Anxiety disorders and anxiolytics Flashcards

Question

``` Physiological activity associated with PTSD include all except A. decreased parasympathetic tone B. elevated baseline heart rate C. excessive sweating D. increased circulating thyroxine E. increased blood pressure ```

Answer 1

The answer is D According to current conceptualizations, PTSD is associated with objective measures of physiological arousal. This includes elevated baselines heart rate, increased blood pressure, and excessive sweating. Furthermore, evidence from studies of baseline cardiovascular activity revealed a positive association between heart rate and PTSD. The finding of elevated baseline heart rate activity is consistent with the hypothesis of tonic sympathetic nervous system arousal in PTSD. Disturbance in autonomic nervous system activity in individuals with PTSD is characterized by increased sympathetic and decreased parasympathetic tone. Preliminary evidence suggests that this autonomic imbalance can be normalized with selective serotonin reuptake inhibitor treatment. There is no change in blood level of thyroxine in those with PTSD

Answer 2

The answer is B Unexpected panic attacks are required for the diagnosis of panic disorder, but panic attacks can occur in several anxiety disorders. The clinician must consider the context of the panic attack when making a diagnosis. Panic attacks can be divided into two types: (1) unexpected panic attacks, which are not associated with a situational trigger, and (2) situationally bound panic attacks, which occur immediately after exposure in a situational trigger or in anticipation of the situational trigger. Situationally bound panic attacks are most characteristic of social phobia and specific phobia. In generalized anxiety disorder, the anxiety cannot be about having a panic attack

Answer 3

Some differences between the DSM-IV-TR and earlier versions in the diagnostic criteria of panic disorder are interesting. For example, no longer is a specific number of panic attacks necessary in a specific period of time to meet criteria for panic disorder. Rather, the attacks must be recurrent, and at least one attack must be followed by at least 1 month of anticipatory anxiety or phobic avoidance. This recognizes for the first time that although the panic attack is obviously the seminal event for diagnosing panic disorder, the syndrome involves a number of disturbances that go beyond the attack itself. Isolated panic attacks without functional disturbances are not diagnosed as panic disorder. Furthermore, isolated panic attacks without functional disturbance are common, occurring in approximately 15 percent of the population.

Answer 4

d the obsessions must be acknowledged as excessive or unreasonable (with the exception that children need not acknowledge this fact), there must be attempts to suppress these intrusive thoughts, and the obsessions or compulsions are time consuming to the point of requiring at least 1 hour a day, among other diagnostic criteria. As part of the criteria, however, is not that the thoughts are a product of outside the person, as in thought insertion, but that the person recognizes that the thoughts are a product of his or her own mind.

Answer 5

The answer is A After the first one or two panic attacks, patients may be relatively unconcerned about their condition.With repeated attacks, however, the symptoms may become a major concern. Patients may attempt to keep the panic attacks secret and thereby cause their families and friends concern about unexplained changes in behavior. Panic disorder, in general, is a chronic disorder, although its course is variable, both among patients and within a single patient. The frequency and severity of the attacks can fluctuate. Panic attacks can occur several times a day or less than once a month. Excessive intake of caffeine or nicotine can exacerbate the symptoms. Depression can complicate the symptom picture in anywhere from 40 to 80 percent of all patients. Although the patients do not tend to talk about suicidal ideation, they are at increased risk for committing suicide. Recovery rates appear to be higher in patients without comorbid agoraphobia than in those who meet criteria for both conditions. Family interactions and performance in school and at work commonly suffer. Patients with good premorbid functioning and symptoms of brief duration tend to have a good prognosis

Answer 6

The answer is B An interesting set of findings concerns the possible relationship between a subset of cases of OCD and certain types of motor tic syndromes (i.e., Tourette’s disorder and chronic motor tics). Increased rates of OCD, Tourette’s disorder, and chronic motor tics were found in the relatives of Tourette’s disorder patients compared with relatives of control subjects whether or not the patient had OCD. However, most family studies of probands with OCD have found elevated rates of Tourette’s disorder and chronic motor tics only among the relatives of probands with OCD who also have some form of tic disorder.Taken together, these data suggest that there is a familial and perhaps genetic relationship between Tourette’s disorder and chronic motor tics and some cases of OCD. Cases of the latter in which the individual also manifests tics are the most likely to be related to Tourette’s disorder and chronic motor tics. Because there is considerable evidence of a genetic contribution to Tourette’s disorder, this finding also supports a genetic role in a subset of cases of OCDs

Answer 7

The answer is D Structural brain imaging studies, such as magnetic resonance imaging (MRI), in patients with panic disorder have implicated pathological involvement in the temporal lobes, particularly the hippocampus. One MRI study reported abnormalities, especially cortical atrophy, in the right temporal lobes of these patients. Functional brain imaging studies, such as positron emission tomography (PET), have implicated dysregulation of cerebral blood flow. Specifically, anxiety disorders and panic attacks are associated with cerebral vasoconstriction, which may result in central nervous system symptoms such as dizziness and in peripheral nervous system symptoms that may be induced by hyperventilation and hypocapnia. Increased blood flow to the basal ganglia has not been noted in patients with panic disorder

Answer 8

The answer is E Brain imaging studies of patients with OCD using PET scans have found abnormalities in frontal lobes, cingulum, and basal ganglia. PET scans have shown higher (not lower) levels of metabolism and blood flows to those areas in OCD patients than in control subjects.Volumetric computed tomography scans have shown decreased caudate volumes bilaterally in OCD patients compared with normal control subjects. Morphometric MRI has revealed that OCD patients have significantly more gray matter and less white matter than normal control subjects. MRI has also shown longer mean T1 relaxation times in the frontal cortex in OCD patients than is seen in normal control subjects

Answer 9

The answer is D Buspirone (Buspar) is a serotonin receptor partial agonist and is most likely effective in 60 to 80 percent of patients with generalized anxiety disorder (GAD). Data indicate that buspirone is more effective in reducing the cognitive symptoms of GAD than in reducing the somatic symptoms. The major disadvantage of buspirone is that its effects take 2 to 3 weeks to become evident in contrast to the almost immediate anxiolytic effects of the benzodiazepines.

Answer 10

The answer is B Clinical trials of drugs have supported the hypothesis that dysregulation of serotonin is involved in the symptom formation of obsessions and compulsions. Data show that serotonergic drugs are an effective treatment, but it is unclear whether serotonin is involved in the cause of OCD. Clinical studies have shown that measures of platelet binding sites of imipramine and of serotonin metabolites in cerebrospinal fluid are variable, neither consistently abnormally low nor abnormally high.

Answer 11

The answer is D A high prevalence of generalized anxiety disorder (not panic disorder) symptoms has been reported in patients with Sj¨ogren’s syndrome. Sj¨ogren’s syndrome is a chronic autoimmune disease in which a person’s white blood cells attack their moistureproducing glands. The hallmark symptoms are dry eyes and dry mouth; however, it may also cause dysfunction of other organs. The symptoms of anxiety disorder caused by a general medical condition can be identical to those of the primary anxiety disorders. A syndrome similar to panic disorder is the most common clinical picture. Patients who have cardiomyopathy may have the highest incidence of panic disorder secondary to a general medical condition. Cardiomyopathy is a disease of the heart muscle (myocardium). One study reported that 83 percent of patients with cardiomyopathy awaiting cardiac transplantation had panic disorder symptoms. Increased noradrenergic tone in these patients may be the provoking stimulus for the panic attacks. In some studies, about 25 percent of patients with Parkinson’s disease and chronic obstructive pulmonary disease have symptoms of panic disorder. Other medical disorders associated with panic disorder include chronic pain; primary biliary cirrhosis (an autoimmune disease of the liver); and epilepsy (a chronic disorder characterized by paroxysmal brain dysfunction caused by excessive neuronal discharge), particularly when focus is in the right parahippocampal gyrus.

Answer 12

The answer is B Specific phobia is usually easily distinguished from anxiety stemming from primary medical problems by the focused nature of the anxiety. Such specificity is not typical of anxiety disorders related to medical problems. Panic disorder with or without agoraphobia must be differentiated from a number of medical conditions that produce similar symptomatology. Panic attacks are associated with a variety of endocrinologic disorders, including hypo- and hyperthyroid states, hyperparathyroidism, and pheochromocytomas. Episodic hypoglycemia associated with insulinomas can also produce panic-like states, as can primary neuropathologic processes. These include seizure disorders, vestibular dysfunction, neoplasms, and the effects of both prescribed and illicit substances on the central nervous system. Finally, disorders of the cardiac and pulmonary systems, including arrhythmias, chronic obstructive disease, and asthma, can produce autonomic symptoms and accompanying crescendo anxiety that can be difficult to distinguish from panic disorder. A number of primary medical disorders can produce syndromes that bear a striking resemblance to obsessive-compulsive disorder (OCD). In fact, the current conceptualization of OCD as a disorder of the basal ganglia derives from the phenomenological similarity between idiopathic OCD and OCD-like disorders that are associated with basal ganglia diseases, such as Sydenham’s chorea and Huntington’s disease. It should be noted thatOCDfrequently develops before age 30 years, and new-onset OCDin an older individual should raise questions about potential neurological contributions to the disorder. Also, among children with pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS), the syndrome appears to emerge relatively acutely, in contrast to the more insidious onset of childhoodOCDin the absence of infection. Hence, children with acute presentations, the role of such an infectious process should be considered. It is particularly important to recognize potentially treatable contributors to posttraumatic symptomatology in the differential for posttraumatic stress disorder (PTSD). For example, neurological injury after head trauma can contribute to the clinical picture, as can psychoactive substance use disorders or withdrawal syndromes, either in the period immediately surrounding the trauma or many weeks after the trauma. Medical contributors can usually be detected through careful history and physical examination. Generalized anxiety disorder (GAD) must be differentiated from both medical and other psychiatric disorders. Similar neurological, endocrinologic, metabolic, and medication-related disorders to those considered in the differential diagnosis of panic disorder are relevant to the differential diagnosis of GAD.

Answer 13

The answer is E (all) Since the original finding that sodium lactate infusion can induce panic attacks in patients with panic disorder, many substances have shown similar panicogenic properties, including the noradrenergic stimulant yohimbine (Yocon), carbon dioxide, the respiratory stimulant doxapram (Dopram), and cholecystokinin. Disordered serotonergic, noradrenergic, and respiratory systems are doubtless implicated in panic disorder, and the condition appears to be caused both by a genetic predisposition and some type of traumatic distress. More recently, neuroimaging studies revealed that patients with panic disorder have abnormally brisk cerebrovascular responses to stress, showing greater vasoconstriction during hypocapnic respiration than normal control subjects.

Answer 14

The answer is A Antidepressant medication is increasingly seen as the medication treatment of choice for the anxiety disorders. More specifically, drugs with primary effects on the serotonin neurotransmission system have become first-line recommendations for panic disorder, social phobia, OCD, and PTSD. Evidence now exists that such medications are also effective for generalized anxiety disorder. Although they typically take longer to work than benzodiazepines, the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa), as well as venlafaxine (Effexor) and nefazodone (Serzone), are probably more effective than benzodiazepines and easier to discontinue. Increasingly, benzodiazepines such as diazepam (Valium) are used only for the temporary relief of extreme anxiety as clinician and patient wait for the effects of antidepressants to take hold. Longer-term administration of benzodiazepines is reserved for patients who do not respond to or cannot tolerate antidepressants

Answer 15

The answer is A A counterphobic attitude is not a therapy for phobias, although it may lead to counterphobic behavior. Many activities may mask phobic anxiety, which can be hidden behind attitudes and behavior patterns that represent a denial, either that the dreaded object or situation is dangerous or that one is afraid of it. Basic to this phenomenon is a reversal of the situation in which one is the passive victim of external circumstances to a position of attempting actively to confront and master what one fears. The counterphobic person seeks out situations of danger and rushes enthusiastically toward them. The devotee of dangerous sports, such as parachute jumping, rock climbing, bungee jumping, and parasailing, may be exhibiting counterphobic behavior. Both behavioral and pharmacological techniques have been used in treating phobias. The most common behavioral technique is systematic desensitization, in which the patient is exposed serially to a predetermined list of anxiety-provoking stimuli graded in a hierarchy from least to most frightening. Patients are taught to self-induce a state of relaxation in the face of each anxietyprovoking stimulus. In flooding, patients are exposed to the phobic stimulus (actually [in vivo] or through imagery) for as long as they can tolerate the fear until they reach a point at which they can no longer feel it. The social phobia of stage fright in performers has been effectively treated with such β-adrenergic antagonists as propranolol (Inderal), which blocks the physiological signs of anxiety (e.g., tachycardia). Phenelzine (Nardil), a monoamine oxidase inhibitor, is also useful in treating social phobia.

Answer 16

The answer is C Patients with specific phobias are often treated with as-needed benzodiazepines, such as lorazepam (Ativan). In the clinical case described, this is the most appropriate choice of treatment given their high safety margin (e.g., in overdose) and their overall excellent efficacy and rapid onset of action. β-adrenergic receptor antagonists (not agonists) may be useful in the treatment of specific phobia, especially when the phobia is associated with panic attacks. The most commonly used treatment for specific phobia is exposure therapy. In this method, therapists desensitize patients by using a series of gradual, self-paced exposures to the phobic stimulus; thus, this method would not be appropriate when immediate relief is required. Paroxetine, an SSRI, is not indicated for the immediate treatment of phobias

Answer 17

The answer is C The symptoms of an individual patient withOCDcan overlap and change with time, butOCDhas four major symptoms patterns. In this case, Mrs. K presents the symptom pattern of pathological doubt followed by a compulsion of checking. It is the second most common symptom pattern. The obsession often implies some danger of violence, in this case forgetting to lock the car door or the door to the apartment. The checking may involve multiple trips back into the house to check the stove, for example For Mrs. K, checking involves trips back to her car and her apartment to make sure both are secure, thereby making her constantly late for work. The patients have an obsessional selfdoubt and always feel guilty about having forgotten or committed something. The most common symptom pattern in OCD is an obsession of contamination followed by washing or accompanied by compulsive avoidance of the presumably contaminated object. The feared object is often hard to avoid (e.g., feces, urine, dust, or germs). Patients with contamination obsessions usually believe that the contamination is spread from object to object or person to person by the slightest contact. In the third most common pattern, there are intrusive obsessional thoughts without a compulsion. Such obsessions are usually repetitious thoughts without a compulsion. Such obsessions are usually repetitious thoughts of a sexual or aggressive act that are reprehensible to the patient. Patients obsessed with thoughts or aggressive or sexual acts may report themselves to the police or confess to a priest. The fourth most common pattern is the need for symmetry or precision, which can lead to a compulsion of slowness. Patients can literally take hours to eat a meal or shave their faces

Answer 18

The answer is D Excessive and uncontrollable worry characterized by irritability, insomnia, and fatigue is the most likely attributable to generalized anxiety disorder. The patient’s worries typically include various aspects of the patient’s life and cause functional impairment. These symptoms must persist for at least 6 months. Patients with avoidant personality disorder have a long-standing pattern of avoiding activities because they fear judgment and feel inadequate. These symptoms are part of a lifelong pattern rather than new onset. Obsessive-compulsive disorder involves intrusive thoughts that result in compulsive activity to relieve anxiety. These patients’ symptoms are ego dystonic in that they are able to recognize their problematic compulsions and obsessions. Patients with obsessive-compulsive personality disorder often seek perfection and organization to a degree that it causes functional impairment. Their symptoms are ego syntonic in that they do not recognize the unreasonable nature of their behaviors.

Answer 19

b Whereas patients with agoraphobia are often comforted by the presence of another person in an anxiety-provoking situation, patients with social phobia are made more anxious than before by the presence of other persons. Breathlessness, dizziness, a sense of suffocation, and fear of dying are common with panic disorder and agoraphobia; however, the symptoms associated with social phobia usually involve blushing, muscle twitching, and anxiety about scrutiny. Most cases of agoraphobia are thought to be caused by panic disorder. When the panic disorder is treated, the agoraphobia often improves with time. Agoraphobia without a history of panic disorder is often incapacitating and chronic, and depressive disorders and alcohol dependence often complicate its course

Answer 20

a Social phobia is the excessive fear of humiliation or embarrassment in various social setting, such as speaking in public, urinating in a public rest room (also called shy bladder), or speaking to a date. It can sometimes be difficult to differentiate from agoraphobia, which is the fear of or anxiety regarding places from which escape may be difficult. Both disorders can be associated with panic attacks, agoraphobia more so than social phobia.

Answer 21

neither Buspirone was promoted as a less sedating alternative to benzodiazepines in the treatment of panic disorder. Buspirone has lower potential for abuse and dependence than benzodiazepines and produces relatively few adverse effects and no withdrawal syndrome. Buspirone does not alter cognitive or psychomotor function, does not interact with alcohol, and is not a muscle relaxant or an anticonvulsant. However, the efficacy of buspirone in patients with panic disorder is disappointing, and with its further drawback of delayed onset of action and the need for multiple dosings, its use is limited to potentiating the efficacy of other antidepressants and counteracting the adverse sexual effects of SSRIs.

Answer 22

both Although the short-term efficacy of antipanic medications has been established, the question of howlong to treat a panic patient who responds to treatment remains open. The results of followup studies are mixed. Several reports indicate that most panic patients relapse within 2 months to 2 years after the medication is discontinued. Following medication discontinuation, only about 30 to 45 percent of the patients remain well, and even remitted patients rarely revert back to significant phobic avoidance or serious vocational or social disability. Improvement may continue for years after a single course of medication treatment. Given the uncertainty about the optimal duration of treatment, the current recommendation is to continue full-dosage medication for panic-free patients for at least 1 year. Medication taper should be slow, with careful monitoring of symptoms. Distinction should be made among return symptoms, withdrawal, and rebound anxiety.

Answer 23

a Some studies have shown that cognitive-behavioral treatment of panic disorder, or panic control therapy, produces 80 to 90 percent panic-free status within at least 6 months of treatment. Two-year follow-up indicates that more than 50 percent of patients who originally responded to panic control therapy have occasional panic attacks, and more 25 percent seek additional treatment. Nonetheless, these treatment responders do tend to have a significant decline in panic-related symptoms and most maintain many of their treatment gains

Answer 24

a Imaginal exposure typically involves having the patient close his or her eyes and imagine feared stimuli as vividly as possible. The primary use of this type of exposure is to help patients confront feared thoughts, images, and memories. For example, individuals with OCD may experience obsessional thoughts and images about causing harm to people they love.

Answer 25

b Interoceptive exposure is the most recent form of exposure therapy to be introduced. This procedure is designed to induce feared physiological sensations under controlled circumstances. A number of specific exercises have been developed to induce specific panic-like sensations. For example, the step-up exercise, in which the patient repeatedly steps up and down on a single step as rapidly as possible, produces rapid heart rate and shortness of breath.

Anxiety disorders and anxiolytics Flashcards

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