Anxiety

Anxiety US Medical PG Question 1: A 23-year-old man presents to the emergency department with a chief complaint of being assaulted on the street. The patient claims that he has been followed by the government for quite some time and that he was assaulted by a government agent but was able to escape. He often hears voices telling him to hide. The patient has an unknown past medical history and admits to smoking marijuana frequently. On physical exam, the patient has no signs of trauma. When interviewing the patient, he is seen conversing with an external party that is not apparent to you. The patient states that he is afraid for his life and that agents are currently pursuing him. What is the best initial response to this patient’s statement?

• A. I think you are safe from the agents here.
• B. You have a mental disorder but don’t worry we will help you.
• C. I don’t think any agents are pursuing you.
• D. What medications are you currently taking?
• E. It sounds like you have been going through some tough experiences lately. (Correct Answer)

Anxiety Explanation: ***It sounds like you have been going through some tough experiences lately.*** - This response **acknowledges the patient's distress** and experience without validating or refuting their delusional beliefs. - It helps establish **rapport** and encourages the patient to share more about their symptoms, which is crucial for assessment in a psychiatric emergency. *I think you are safe from the agents here.* - While intended to reassure, directly addressing the delusion can be perceived as dismissive and may **escalate the patient's paranoia** or agitation. - It does not validate their *feelings* of fear, which are real to them, even if the source is delusional. *You have a mental disorder but don’t worry we will help you.* - This statement is **confrontational** and judgmental, labeling the patient immediately with a diagnosis. - This approach can cause the patient to become defensive, shut down, or feel stigmatized, making further assessment and trust-building very difficult in the **initial interaction**. *I don’t think any agents are pursuing you.* - Directly **challenging a patient's delusion** is generally unhelpful in acute settings and can lead to increased agitation. - It invalidates their subjective reality and can make them feel misunderstood or distrustful of the healthcare provider. *What medications are you currently taking?* - While important information, asking about medications is too premature as an *initial response* to a patient expressing severe paranoia and fear. - This question comes across as dismissive of their current emotional state and **prioritizes medical history over emotional support** and rapport-building.

Anxiety US Medical PG Question 2: A 48-year-old woman is brought to the emergency department by her family at her psychiatrist's recommendation. According to her family, she has been more restless than her baseline over the past week. The patient herself complains that she feels her mind is racing. Her past medical history is significant for bipolar disorder on lithium and type 1 diabetes mellitus. The family and the patient both assert that the patient has been taking her medications. She denies any recent illness or sick contacts. The patient's temperature is 100°F (37.8°C), blood pressure is 100/60 mmHg, pulse is 130/min, and respirations are 20/min. She appears diaphoretic, and her cardiac exam is notable for an irregularly irregular rhythm with a 2/6 early systolic murmur. Blood counts and metabolic panel are within normal limits. The patient's lithium level is within therapeutic range. Which of the following laboratory tests would be the most useful to include in the evaluation of this patient?

• A. Thyroglobulin level
• B. Thyroid stimulating hormone and total thyroxine levels
• C. Thyrotropin-releasing hormone stimulation test
• D. Triiodothyronine and thyroxine levels
• E. Thyroid stimulating hormone and free thyroxine levels (Correct Answer)

Anxiety Explanation: ***Thyroid stimulating hormone and free thyroxine levels*** - This patient presents with symptoms highly suggestive of **hyperthyroidism**, including **restlessness**, **tachycardia** (pulse 130/min), **diaphoresis**, and a **racing mind**. These symptoms, particularly in a patient on lithium (which can induce thyroid dysfunction), necessitate a thorough thyroid evaluation. - While total T4 can be influenced by protein binding, **free T4** is the active form of the hormone and provides a more accurate assessment of thyroid status, along with **TSH** as the primary screening test. *Thyroglobulin level* - **Thyroglobulin** is primarily used as a tumor marker in the follow-up of patients treated for differentiated thyroid cancer to detect recurrence. - It is not a primary diagnostic test for hyperthyroidism and would not be the most useful initial test in this scenario. *Thyroid stimulating hormone and total thyroxine levels* - While TSH and total T4 are used, **total T4** levels can be affected by changes in **thyroid-binding globulin (TBG)**, which can be altered by various conditions or medications (e.g., estrogen, liver disease). - Therefore, **free thyroxine** provides a more accurate reflection of thyroid function than total thyroxine. *Thyrotropin-releasing hormone stimulation test* - A **TRH stimulation test** is primarily used to investigate subtle abnormalities in the hypothalamic-pituitary-thyroid axis, often when other thyroid function tests are equivocal. - It is not a first-line diagnostic test for overt hyperthyroidism and would be overly complex for initial evaluation of this patient's symptoms. *Triiodothyronine and thyroxine levels* - While T3 and T4 levels are part of thyroid function assessment, specifying **free thyroxine** versus total thyroxine is crucial for accuracy. - **Free T4** levels, along with TSH, are generally the most informative initial tests for diagnosing conditions like hyperthyroidism.

Anxiety US Medical PG Question 3: An 18-year-old man presents to the student health department at his university for recurrent palpitations. The patient had previously presented to the emergency department (ED) for sudden onset palpitations five months ago when he first started college. He had a negative cardiac workup in the ED and he was discharged with a 24-hour Holter monitor which was also negative. He has no history of any medical or psychiatric illnesses. The patient reports that since his initial ED visit, he has had several episodes of unprovoked palpitations associated with feelings of dread and lightheadedness though he cannot identify a particular trigger. Recently, he has begun sitting towards the back of the lecture halls so that he can “quickly escape and not make a scene” in case he gets an episode in class. Which of the following is the most likely diagnosis?

• A. Social phobia
• B. Specific phobia
• C. Adjustment disorder
• D. Panic disorder (Correct Answer)
• E. Somatic symptom disorder

Anxiety Explanation: ***Panic disorder*** - The patient experiences **recurrent, unprovoked panic attacks** characterized by palpitations, feelings of dread, and lightheadedness, which align with the diagnostic criteria for panic disorder. - His behavior of sitting at the back of lecture halls to "quickly escape" indicates **avoidance behaviors** and **anticipatory anxiety** related to potential future attacks, a hallmark of panic disorder. *Social phobia* - This condition is characterized by **fear or anxiety about social situations** where the individual might be scrutinized or judged, which is not the primary driver of the patient's symptoms or avoidance behavior. - While he avoids public situations, his motivation is fear of a panic attack, not fear of social judgment. *Specific phobia* - This involves an **intense, irrational fear of a specific object or situation** (e.g., heights, spiders, flying), which does not fit the generalized, unprovoked nature of the patient's panic attacks. - The patient's symptoms are not tied to a single, clearly defined phobic stimulus. *Adjustment disorder* - This diagnosis is typically made when individuals experience **emotional or behavioral symptoms in response to an identifiable stressor**, arising within three months of the onset of the stressor. - While starting college is a stressor, the patient's panic attacks are recurrent and unprovoked, evolving into a pattern beyond a typical adjustment response, and he has a negative cardiac workup. *Somatic symptom disorder* - This involves **distressing somatic symptoms accompanied by excessive thoughts, feelings, or behaviors related to the symptoms**, such as disproportionate thoughts about the seriousness of one's symptoms or high levels of anxiety about health. - Although the patient experiences physical symptoms (palpitations), the presence of clear panic attacks, dread, and avoidance behavior points more specifically to panic disorder rather than a primary focus on the somatic symptoms themselves.

Anxiety US Medical PG Question 4: An epidemiologist is evaluating the efficacy of Noxbinle in preventing HCC deaths at the population level. A clinical trial shows that over 5 years, the mortality rate from HCC was 25% in the control group and 15% in patients treated with Noxbinle 100 mg daily. Based on this data, how many patients need to be treated with Noxbinle 100 mg to prevent, on average, one death from HCC?

• A. 20
• B. 73
• C. 10 (Correct Answer)
• D. 50
• E. 100

Anxiety Explanation: ***10*** - The **number needed to treat (NNT)** is calculated by first finding the **absolute risk reduction (ARR)**. - **ARR** = Risk in control group - Risk in treatment group = 25% - 15% = **10%** (or 0.10). - **NNT = 1 / ARR** = 1 / 0.10 = **10 patients**. - This means that **10 patients must be treated with Noxbinle to prevent one death from HCC** over 5 years. *20* - This would result from an ARR of 5% (1/0.05 = 20), which is not supported by the data. - May arise from miscalculating the risk difference or incorrectly halving the actual ARR. *73* - This value does not correspond to any standard calculation of NNT from the given mortality rates. - May result from confusion with other epidemiological measures or calculation error. *50* - This would correspond to an ARR of 2% (1/0.02 = 50), which significantly underestimates the actual risk reduction. - Could result from incorrectly calculating the difference as a proportion rather than absolute percentage points. *100* - This would correspond to an ARR of 1% (1/0.01 = 100), grossly underestimating the treatment benefit. - May result from confusing ARR with relative risk reduction or other calculation errors.

Anxiety US Medical PG Question 5: A 33-year-old woman presents with lethargy and neck pain. She says that, for the past 6 months, she has been feeling tired all the time and has noticed a lot of muscle tension around the base of her neck. She also says she finds herself constantly worrying about everything, such as if her registered mail would reach family and friends in time for the holidays or if the children got their nightly bath while she was away over the weekend. She says that this worrying has prevented her from sleeping at night and has made her more irritable and edgy with her family and friends. Which of the following is the best course of treatment for this patient?

• A. Support groups
• B. A vacation
• C. Diazepam
• D. Family therapy
• E. Buspirone (Correct Answer)

Anxiety Explanation: ***Buspirone*** - **Buspirone** is a non-benzodiazepine anxiolytic agent. It is often preferred for long-term management of **generalized anxiety disorder (GAD)** due to its favorable side effect profile and lack of dependence potential, addressing the patient's chronic symptoms effectively. - Unlike benzodiazepines, buspirone does not cause sedation or withdrawal symptoms, making it suitable for a patient experiencing prolonged anxiety, sleep disturbances, and irritability. *Support groups* - While **support groups** can provide emotional support and coping strategies, they are typically used as an adjunct to pharmacotherapy or psychotherapy, not as a primary standalone treatment for moderate to severe GAD. - This patient's symptoms (lethargy, significant muscle tension, chronic worrying, sleep disturbance) suggest a need for a more direct pharmacological intervention to alleviate her symptoms. *A vacation* - A vacation might offer temporary relief from stress but will not address the underlying physiological and psychological components of her **generalized anxiety disorder**. - Her chronic and pervasive worrying, along with physical symptoms, indicates a need for sustained medical management. *Diazepam* - **Diazepam** is a benzodiazepine that provides rapid, short-term relief from anxiety, but it is generally not recommended for long-term management due to the risks of **dependence, tolerance, and withdrawal symptoms**, especially in a patient with chronic symptoms. - Given the patient's 6-month history of symptoms, a medication with a better long-term safety profile is preferred. *Family therapy* - **Family therapy** could be beneficial if family dynamics are a significant contributor to her stress or if her symptoms are impacting family relationships negatively. However, it does not directly address the primary diagnosis of generalized anxiety disorder with its constellation of chronic symptoms. - While it may provide some support, it is not the initial best course of treatment for the patient's core anxiety symptoms.

Anxiety Flashcard 1 of 5

Question: If a psychosocial stressor causes continued impairment > 6 months after the stressor ends, it is _____ disorder

Answer: generalized anxiety

Anxiety Flashcard 2 of 5

Question: What is the first-line treatment for agoraphobia? _____

Answer: CBT + SSRIs

Anxiety Flashcard 3 of 5

Question: Anxiety is characterized by _____ serotonin

Answer: decreased

Anxiety Flashcard 4 of 5

Question: People with cluster _____ personality disorders are described as anxious or fearful

Answer: C

Anxiety Flashcard 5 of 5

Question: Specific phobias can be treated with _____ therapy (a form of behavioral therapy)

Answer: systematic desensitization