-old female with extreme mood changes ranging from mania to severe depression*
- This presentation is highly indicative of **bipolar disorder**. Alprazolam (a benzodiazepine) **does not treat bipolar disorder** and could potentially worsen mania or contribute to rapid cycling in some individuals.
- Treatment for bipolar disorder involves **mood stabilizers** (e.g., lithium, valproate) and sometimes atypical antipsychotics.
*A 65-year-old male with narrow angle glaucoma that complains of excessive worry, rumination, and uneasiness about future uncertainties*
- This patient's symptoms could suggest an anxiety disorder, but the presence of **narrow-angle glaucoma** is a **contraindication for benzodiazepines** like alprazolam, as they can cause mydriasis (pupil dilation) leading to an acute attack of angle-closure glaucoma.
- For anxiety in elderly patients, especially with comorbidities, non-pharmacological interventions or other anxiolytics with a safer profile would be considered.
Question 90: A 39-year-old man presents to the emergency department for severe abdominal pain. His pain is located in the epigastric region of his abdomen, which he describes as sharp and persistent. His symptoms began approximately 2 days prior to presentation, and he has tried acetaminophen and ibuprofen, which did not improve his symptoms. He feels nauseated and has had 2 episodes of non-bloody, non-bilious emesis. He has a medical history of hypertension and hyperlipidemia for which he is on chlorthalidone and simvastatin. He has smoked 1 pack of cigarettes per day for the last 20 years and drinks 1 pint of vodka per day. On physical exam, there is tenderness to palpation of the upper abdomen, and the patient is noted to have tender hepatomegaly. Serum studies demonstrate:
Amylase: 350 U/L (25-125 U/L)
Lipase: 150 U/L (12-53 U/L)
AST: 305 U/L (8-20 U/L)
ALT: 152 U/L (8-20 U/L)
He is admitted to the hospital and started on intravenous fluids and morphine. Approximately 18 hours after admission the patient reports to feeling anxious, tremulous, and having trouble falling asleep. His blood pressure is 165/105 mmHg and pulse is 140/min. On exam, the patient appears restless and diaphoretic. Which of the following will most likely improve this patient's symptoms?
A. Chlordiazepoxide
B. Lorazepam (Correct Answer)
C. Risperidone
D. Thiamine
E. Haloperidol
Explanation: ***Lorazepam***
- The patient is exhibiting symptoms of **alcohol withdrawal**, including anxiety, tremors, restlessness, diaphoresis, hypertension, and tachycardia, which require treatment with a **benzodiazepine**.
- **Lorazepam** is a short-to-intermediate acting benzodiazepine that is preferred in patients with **liver disease** (indicated by elevated AST/ALT and tender hepatomegaly) because it is metabolized by glucuronidation and does not rely on oxidative hepatic metabolism.
*Chlordiazepoxide*
- **Chlordiazepoxide** is a long-acting benzodiazepine primarily metabolized by the **liver's oxidative pathways**, which can accumulate and lead to toxicity in patients with liver dysfunction.
- While effective for alcohol withdrawal, its long half-life and hepatic metabolism make it less ideal for patients with signs of **liver injury** such as this patient with elevated AST/ALT and hepatomegaly.
*Risperidone*
- **Risperidone** is an atypical antipsychotic primarily used to treat **psychosis** or severe agitation, not the core symptoms of alcohol withdrawal.
- It does not address the underlying **neurotransmitter imbalance** (GABAergic hypofunction) characteristic of alcohol withdrawal.
*Thiamine*
- **Thiamine** (vitamin B1) is essential for preventing **Wernicke-Korsakoff syndrome** in patients with chronic alcohol use, and should be administered in this patient.
- However, thiamine does not alleviate the acute symptoms of alcohol withdrawal like anxiety, tremors, or autonomic hyperactivity.
*Haloperidol*
- **Haloperidol** is a potent antipsychotic that can be used for severe agitation or psychotic symptoms, but it **lowers the seizure threshold**, which is particularly dangerous in alcohol withdrawal where seizure risk is already elevated.
- It does not provide the anxiolytic or sedative effects needed to reverse the **GABAergic hypofunction** seen in alcohol withdrawal syndrome.
