Anxiety, Somatoform, and Dissociative Disorders

Question 1

Intermittent Explosive Disorder

Lab findings?

Treatment?

Answer 1

Lab Findings:

Low levels of 5-HIAA in CSF associated with impulsiveness and aggression

Treatment:

SSRIs, anticonvulsants, or lithium

CBT

Group therapy and/or family therapy

Question 2

Kleptomania

Diagnosis?

Most common comorbid condition?

Treatment?

Answer 2

Diagnosis

• Failure to resist uncontrollable urges to steal objects that are not needed for personal use or monetary value
• Inc. tension immediately prior to theft
• Pleasure or relief is experienced while stealing

Most common co-morbid condition

65% of pts with kleptomania suffer from bulimia nervosa

Treatment

1. CBT
2. SSRI

Question 3

GAD

First-line pharmacotherapy

Answer 3

SSRI

Question 4

Panic Attacks / Performance Anxiety

Treatment

Answer 4

Beta-blockers (e.g., propranolol)

Question 5

What type of psychotherapies helpful for anxiety disorders?

Answer 5

• CBT - examines relationship between anxiety-driven cognitions (thoughts), emotions, and behavior
• Psychodynamic psychotherapy - facilitates understanding and insight into the dvlpmt of anxiety and ultimately increases anxiety tolerance

Question 6

Symptoms of panic attack

Da PANICS

Answer 6

• Dizziness, disconnectedness, derealization (unreality), depersonalization (detached from self)
• Palpitations, paresthesias
• Abdominal distress
• Numbness, nausea
• Intense fear of dying, “going crazy”
• Chills, chest pain
• Sweating, shaking, SOB

Question 7

Risk factor for panic attack

Answer 7

Smoking

Question 8

Agoraphobia

Diagnosis and treatment

Answer 8

Intense fear of being in public places where escape or obtaining help may be difficult (bridges, trains, subways) / Sx last > 6 mo

Tx: (similar approach as panic disorder)

CBT and SSRIs (for panic symptoms)

Question 9

Triad of uncontrollable urges

Answer 9

OCD, ADHD, tic disorder

Question 10

PTSD

Pharmacological tx

Answer 10

• First-line antidepressants: SSRIs
• Prazosin (a1-receptor antagonist) –> target nightmares
• Psychotherapy

Question 11

23 yo woman arrives at ER complaining that, out of the blue, she had been seized by an overwhelming fear associated with SOB and a pounding. heart. These sx lasts for approx 20 min, and while she was experiencing them, she feared that she was dying or going crazy.

Pt had 4 similar episodes during the past month, and she has been worrying that they will continue to recur. Which of the following is most likely dx?

a. Acute psychotic episode
b. Hypochondriasis
c. Panic disorder
d. GAD
e. PTSD

Answer 11

c. Panic disorder

Dx when at least 1 month of persistent concern, worry, or behavioral change associated with the attacks

GAD does not have discrete episode or panic attack as described in this question

Question 12

Middle-aged man is chronically preoccupied with his health. For many years, he feared that his irregular bowel functions meant he had cancer. Now he is very worried about having a serious heart disease, despite his physician’s assurance that the occasional “extra beats” he detects when he checks his pulse are completely benign. Which of the following is the most likely dx?

a. Somatization disorder
b. Hypochondriasis
c. Delusional disorder
d. Pain disorder
e. Conversion disorder

Answer 12

b. Hypochondriasis

Fear of developing or having a serious disease, based on the patients distorted interpretation of normal physical sensations or signs / pt continues to worry even though physical exams and diagnostic tests fail to reveal any pathological process

Question 13

20 yo woman comes to primary care doctor with multiple symptoms which are. present across several organ systems. She has seen five doctors in the past 3 months, and has had six surgeries since the age of 18.

a. Somatization disorder
b. Conversion disorder
c. Hypochondriasis
d. Body dysmorphic disorder
e. Pain disorder

Answer 13

a. Somatization disorder

Polysymptomatic presentation, with the patient presenting as someone who has been chronically sick.

Question 14

17 yo girl presents to physician complaining that her face is “out of proportion” and that she looks like “Mr Hyde.” On exam, girl is pleasant-looking with no deformities.

a. Somatization disorder
b. Conversion disorder
c. Hypochondriasis
d. Body dysmorphic disorder
e. Pain disorder

Answer 14

d. BDD

Question 15

45 yo woman presents to doctor with cc: severe headache that is increasing in severity over past 3 weeks. Pt states that 1 mo ago she was in an auto accident and was diagnosed with a concussion. Pt states that the headache has been. increasing since then and she is completely unable to work. MRI of head is normal.

a. Somatization disorder
b. Conversion disorder
c. Hypochondriasis
d. Body dysmorphic disorder
e. Pain disorder

Answer 15

e. Pain disorder

These pts have often had some precipitating event to their pain, but it continues with an intensity incompatible with known physiologic mechs

Question 16

Young woman who has a v limited memory of her childhood years but knows that she was removed from her parents b/c of their abuse and neglect, frequently cannot account for hours or even days of her life. She hears voices that alternately plead, reprimand, or simply comment on what she is doing. Occasionally, she does not remember how and when she arrived at a specific location. She finds clothes she does not like in her closet, and she does not remember having bought them. Her friends are puzzled b/c sometimes she acts in a childish, dependent way and at other times becomes uncharacteristically aggressive and controlling. These sx are most commonly seen in which of the following disorders?

a. Dissociative amnesia
b. Depersonalization disorder
c. Korsakoff dementia
d. Dissociative identitiy disorder
e. Schizophrenia

Answer 16

d. Dissociative identitiy disorder

Losing time and memory gaps, including significant. gaps in autobiographical memory, are typical sx of dissociative identity disorder (previously known as multiple personality disorder). Patients also report fluctuation in their skills, well-learned abilities, and habits. This is explained as a state-dependent disturbance of implicit memory. Hallucinations in all sensory modalities are common. Dramatic changes in mannerisms, tone of voice, and affect are manifestations of this disorder.

Question 17

A nun is found in a distant city working in a cabaret. She is unablet o remember anything about her previous life.

a. Somatization disorder
b. Specific phobia
c. Dissociative identity disorder
d. OCD
e. Dissociative fugue
f. PTSD
g. BDD
h. Dysthymia

Answer 17

e. Dissociative fugue

Essential feature is suddent ravel away from home accompanied by temporary loss of autobiographic memory. Patients are confused about their identitiy and at times form new identities. Dissociative fugue may last from hours to months. During the fugue, individuals do not appear to have any psychopathology; usually they come to attention when their identity is questioned

Question 18

A woman washes her hands hundreds of times a day out of a fear of contamination. She cannot stop herself, although her hands are raw and chafed.

a. Antipsychotic
b. Antianxiety agent (non-benzo)
c. TCA
d. Mood stabilizer
e. SSRI
f. Beta-blocker

Answer 18

e. SSRI

Tx of OCD sx may require higher dosages and longer trial periods than those recommended for depression. Before a trial is considered ineffective, the pt should have received minimum daily doses of sertraline 200 mg, fluoxetine 60 mg, fluvoxamine 300 mg, paroxetine 60 mg, and/or clomipramine 250 mg, since this disorder often requires higher doses than what would be seen if a major depression were being treated with the same medication. Each drug trial should be no less than 12 weeks.

Question 19

A 24 yo woman comes to the psychiatrist with a 2-month hx of short episodes of “feeling like I am going to die.” During these episodes, she also notes feelings of dizziness and nausea, along with a feeling of choking. She describes these episodes as very frightening and she is terrified of having another. She denies substance use or any medical problems. Which of the following tx regimens should be started?

a. Imipramine
b. Fluoxetine
c. Phenelzine
d. Paroxetine and alprazolam
e. Buspirone and citalopram

Answer 19

d. Paroxetine and alprazolam

Combo of an SSRI (paroxetine) and a benzo (alprazolam) is considered optimal for this young woman with panic disorder. She is terrified of panic attacks and needs swift relief. She has no hx of substance abuse. Alprazolam will shut off the panic attacks almost immediately, and should be continued until the SSRI begins to take effect (typically several weeks). At that time, the pt can be slowly tapered off the alprazolam and continued on the SSRI.

Question 20

What is an effective adjunct in patients with PTSD symptoms partially improved by SSRIs?

Answer 20

2nd gen antipsychotics –> can treat co-occurring psychotic sx

Question 21

Which neurotransmitter is thought to play the most significant role in social phobia?

a. Cortisol
b. GABA
c. Serotonin
d. Dopamine
e. Epinephrine

Answer 21

d. Dopamine

Thought to mediate social interest, gregariousness, confidence, and sensitivity to rejection

People with low levels of dopamine in the CSF and Parkinson’s disease are more likely to be introverted and to have social phobia as well.

Question 22

A 47 yo woman is brought. to ED by her husband for a change in mental status. The husband explains that he was in the garage for about an hour and that when he returned to the living room, he found his wife staring blankly out the window. She responded to. her name immediately when called, although. she appeared confused, asking “What’s going on?” several times. The pt’s husband relates her PMH of migraines, for which she occasionally takes combo tablet containing caffeine, acetaminophen, and aspirin.

What could this be?

Answer 22

Ischemia (transient global amnesia)

Last from 6-24 hrs… likely to involve ischemia of temporal lobe and diencephalic brain regions.

Question 23

Which of the following disorders is often a comorbid state with body dysmorphic disorder?

a. Social phobia
b. GAD
c. Bipolar disorder
d. Specific phobia
e. Hypochondriasis

Answer 23

a. Social phobia

Question 24

Which of the following disorders is highly comorbid (up to 59%) with GAD?

a. Major depression
b. Schizophrenia
c. Bipolar disorder
d. Dysthymia
e. Cyclothymia

Answer 24

a. Major depression

Treatment: SSRI and SNRI as well as. buspirone

Benzos: effective in reducing physical sx of anxiety

Beta-blockers: reduce palpitations and tremors

Question 25

Whenever 34 yo Margaret has to give a presentation in front of a group, she becomes very nervous. She starts sweating profusely, her legs feel like “spaghetti,” and she often has immense trouble remembering what she wanted to say. The pt states that these events are infrequent. She is otherwise without anxiety sx.

What is the most appropriate prescription?

a. Fluoxetine
b. Buspirone
c. Lorazepam
d. Propranolol
e. CBT

Answer 25

d. Propranolol

Question 26

A 27 yo female who had a recent miscarriage presents to the ED complaining of paralysis of her left arm. A nurse witnessed the patient moving her left extremity when distracted or dressing, and this is corroborated by the medical resident. The patient requests to be discharged and does not seem interested in receiving medical care or a dx. What is the correct dx?

Answer 26

Conversion disorder

Question 27

What is the first-line category of psychopharmacological tx for panic disorder?

a. TCAs
b. SSRIs
c. Benzos
d. Antipsychotics
e. Buspirone

Answer 27

b. SSRIs

Question 28

FDA-approved treatments for social phobia

Answer 28

Paroxetine, sertraline, and long-acting form of venlafaxine

Question 29

Treatment for OCD

Answer 29

Clomipramine or SSRIs as well as psychotherapy

Question 30

In rare cases, obsessive-compulsive disorder is associated with which of the following infections?

a. GBS
b. GAS
c. Pneumococcus
d. E. coli

Answer 30

b. GAS

GAS (e.g. strep throat) in a small subgroup is associated with OCD and is also associated with neurological abnormalities and an abrupt prepubertal onset.

PANDAS = pediatric autoimmune neuropsychiatric disorders associated with strep infections, a pediatric neurological disease in which a subset of children exhibit rapid onset of OCD and/or tic disorders with neuropsychiatric sx following GAS infection

Question 31

About 35-50% of patients with which condition also have OCD?

A. Down’s syndrome

B. Social phobia

c. Tourette’s disorder
d. GAD
e. PTSD

Answer 31

c. Tourette’s

Tourette’s syndrome, OCD, and ADHD = often comorbid and. have common genetic links

Question 32

Tx:

Panic Disorder

Panic Attack

Answer 32

PD: SSRI

PA: Alprazolam