Anxiety Disorders
A 29-year-old woman was evaluated in the ED for sudden chest pain, palpitations, choking, and a feeling that she was "going to die"; troponin and ECG were normal. Over the 5 weeks since, she has had two more episodes out of nowhere, constantly fears the next one, and has started avoiding the gym because exercise makes her heart race. Diagnosis?
What is panic disorder?
A patient describes sudden episodes of palpitations, sweating, and intense fear of dying that peak within 10 minutes, but no other symptoms. DSM-5 requires at least this many symptoms for a full panic attack; with fewer, what is the episode called?
What is four, with fewer symptoms called a limited-symptom attack?
A 22-year-old with new panic disorder reports that her mother and maternal aunt "had the same attacks." Name this strong risk factor, and the outcome panic disorder raises the risk of that clinicians must screen for at every visit.
What are family history (genetic heritability) and suicide?
This medial temporal lobe structure is hyperactive during panic attacks. Its bilateral destruction, classically by HSV-1 encephalitis, produces hyperorality, hypersexuality, docility, and loss of fear.
What is the amygdala?
A patient in the ED with an acute panic attack does not improve with breathing exercises and is given lorazepam. Name the drug class, the receptor it acts on, and exactly how it changes that receptor's chloride channel.
What are benzodiazepines, acting at GABA-A to increase the frequency of chloride channel opening?
A 41-year-old man has stopped taking the subway, standing in grocery lines, and going to concerts. He explains that if he suddenly felt faint, he could not get out or get help. He now rarely leaves the house unless his brother comes with him. Name the diagnosis and its first-line pharmacotherapy.
What is agoraphobia, treated with an SSRI (plus CBT)?
Give the required symptom duration for each: panic disorder (worry after attacks), PTSD, acute stress disorder, and generalized anxiety disorder.
Panic Disorder ≥1 month
PTSD >1 month
Acute stress disorder 3 days to 1 month
GAD ≥ 6 months
A barista who drinks six espressos a day has new episodes of palpitations, tremor, and anxiety. The responsible substance is structurally similar to the drug used to terminate SVT and blocks its receptor. Name the substance, its mechanism, and the effect on cAMP.
What is caffeine, an adenosine receptor antagonist that increases cAMP?
During a panic attack, this dorsal pontine nucleus floods the brain with a neurotransmitter that is increased in anxiety and decreased in depression. An α2 antagonist provokes attacks in patients with panic disorder, while an α2 agonist blunts them. Name the neurotransmitter involved here.
Double Jeopardy: What is the nucleus involved here?
What is norepinephrine?
What is locus coeruleus?
A 74-year-old woman started sertraline for GAD 3 weeks ago. She now has confusion and nausea. Na+ is 123 mEq/L, she appears euvolemic, and her urine osmolality is inappropriately high. Name the adverse effect and the drug's mechanism of action.
What is SIADH, caused by an SSRI that inhibits serotonin reuptake (SERT)?
A 33-year-old consultant has had three episodes of pounding heart, trembling, and shortness of breath that peaked within minutes. Every episode began while boarding a plane. For 8 months she has refused all air travel, which is hurting her career, but she has no worry about attacks in other settings. Name the diagnosis and its first-line treatment.
What is specific phobia (fear of flying), treated with CBT using exposure therapy?
Twelve days after being robbed at gunpoint, a 28-year-old has flashbacks and nightmares, avoids the street where it happened, and startles easily. Name the diagnosis and the first-line treatment, and say what the diagnosis becomes if symptoms persist past 1 month.
What is acute stress disorder, treated with CBT, which becomes PTSD after 1 month?
A 27-year-old with panic disorder smokes a pack a day and wants to quit. She has a history of bulimia nervosa. Name the smoking-cessation drug that is contraindicated and why, and a safer drug with its mechanism.
What is bupropion (lowers the seizure threshold), with varenicline (a partial nicotinic ACh receptor agonist) as a safer option?
During a panic attack a 23-year-old has lightheadedness and tingling around her mouth and fingertips, and her hand spasms when a blood pressure cuff is inflated. ABG: pH 7.53, PaCO2 26 mm Hg, HCO3− 22 mEq/L. Name the acid-base disorder and the electrolyte change behind her symptoms.
What is acute respiratory alkalosis with low ionized calcium?
Ten days after starting escitalopram for panic disorder, a patient says it "isn't working" and wants to stop. She has no side effects. Name the best next step and the receptor whose gradual desensitization explains the delay.
What is continuing the current dose, because 5-HT1A autoreceptors must desensitize (taking 4–8 weeks)?
Five weeks after a building collapse, a firefighter has nightmares, flashbacks, an exaggerated startle response, and avoids driving past the site. He started sertraline, but his nightmares persist. Name the diagnosis and the drug, with its receptor target, most appropriate for the nightmares.
What is PTSD, with prazosin (an α1 antagonist) for nightmares?
A 10-year-old has worried for 7 months about grades, her parents' health, and news stories, most days and out of proportion to events. Her only other symptom is trouble falling asleep. Does she meet criteria for GAD, and why?
What is yes, because children need only one associated symptom (adults need three)?
A 30-year-old lawyer with moderate persistent asthma has tremor, sweating, and fear of humiliation only before giving closing arguments. Name the diagnosis, the usual as-needed drug for it, and why that drug is a poor choice for this patient.
What is social anxiety disorder, performance type, usually treated with propranolol, which is avoided here because nonselective β-blockade can cause bronchospasm?
Chronic stress keeps CRH, ACTH, and cortisol elevated. Sustained cortisol is linked to atrophy of this glucocorticoid receptor-rich structure, which normally gives negative feedback to the HPA axis and tells the amygdala when a setting is safe. It is smaller in many patients with PTSD.
What is the hippocampus?
A woman stopped paroxetine abruptly 3 days ago. She has dizziness, "electric shock" sensations, nausea, insomnia, and irritability, with normal temperature, normal reflexes, and no clonus. Name the syndrome and how it is prevented.
What is SSRI discontinuation syndrome, prevented by tapering the dose over weeks?
A woman with agoraphobia feels instant relief whenever she cancels a trip to the mall, and she now cancels nearly every outing. Her therapist teaches her deep muscle relaxation, then has her imagine and later perform a ranked list of feared steps, from looking at the mall's website to shopping alone. Name the conditioning principle that maintains her avoidance and the CBT technique her therapist is using.
What are negative reinforcement and systematic desensitization?
A 24-year-old woman with heavy menses is referred for "panic attacks" with palpitations and dyspnea on stairs. She admits to compulsively chewing ice. Hb 9.0 g/dL, MCV 68 fL. Name the cause of her symptoms and the expected ferritin and TIBC, and name the first test to exclude the classic endocrine mimic of anxiety.
What is iron deficiency anemia (low ferritin, high TIBC), and TSH to exclude hyperthyroidism?
A 45-year-old woman from Puerto Rico is brought in after uncontrollable screaming, crying, trembling, a sensation of heat rising to her head, and brief aggression that began during an argument with her son. Name this DSM-5 cultural concept of distress and one feature that distinguishes it from a panic attack in panic disorder.
What is ataque de nervios, which is typically triggered by a stressor (unlike the unexpected attacks of panic disorder)?
In these midline brainstem nuclei, the rate-limiting enzyme for a neurotransmitter that is decreased in both anxiety and depression requires tetrahydrobiopterin (BH4) and iron. Name the nuclei, the neurotransmitter, and the enzyme.
What are the raphe nuclei, serotonin, and tryptophan hydroxylase?
A 52-year-old with GAD and alcohol use disorder has not tolerated two SSRIs. She asks for a medication that will not sedate her, cause dependence, or interact with alcohol. Name the drug and its mechanism, and explain why it cannot be used as needed for a panic attack.
What is buspirone, a partial 5-HT1A agonist whose onset takes 1–2 weeks?