Anxiety

1. The nurse observes a client who is becoming increasingly upset. He is rapidly pacing, hyperventilating, clenching his jaw, wringing his hands, and trembling. His speech is high-pitched and random; he seems preoccupied with his thoughts. He is pounding his fist into his other hand. The nurse identifies his anxiety level as a. mild. b. moderate. c. severe. d. panic.

c. severe

1. When working with a client with moderate anxiety, the nurse would expect to see a. inability to complete tasks. b. failure to respond to redirection. c. increased automatisms or gestures. d. narrowed perceptual field. e. selective attention. f. inability to connect thoughts independently.

c, d, e, f

33. The nurse is assessing a newly admitted client diagnosed with generalized anxiety disorder. The nurse determines that which findings would be consistent with generalized anxiety disorder? Select all that apply. A. Irritability B. Muscle tension C. Expansive mood with pressured speech D. Restlessness or feeling keyed up or on edge E. The client finding it difficult to control the anxiety

ANSWER: A, B, D, E A. Irritability is a criterion for generalized anxiety. B. Muscle tension is a DSM-S criterion for generalized anxiety. C. Expansive mood and pressured speech are symptoms of bipolar disorder, not generalized anxiety. D. Restlessness or feeling keyed up is a criterion for generalized anxiety. E. Difficulty controlling anxiety is a criterion for generalized anxiety.

33. The nurse is teaching an education class to clients with mild to moderate anxiety. Which teaching strategies should the nurse practice when educating the clients? Select all that apply. A. Maintain a calm, nonthreatening manner. B. Create an atmosphere of low stimulation. C. Reinforce reality by focusing on the "here and now." D. Limit the class time and the amount of information. E. Remove objects that the client could use to cause harm.

ANSWER: A, B, D A. The client with anxiety develops a sense of security when in the presence of a calm staff person. B. The client's anxiety level may increase in a stimulating environment, so the environment should have low stimulation. C. Reinforcing reality is a strategy used with a thought disorder, and not anxiety. D. The client with anxiety has a decreased attention span and a diminished level of concentration, so class time and amount of information should be limited. E. Self-harming behavior in the client with mild to moderate anxiety is usually not a concern.

33. The client tells the nurse about an intense fear of dogs that causes the client to avoid visiting others unless it is continued that there are no dogs on the premises. The client further explains that these fears seem unreasonable, but the fear continues in spite of this acknowledgment. Which conclusion by the nurse is accurate? A. The client has a recognized fear, but there is no evidence of psychopathology. B. Phobias begin in childhood and are diagnosed more often in men than women. C. A fear that is recognized as excessive and unreasonable is a criterion for phobias. D. True phobias are rare in the general population, but common with anxiety disorders.

ANSWER: C A. The client's symptoms meet diagnostic criteria for a psychopathological anxiety disorder. B. Phobias can occur at any age. The disorder is diagnosed more often in women than in men. C. Marked fear due to the presence or anticipation of a specific object (e.g., dogs), recognition that the fear is excessive, and avoidance of the object/situation are diagnostic criteria for a specific phobia. D. True phobias are common in the general population. Specific phobias do frequently occur concurrently with other anxiety disorders.

37. The client with an anxiety disorder tells the nurse that being in crowds creates thoughts of losing control and the need to hurriedly leave. What should the nurse recommend as an effective, nonpharmacological therapy for managing the client's symptoms of anxiety? A. Family systems therapy B. Psychoanalytical therapy C. Electroconvulsive therapy (ECT) D. Cognitive behavioral therapy(CBT)

ANSWER: D A. Family systems therapy is an intervention warranted when the client's symptoms signal the presence of dysfunction within the whole family. B. Psychoanalytic therapy focuses on repressed conflicts that are both conscious and unconscious. C. ECT is primarily used as an intervention for major depression; medications are administered during ECT. D. CBT is a treatment that focuses on patterns of thinking that are maladaptive and would be an effective choice for the described symptoms.

16.1. Therapy for phobias may include all of the following except A. counterphobic attitudes B. flooding C. phenelzine (Nardil) D. propranolol (Inderal) E. systematic desensitization

Answer: 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 anxiety- provoking 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 ß- 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.

16.1. Tourette's disorder has been shown to possibly have a familial and genetic relationship with A. generalized anxiety disorder B. obsessive-compulsive disorder C. panic disorder D. social phobia E. none of the above

Answer: 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.

16.1. Posttraumatic stress disorder (PTSD) differs from acute stress disorder in that A. acute stress disorder occurs earlier than PTSD B. PTSD is associated with at least three dissociative symptoms C. reexperiencing the trauma is not found in acute stress disorder D. avoidance of stimuli associated with the trauma is only found in PTSD E. PTSD lasts less than 1 month after a trauma

Answer: A Acute stress disorder is a disorder that is similar to posttraumatic stress disorder (PTSD), but acute stress disorder occurs earlier than PTSD (within 4 weeks of the traumatic event) and remits within 2 days to 1 month after a trauma (not PTSD). · PTSD shows three domains of symptoms: reexperiencing the trauma; avoiding stimuli associated with the trauma; and experiencing symptoms of increased autonomic arousal, such as enhanced startle. Flashbacks, in which the individual may act and feel as if the trauma is recurring, represent a classic form of reexperiencing. Other forms of reexperiencing symptoms include distressing recollections or dreams and either physiological or psychological stress reactions on exposure to stimuli that are linked to the trauma. · Symptoms of avoidance associated with PTSD include efforts to avoid thoughts or activities related to trauma, anhedonia, reduced capacity to remember events related to trauma, blunted effect, feelings of detachment or derealization, and a sense of a foreshortened future. Symptoms of increased arousal include insomnia, irritability, hypervigilance, and exaggerated startle. The diagnosis of PTSD is only made when symptoms persist for at least 1 month; the diagnosis of acute stress disorder is made in the interim. · Acute stress disorder is characterized by reexperiencing, avoidance, and increased arousal, similar to PTSD. Acute stress disorder (not PTSD) is also associated with at least three dissociative symptoms.

16.1. All of the following are true for the course of panic disorder except A. patients become concerned after the first one or two panic attacks B. excessive caffeine intake can exacerbate symptoms C. comorbid depression increases risk for committing suicide D. the overall course is variable E. patients without comorbid agoraphobia have a higher recovery rate

Answer: 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.

16.1. First-line medication treatments of anxiety disorders may generally include all of the following except A. diazepam (Valium) B. fluoxetine (Prozac) C. fluvoxamine (Luvox) D. nefazodone (Serzone) E. venlafaxine (Effexor)

Answer: 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.

16.1. Anxiety disorders A. are greater among people at lower socioeconomic levels B. are highest among those with higher levels of education C. are lowest among homemakers D. have shown different prevalences with regard to social class but not ethnicity E. all of the above

Answer: A Community studies have consistently found that rates of anxiety disorders in general are greater among those at lower levels of socioeconomic status and education level. Anxiety disorders are negatively associated with income and education levels. For example, there is almost a twofold difference between rates of anxiety disorders in individuals in the highest income bracket and those in the lowest and between those who completed more than 16 years of school and those who completed less than 11 years of school. In addition, certain anxiety disorders seem to be elevated in specific occupations. Anxiety disorders are higher in homemakers and those who are unemployed or have a disability. Several community studies have also yielded greater rates of anxiety disorders, particularly phobic disorders, among African Americans. The reasons for ethnic and social class differences have not yet been evaluated systematically; however, both methodological factors and differences in exposure to stressors have been advanced as possible explanations.

16.1. Isolated panic attacks without functional disturbances A. usually involves anticipatory anxiety or are phobic B. are part of the criteria for diagnostic panic disorder C. occur in less than 2 percent of the population D. rarely involve avoidance E. none of the above

Answer: A 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.

1. Interventions for a client with panic disorder would include a. encouraging the client to verbalize feelings. b. helping the client avoid panic-producing situations. c. reminding the client to practice relaxation when anxiety level is low. d. teaching the client reframing techniques. e. teaching relaxation exercises to the client. f. telling the client to ignore any anxious feelings.

a, c, d, e

16.1. Which of the following choices most accurately describes the role of serotonin in OCD? A. Serotonergic drugs are an ineffective treatment. B. Dysregulation of serotonin is involved in the symptom formation. C. Measures of platelet binding sites of titrated imipramine are abnormally low. D. Measures of serotonin metabolites in cerebrospinal fluid are abnormally high. E. None of the above

Answer: 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.

16.1. Which of the following disorders is rarely confused with anxiety that stems primarily from medical disorders? A. Panic disorder B. Specific phobia C. Obsessive-compulsive disorder D. Posttraumatic stress disorder E. Generalized anxiety disorder

Answer: 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.

16.1. Unexpected panic attacks are required for the diagnosis of A. generalized anxiety disorder B. panic disorder C. social phobia D. specific phobia E. all of the above

Answer: 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.

16.1. Which of the following is not a sign of poor prognosis in obsessive-compulsive disorder (OCD)? A. Childhood onset B. Coexisting major depression C. Good social adjustment D. Bizarre compulsions E. Delusional beliefs

Answer: C A good prognosis for people with obsessive-compulsive disorder (OCD) is indicated by good social and occupational adjustment, the presence of a precipitating event, and an episodic nature of symptoms. About one-third of patients with OCD have major depressive disorder, and suicide is a risk for all patients with OCD. A poor prognosis is indicated by yielding to (rather than resisting) compulsions, childhood onset, bizarre compulsions, the need for hospitalization, a coexisting major depressive disorder, delusional beliefs, the presence of overvalued ideas (i.e., some acceptance of obsessions and compulsions), and the presence of a personality disorder (especially schizotypal personality disorder). The obsessional content does not seem to be related to the prognosis.

16.1. Which of the following epidemiological statements is true regarding anxiety disorders? A. Panic disorder has the lowest heritability. B. The mean age of onset is higher in girls. C. The age of onset is earlier than that of mood disorders. D. Rates in males peak in the fourth and fifth decades of life. D. All of the above

Answer: C Anxiety disorders have been shown to have the earliest age of onset of all major classes of mental and behavioral disorders with a median onset by the age of 12 years. This is far earlier than the onset of mood disorders or substance use disorders and comparable to that of impulse control disorders. Women have greater rates of anxiety disorders than men. This difference in gender rates can be seen as early as 6 years of age. Despite the far more rapid increase in anxiety disorders with age in girls than in boys, there are no gender differences in the mean age at onset of anxiety disorders (not higher in girls) or in their duration. Female preponderance of anxiety disorders is present across all stages of life but is most pronounced throughout early and mid-adulthood. The rates of anxiety disorders in men are also rather constant throughout adult life, but the rates in women peak in the fourth and fifth decades of life and decrease thereafter. Studies show a three- to fivefold increased risk of anxiety disorders among first-degree relatives of persons with anxiety disorders. Twin studies reveal that panic disorder has the highest heritability and has been shown to have the strongest degree of familial aggregation, with an almost sevenfold elevation in risk.

16.1. Mr. A was a successful businessman who presented for treatment after a change in his business schedule. Although he had formerly worked largely from an office near his home, a promotion led to a schedule of frequent out-of-town meetings requiring weekly flights. Mr. A reported being \"deathly afraid\" of flying. Even the thought of getting on an airplane led to thoughts of impending doom in which he envisioned his airplane crashing to the ground. These thoughts were associated with intense fear, palpitations, sweating, clamminess, and stomach upset. Although the thought of flying was terrifying enough, Mr. A became nearly incapacitated when he went to the airport. Immediately before boarding, Mr. A would often have to turn back from the plane, running to the bathroom to vomit. Which of the following is the most appropriate treatment for this patient who has another flight scheduled tomorrow? A. ß-agonists B. E

Answer: 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. ß-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.

The best goal for a client learning a relaxation technique is that the client will a. confronts the source of anxiety directly. b. experience anxiety without feeling overwhelmed. c. report no episodes of anxiety. d. suppresses anxious feelings.

b

16.1. Which of the following medical disorders are not associated with panic disorder due to a general medical condition? A. Cardiomyopathy B. Parkinson's disease C. Epilepsy D. Sjogren's syndrome E. Chronic obstructive pulmonary disease (COPD)

Answer: D A high prevalence of generalized anxiety disorder (not panic disorder) symptoms has been reported in patients with Sjogren's syndrome. Sjogren's syndrome is a chronic autoimmune disease in which a person's white blood cells attack their moisture-producing 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 Para hippocampal gyrus.

16.1. 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: 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.

16.1. Buspirone (Buspar) acts as a A. dopamine partial agonist useful in the treatment of OCD B. serotonin partial agonist useful in the treatment of OCD C. dopamine partial agonist useful in the treatment of generalized anxiety disorder D. serotonin partial agonist useful in treatment of generalized anxiety disorder E. none of the above

Answer: 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.

16.1. The risk of developing anxiety disorders is enhanced by A. eating disorders B. depression C. substance abuse D. allergies E. all of the above

Answer: D Disorders that may enhance the risk for the development of anxiety disorders include eating disorders, depression, and substance use and abuse. In contrast, anxiety disorders have been shown to elevate the risk of subsequent substance use disorders and may comprise a mediator of the link between depression and the subsequent development of substance use disorders in a clinical sample. Several studies have also suggested that there is an association between anxiety disorders and allergies, high fever, immunological diseases and infections, epilepsy, and connective tissue diseases. Likewise, prospective studies have revealed that the anxiety disorders may comprise risk factors for the development of some cardiovascular and neurological diseases, such as ischemic heart disease and migraine.

16.1. A 23-year-old woman presents to clinic with a chief complaint of \"difficulty concentrating because I worry about my child.\" She had recently gone back to teaching after having her third child. The patient states she is constantly wondering about other things as well. For example, she is going to help her sister-in-law throw a goodbye party and finds herself constantly going over what she needs to do to prepare for the party. At the end of the day, her husband claims she is irritable and tired. At night, she is unable to sleep and keeps thinking about her tasks for the next day. What is the most likely diagnosis? A. Avoidant personality disorder B. Obsessive-compulsive disorder C. Obsessive-compulsive personality disorder D. Generalized anxiety disorder E. None of the above

Answer: 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.

16.1. Induction of panic attacks in patients with panic disorder can occur with A. carbon dioxide B. cholecystokinin C. doxapram D. yohimbine E. all of the above

Answer: E 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.

16.1. Generalized anxiety disorder A. is least likely to coexist with another mental disorder B. has a female-to-male ratio of 1:2 C. is a mild condition D. has about a 50 percent chance of a recurrence after recovery E. has a low prevalence in primary care settings

Answer: D Generalized anxiety disorder (GAD) is a chronic (not mild) condition, and nearly half of patients who eventually recover experience a later recurrence. GAD is characterized by frequent, persistent worry and anxiety that is disproportionate to the impact of the events or circumstances on which the worry focuses. The distinction between GAD and normal anxiety is emphasized by the use of the words \"excessive\" and \"difficult to control\" in the criteria and by the specification that the symptoms cause significant impairment or distress. The anxiety and worry are accompanied by a number of physiological symptoms, including motor tension (i.e., shakiness, restlessness, headache), autonomic hyperactivity (i.e., shortness of breath, excessive sweating, palpitations), and cognitive vigilance (i.e., irritability). The ratio of women to men with the disorder is about 2:1 (not 1:2). The disorder usually has its onset in late adolescence or early adulthood, although cases are commonly seen in older adults. Also, some evidence suggests that the prevalence is particularly high (not low) in primary care settings. This is because patients with GAD usually seek out a general practitioner or internist for help with a somatic symptom. GAD is probably the disorder that most (not least) often coexist with another mental disorder, usually social phobia, specific phobia, panic disorder, or a depressive disorder.

16.1. Which of the following is not a component of the DSM-IV-TR diagnostic criteria for OCD? A. Children need not recognize that their obsessions are unreasonable. B. Obsessions are acknowledged as excessive or unreasonable. C. Obsessions or compulsions are time consuming and take more than 1 hour a day. D. The person recognized the obsessional thoughts as a product of outside him or herself. E. The person attempts to ignore or suppress compulsive thoughts or impulses.

Answer: D Obsessions and compulsions are the essential features of OCD. An individual must exhibit either obsessions or compulsions to meet DSM-IV-TR criteria. The DSM-IV-TR recognizes obsessions as \"persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate, \" causing distress. Obsessions provoke anxiety, which accounts for the categorization of OCD as an anxiety disorder. However, they must be differentiated from excessive worries about real-life problems and associated with efforts to either ignore or suppress the obsessions. The DSM-IV-TR diagnostic criteria for OCD indicate that 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.

16.1. Sigmund Freud postulated that the defense mechanisms necessary in phobias are A. regression, condensation, and dissociation B. regression, condensation, and projection C. regression, repression, and isolation D. repression, displacement, and avoidance E. repression, projection, and displacement

Answer: D Sigmund Freud viewed phobias as resulting from conflicts centered on an unresolved childhood oedipal situation. In adults, because the sexual drive continues to have a strong incestuous coloring, its arousal tends to create anxiety that is characteristically a fear of castration. The anxiety then alerts the ego to exert repression to keep the drive away from conscious representation and discharge. Because repression is not entirely successful in its function, the ego must call on auxiliary defenses. In phobic patients, the defenses, arising genetically from an earlier phobic response during the initial childhood period of the oedipal conflict, involves primarily the use of displacement-that is, the sexual conflict is transposed or displaced from the person who evoked the conflict to a seemingly unimportant, irrelevant object or situation, which has the power to elicit anxiety. The phobic object or situation selected has a direct associative connection with the primary source of the conflict and has thus, come naturally to symbolize it. Furthermore, the situation or object is usually such that the patient is able to keep out of its way and by the additional defense mechanism of avoidance to escape suffering from serious anxiety.

16.1. All of the following have been noted through brain imaging in patients with panic disorder except A. magnetic resonance imaging (MRI) studies have shown pathological involvement of both temporal lobes B. generalized cerebral vasoconstriction C. right temporal cortical atrophy D. increased blood flow to the basal ganglia E. positron emission tomography scans have implicated dysregulation of blood flow in panic disorder

Answer: 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.

16.1. A patient with OCD might exhibit all of the following brain imaging findings except A. longer mean T1 relaxation times in the frontal cortex than normal control subjects B. significantly more gray matter and less white matter than normal control subjects C. abnormalities in the frontal lobes, cingulum, and basal ganglia D. decreased caudate volumes bilaterally compared with normal control subjects E. lower metabolic rates in basal ganglia and white matter than in normal control subjects

Answer: 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.

16.1. Which of the following statements regarding anxiety and gender differences is true? A. Women have greater rates of almost all anxiety disorders. B. Gender ratios are nearly equal with OCD. C. No significant difference exists in average age of anxiety onset. D. Women have a twofold greater lifetime rate of agoraphobia than men. E. All of the above

Answer: E The results of community studies reveal that women have greater rates of almost all of the anxiety disorders. Despite differences in the magnitude of the rates of specific anxiety disorders across studies, the gender ratio is strikingly similar. Women have an approximately twofold elevation in lifetime rates of panic, generalized anxiety disorder, agoraphobia, and simple phobia compared with men in nearly all of the studies. The only exception is the nearly equal gender ratio in the rates of OCD and social phobia. Studies of youth report similar differences in the magnitude of anxiety disorders among girls and boys. Similar to the gender ratio for adults, girls tend to have more of all subtypes of anxiety disorders irrespective of the age composition of the sample. However, it has also been reported that despite the greater rates of anxiety in girls across all ages, there is no significant difference between boys and girls in the average age at onset of anxiety.

1. A client with GAD states, "I have learned that the best thing I can do is to forget my worries." How would the nurse evaluate this statement? a. The client is developing insight. b. The client's coping skills have improved. c. The client needs encouragement to verbalize feelings. d. The client's treatment has been successful.

c

1. Which would be the best intervention for a client having a panic attack? a. Involve the client in a physical activity. b. Offer a distraction such as music. c. Remain with the client. d. Teach the client a relaxation technique.

c

1. A client with anxiety is beginning treatment with lorazepam (Ativan). It is most important for the nurse to assess the client's a. motivation for treatment. b. family and social support. c. use of coping mechanisms. d. use of alcohol.

d

1. Which of the four classes of medications used for panic disorder is considered the safest because of low incidence of side effects and lackof physiological dependence? a. Benzodiazepines b. Tricyclics c. Monoamine oxidase inhibitors d. SSRIs

d

When assessing a client with anxiety, the nurse's questions should be a. avoided until the anxiety is gone. b. open-ended. c. postponed until the client volunteer's information. d. specific and direct.

d