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A 21-year-old college student presents to your office for evaluation. She is complaining of feeling stressed out. She is taking classes full-time and is also in one of the military reserve units at the college. One weekend a month, she must attend drill that involves handling weapons. Although she did not have problems handling the weapons initially, she now gets very emotional and upset when she thinks about having to use them at the next drill weekend. She is nervous and is afraid that she might accidentally fire a weapon. She knows that her fears are silly and she has been telling herself to "just get over it." Last weekend, while at drill, she suddenly felt that she was going to have a heart attack. She developed tightness in her chest, her heart was racing, and she felt unable to breathe. Although the symptoms eventually abated, the episode made her even more alarmed, and now she is worried that it will happen again and she will have a heart attack. She comes to see if you can help.
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Question 23.6.1 Which of the following is UNNECESSARY for the initial workup?
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A) Take more medical, psychiatric, and family history
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B) Order an echocardiogram
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C) Perform a physical examination
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D) Order thyroid function tests
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E) Perform a mental status examination
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Answer 23.6.1 The correct answer is "B." Given the information you have so far, an echocardiogram is not indicated and is rarely used as part of a primary workup. When it comes to test questions, never say no to more history (unless you are supposed to be managing a patient's airway). A complete history and physical examination are essential in the evaluation of this new patient. Thyroid abnormalities can be a cause of some of these symptoms, including palpitations and chest tightness.
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She has no prior psychiatric history, but her mother is taking medication for depression. While taking her social history, you ask questions regarding substance abuse.
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Question 23.6.2 Use of which of the following substances might explain her symptoms?
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D) Herbal weight loss medication
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Answer 23.6.2 The correct answer is "E." Many substances can cause symptoms like this patient has. These include stimulants, such as caffeine and nicotine, and some herbal weight loss products containing ephedra (Ma Huang). Withdrawal from hypnotics like alcohol can also lead to similar symptoms.
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She does not smoke, doesn't drink alcohol (you can tell she's not a Hawkeye … no tailgating?!), and drinks coffee on weekday mornings before class. Her physical examination is normal. Her mental status examination is remarkable for a neutral mood, a restricted and anxious affect, but no suicidal thoughts, and no psychotic symptoms. The laboratory tests you order are normal. You are leaning toward a psychiatric diagnosis at this point, specifically an anxiety disorder.
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Question 23.6.3 Which of the following is NOT an anxiety disorder?
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B) Social anxiety disorder
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D) Generalized anxiety disorder
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Answer 23.6.3 The correct answer is "E." Delirium, while it may present with features similar to an anxiety disorder, is a cognitive disorder. Anxiety disorders are the most common form of mental illness in the United States, with a lifetime prevalence of 28.8%. They include options "A" through "D" as well as separation anxiety disorder, specific phobias, selective mutism, unspecified anxiety disorder, and anxiety disorders that are judged to be secondary to a medical condition or a substance.
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Of the listed anxiety disorders, you think she has developed panic disorder and that she has been having panic attacks.
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Question 23.6.4 Which of the following is NOT a typical symptom of a panic attack?
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Answer 23.6.4 The correct answer is "C." The symptoms of a panic attack are those associated with an activation of the "fight-or-flee response," or the overactivation of the sympathetic nervous system. Typical symptoms include chest pain, nausea, dizziness, numbness, palpitations, sweating, trembling, dyspnea, a sense of smothering, fear of dying, tingling, and derealization or depersonalization. (At this point, we'd like to ask Mother Nature how chest pain helps us when facing a saber-toothed tiger.) It would be rare for a patient to actually lose consciousness from a panic attack (though they may feel they might), and actual syncope should force one to look for an alternate diagnosis.
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HELPFUL TIP:
Hyperventilation can cause cerebral vasoconstriction and secondary cerebral hypoxia resulting in syncope. This can occur with panic disorder. However, this is pretty unusual.
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To make your diagnosis of panic disorder, the patient needs to meet certain criteria.
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Question 23.6.5 Which of these is NOT a criterion for panic disorder?
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A) Recurrent and unexpected panic attacks
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B) At least 1 month of worry about having more attacks
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C) Worry about the implication of the attack or its consequences (dying, "going crazy," etc.)
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D) Change in behavior related to the attacks
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E) Predictable panic attacks that occur in response to cues
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Answer 23.6.5 The correct answer is "E." The criteria for panic disorder do not include predictable panic attacks in response to cues. After patients have had repeated panic attacks, they often develop phobic avoidance of places, objects, or events associated with their symptoms (e.g., agoraphobia). Agoraphobia is a separate diagnosis in DSM-5. Patients often scout out routes of escape before going to places that might provoke an attack—of the panic variety as opposed to the terrorist variety.
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HELPFUL TIP:
The vast majority of patients with panic disorder present with somatic complaints rather than cognitive or mood symptoms. Patients are often misdiagnosed initially. Consider panic attacks in patients presenting with the appropriate somatic symptoms. And never rule out a physical diagnosis (e.g., PSVT) without an appropriate workup.
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Your patient is worried that these attacks will keep occurring.
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Question 23.6.6 How would you best describe the prognosis for panic disorder?
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A) It is easily curable in most patients
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B) There is no effective drug treatment beyond benzodiazepines, especially alprazolam (Xanax)
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C) Most patients do not improve over time
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D) It is a recurrent or chronic illness
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Answer 23.6.6 The correct answer is "D." Panic disorder is a recurrent or chronic disease in most patients. "A" and "C" are incorrect. Although panic disorder is not easily curable, almost all patients will improve over time, but very few attain complete remission even with medical treatment. Relapse is common.
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The patient is, of course, very concerned about future panic attacks. She asks what to do when another occurs.
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Question 23.6.7 You advise her to do all of the following EXCEPT:
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B) Slow down her breathing
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C) Reassure herself that she is not dying
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D) Breathe into a brown paper bag
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E) Avoid stimulants like caffeine or nicotine
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Answer 23.6.7 The correct answer is "D." All of the other options are reasonable recommendations for a patient suffering from panic attacks. Although commonly observed in popular lore, breathing into a paper bag is not recommended. Breathing into a brown paper bag can have the opposite effect of that intended—the patient may continue hyperventilating with CO2 building up, which may contribute to more panic symptoms. Hyperventilating (blowing off CO2) does not produce a panic attack nor relieve it. It's just a symptom of one. However, educating the patient on consciously slowing her breathing—using slow, deep breaths—may help abort the panic attack. Quiet rooms and reassurance can also help.
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You begin to discuss treatment options with this patient.
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Question 23.6.8 Which of the following is NOT an effective treatment of panic disorder?
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A) Benzodiazepines such as clonazepam (Klonopin)
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B) Bupropion (Wellbutrin)
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C) Psychotherapy such as CBT
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D) SSRIs such as fluoxetine (Prozac)
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E) TCAs such as imipramine
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Answer 23.6.8 The correct answer is "B." Bupropion does not work for anxiety disorders. Among effective medications (SSRIs, SNRIs, TCAs), no class has proven superior, and medication choice is based on safety, adverse effect profile, tolerability, comorbid illnesses, history of substance use, cost, etc. SSRIs are frequently considered first line. Psychotherapy has been found to be as effective as medications for the treatment of mild-to-moderate panic disorder and can be used in combination with medications for more severe cases.
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As you decide on the medication and dosage, you remember an article you just read in a journal on common mistakes made by physicians treating panic disorder in the community.
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Question 23.6.9 Which of these is NOT one of the common mistakes made in the treatment of panic disorder?
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A) Starting the SSRI too high
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B) Not achieving a high enough target dose
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C) Underutilization of benzodiazepines
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E) Often using medications not proven to work with panic disorder
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Answer 23.6.9 The correct answer is "C." Far from being underutilized, benzodiazepines are often overprescribed. While effective for panic disorder, problems with tolerance, dependence, and abuse limit benzodiazepines as long-term agents for panic disorder. Patients with panic disorder are extremely sensitive to medication side effects and are likely to suffer from jitteriness and restlessness if started at a high dose of an SSRI. In order to reduce the chances of precipitating jitteriness and restlessness, a lower dose of SSRI (about half the starting dose used to treat depression) is usually recommended. The same problems can occur with rapidly increasing doses of SSRIs, so "start low and go slow," increasing the dose every 2 to 4 weeks to reach the maximum allowable dose. Benzodiazepines are at least third line (after CBT and SSRIs). A plea: don't prescribe alprazolam. It is addictive, short-acting, and has a rebound effect (making dependence even more likely). If you are going to choose a benzodiazepine, choose one that is longer acting such as clonazepam or diazepam. Taper benzodiazepines as soon as possible. Avoid them in patients with severe personality disorders and substance abuse.
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Your patient says, "I know another female in the reserve who has something similar, but I've never noticed the guys to have a problem. Is this just something that happens to women?" You tell her a bit about gender differences in anxiety disorders.
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Question 23.6.10 Which of these is NOT true about the gender ratio of the following disorders?
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A) Generalized anxiety disorder affects more women than men in a 2:1 ratio
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B) Panic disorder affects more women than men in a 2:1 ratio
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C) PTSD affects more men than women in a 2:1 ratio
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D) Social anxiety disorder affects slightly more women than men
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Answer 23.6.10 The correct answer is "C." Many affective illnesses (mood and anxiety disorders) including depression and some anxiety disorders are biologically sexist: women are more likely to be affected than men. All of the options listed are correct except "C," which inverts the true ratio.
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Objectives: Did you learn to…
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Evaluate patients with anxiety symptoms?
Recognize panic attacks and diagnose panic disorder?
Initiate treatment of panic disorder?
Describe some epidemiologic issues with anxiety disorders?