Anxiety Disorders - Kaplan Study Guide Questions

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 PTSDE. PTSD lasts less than 1 month after a trauma

ANS: 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 expe- riencing symptoms of increased autonomic arousal, such as en- hanced startle. Flashbacks, in which the individual may act and feel as if the trauma is recurring, represent a classic form of re- experiencing. 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 ex- aggerated 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 disso- ciative symptoms.

49.10. Symptoms of GAD in children often mirror the symptoms of which other disorder? A. Obsessive-compulsive disorder B. Social phobia C. Posttraumatic stress disorder D. Learning disorder E. Elimination disorder

ANS: A Individuals with GAD and perfectionism may superficially re- semble those with OCD. For example, a child with GAD and concern about academic performance may routinely check over homework for accuracy or study material repeatedly for the pur- pose of improving the work product or getting it "perfect." In contrast, children with OCD know the work product is good or perfect but experience doubt that their perception is accurate and then recheck for the purpose of rechecking. Also, individuals with GAD may have recurrent uncontrollable worries that could be mistaken for obsessions; however, worries of GAD do not ap- pear senseless, intrusive, or unwanted; rather, they are described as powerful bona fide concerns and are usually tied to events or situations that would stimulate normal concerns. For example, normal children may worry about bad weather as it happens, but children with GAD may worry that bad weather may happen on a cloudless day, and children with OCD may worry that if they do not count to three in sets of three, then a loved one may die in a weather-related incident.

16.7. 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

ANS: A Community studies have consistently found that rates of anxi- ety 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 home- makers and those who are unemployed or have a disability. Sev- eral community studies have also yielded greater rates of anxiety disorders, particularly phobic disorders, among African Ameri- cans. The reasons for ethnic and social class differences have not yet been evaluated systematically; however, both methodolog- ical factors and differences in exposure to stressors have been advanced as possible explanations.

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

ANS: 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 be- havior 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 se- rially 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 pho- bic 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 physio- logical signs of anxiety (e.g., tachycardia). Phenelzine (Nardil), a monoamine oxidase inhibitor, is also useful in treating social phobia.

16.13. 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

ANS: A After the first one or two panic attacks, patients may be relatively unconcerned about their condition. With repeated attacks, how- ever, 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 be- havior. 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. Pa- tients with good premorbid functioning and symptoms of brief duration tend to have a good prognosis.

6.22. 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)

ANS: A Antidepressant medication is increasingly seen as the medica- tion treatment of choice for the anxiety disorders. More specifi- cally, drugs with primary effects on the serotonin neurotrans- mission 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), paroxe- tine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa), as well as venlafaxine (Effexor) and nefazodone (Serzone), are probably more effective than benzodiazepines and easier to dis- continue. Increasingly, benzodiazepines such as diazepam (Val- ium) 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.

49.8. Which of the following statements is not true about separation anxiety in infants? A. It is not a universal phenomenon in infants. B. It emerges in infants younger than 1 year of age. C. It has survival value. D. It peaks between 9 months and 18 months of age. E. It is pathological in about 15 percent of infants.

ANS: A Anxiety disorders are among the most common disorders in youth, affecting more than 10 percent of children and adoles- cents at some point in their development. Separation anxiety is a universal human developmental phenomenon emerging in infants younger than 1 year of age and marking a child's aware- ness of a separation from his or her mother or primary caregiver. Normative separation anxiety peaks between 9 and 18 months and diminishes by about 2.5 years of age, enabling young chil- dren to develop a sense of comfort away from their parents in preschool. Separation anxiety or stranger anxiety, as it has been termed, most likely evolved as a human response that has sur- vival value. The expression of transient separation anxiety is also normal in young children entering school for the first time. Approximately 15 percent of young children display intense and persistent fear, shyness, and social withdrawal when faced with unfamiliar settings and people. Young children with this pattern of behavioral inhibition are at a higher risk for the development of separation anxiety disorder, generalized anxiety disorder, and social phobia. Behaviorally inhibited children, as a group, exhibit characteristic physiologic traits that include higher than average resting heart rates, higher morning cortisol levels than average, and low heart rate variability.

49.7. There is clinical evidence to support which of the following as predisposing toward overanxious disorders in children? A. First-born children B. Large families C. Last-born children D. Low socioeconomic status E. Low expectations

ANS: A Some clinical evidence suggests that overanxious disorder is most common in small families of upper socioeconomic status, in first-born children, and in situations in which there is unusual concern about performance, even when the child is functioning at an adequate level. In such families, children who develop the overanxious disorder come to believe that they must earn their acceptance in the family by high-level, conforming behavior. They tend to be "goody-two-shoes" children. Although both boys and girls develop this disorder, it has been seen more frequently in girls than in boys.

16.11. 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

ANS: 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.

16.14. 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

ANS: 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). In- creased rates of OCD, Tourette's disorder, and chronic motor tics were found in the relatives of Tourette's disorder patients com- pared 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 mo- tor 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.

16.10. 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

ANS: 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 (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.

16.18. 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 symp- tom 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

ANS: B Clinical trials of drugs have supported the hypothesis that dys- regulation 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 ab- normally high.

49.6. Before the publication of DSM-IV, children with GAD were diagnosed as having which of the following disorders? A. Obsessive-compulsive disorder B. Overanxious disorder C. Social phobia D. Separation anxiety E. None of the above

ANS: B Until publication of DSM-IV, children and adolescents were not eligible for a diagnosis of GAD because the diagnosis required an individual be 18 years or older. Before publication of the DSM- IV, children with multiple fears and worries could be diagnosed with overanxious disorder. Overanxious disorder was characterized by excessive or unrealistic worry for a period of at least 6 months. However, because of the poor reliability and validity of this diagnostic category and symptomatic overlap and continuity with adult generalized anxiety, overanxious disorder was incorporated into the DSM-IV GAD diagnosis. Research comparing cases diagnosed by DSM-III-R and DSM-IV criteria found that the change in terminology did not affect the characteristics of cases.

16.3. 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

ANS: 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 dis- order, delusional beliefs, the presence of overvalued ideas (i.e., some acceptance of obsessions and compulsions), and the pres- ence of a personality disorder (especially schizotypal personality disorder). The obsessional content does not seem to be related to the prognosis.

16.5. 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 dis- orders. D. Rates in males peak in the fourth and fifth decades of life. E. All of the above

ANS: 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

49.2. According to clinical trials, child OCD patients taking clomipramine (Anafranil) showed significant improvement after how many weeks? A. 4 to 6 weeks B. 6 to 8 weeks C. 8 to 10 weeks D. 10 to 12 weeks E. 12 to 14 weeks

ANS: C Clomipramine (Anafranil), a tricyclic antidepressant (TCA), is the most researched medication in the treatment of children with OCD. In a double-blind, 8-week, placebo-controlled study, 60 percent of pediatric patients showed significant improvement. Patients treated with clomipramine reported a 37 percent mean reduction in OCD symptoms compared with 8 percent for the placebo group (with an effect size approaching 1.0). In another 10-week controlled trial, a significant difference was found between clomipramine and placebo, with 75 percent of pediatric patients showing at least moderate improvement. Other research found that clomipramine was superior to the noradrenergic reuptake inhibiting TCA desipramine (Norpramin). This crossover trial found that 64 percent of patients who initially received clomipramine during their first treatment showed relapse of OCD symptoms during desipramine treatment.

49.12. PTSD is the only disorder in DSM-IV-TR where the first diagnostic criterion is A. Biochemical changes B. Hyperarousal C. An identified etiologic factor D. Night terrors E. None of the above

ANS: C PTSD is one of the few conditions in the DSM-IV-TR in which the presence of an identified etiologic factor, such as exposure to an extreme traumatic stressor involving a threat to life, safety, or physical integrity, either experienced or witnessed directly by the child or affecting someone close to the child, is the first diagnostic criterion for the disorder. In addition to such exposure, the child must have at least one reexperiencing symptom such as recurrent intrusive and distressing recollections or dreams about the event or intense psychological or physiological reactions to reminders of the event, at least three symptoms of persistent avoidance of trauma-related stimuli or affective numbing, and at least two hyperarousal symptoms. The duration of these symptoms must be more than 1 month, and the disturbance must cause clini- cally significant distress or functional impairment. Biochemical changes such as changes in cortisol levels have also been found.

49.14. Young children with PTSD tend to experience frightening dreams that lack which of the following characteristics? A. Audible content B. Color content C. Specific content D. Emotional content E. Recognizable content

ANS: E In the case of younger children, there may be frequent fright- ening dreams without any recognizable content. Children may have periods when they act or feel as if the event were reoc- curring in the present moment (a flashback). In young children, trauma-specific reenactment may occur (e.g., sexually abused children may insert objects into their own or other children's pri- vate parts or otherwise recreate abusive acts perpetrated against them). Children may experience intense psychological distress or physiological reactivity when exposed to triggering events, peo- ple, or situations that remind them of the original traumatic event (e.g., children who witnessed a drive-by shooting may become terrified and have difficulty breathing when they hear thunder or a backfiring car). These reminders may be highly idiosyncratic to individual children. School-aged and preteen children may exhibit omen formation in which they believe they can foresee approaching adverse events.

16.24. 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. β-agonists B. Exposure therapy C. Lorazepam D. Paroxetine E. None of the above

ANS: 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 ex- cellent efficacy and rapid onset of action. β-adrenergic receptor antagonists (not agonists) may be useful in the treatment of spe- cific phobia, especially when the phobia is associated with panic attacks. The most commonly used treatment for specific pho- bia 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.

49.15. Selective mutism A. has an age of onset from 2 to 3years old B. rarely manifests outside of the home C. may develop gradually or suddenly D. is unrelated to temper tantrums E. all of the above

ANS: C The diagnosis of selective mutism is not difficult to make after it is clear that a child has adequate language skills in some environ- ments but not in others. The mutism may have developed grad- ually or suddenly after a disturbing experience. The age of onset can range from 4 to 8 years. Mute periods are most commonly manifested in school or outside the home; in rare cases, a child is mute at home but not in school. Children who exhibit selective mutism may also have symptoms of separation anxiety disorder, school refusal, and delayed language acquisition. Because so- cial anxiety is almost always present in children with selective mutism, behavioral disturbances, such as temper tantrums and oppositional behaviors, may also occur in the home.

16.25. Ms. K was referred for psychiatric evaluation by her general practitioner. On interview, Ms. K described a long history of checking rituals that had caused her to lose several jobs and had damaged numerous relationships. She reported, for example, that because she often had the thought that she had not locked the door to her car, it was difficult for her to leave the car until she had checked repeatedly that it was secure. She had broken several car door handles with the vigor of her checking and had been up to an hour late to work because she spent so much time checking her car door. Similarly, she had recurrent thoughts that she had left the door to her apartment unlocked, and she returned several times daily to check the door before she left for work. She reported that checking doors decreased her anxiety about security. Although Ms. K reported that she had occasionally tried to leave her car or apartment without checking the door (e.g., when she was already late for work), she found that she became so worried about her car being stolen or her apartment being broken into that she had difficulty going anywhere. Ms. K reported that her obsessions about security had become so extr

ANS: C The symptoms of an individual patient with OCD can overlap and change with time, but OCD has 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 self- doubt 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.

49.3. Developmentally appropriate separation anxiety usually begins around what age? A. 3 months B. 4 months C. 5 months D. 6 months E. 7 months

ANS: D Developmentally appropriate separation anxiety typically presents around age 6 months and declines between ages 2 and 3 years. Children with separation anxiety disorder have either persistent and worsening or new onset separation anxiety in the school-aged years (i.e., ages 6 to 12 years).

16.8. 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

ANS: 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 usu- ally 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) of- ten coexist with another mental disorder, usually social phobia, specific phobia, panic disorder, or a depressive disorder.

16.6. 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

ANS: D Sigmund Freud viewed phobias as resulting from conflicts cen- tered 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 characteristi- cally 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 pho- bic 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 ob- ject 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. Regression is an unconscious defense mechanism in which a person undergoes a partial or total return to early patterns of adaptation. Condensation is a mental process in which one sym- bol stands for a number of components. Projection is an uncon- scious defense mechanism in which persons attribute to another person generally unconscious ideas, thoughts, feelings, and im- pulses that are undesirable or unacceptable in themselves. In psychoanalysis, isolation is a defense mechanism involving the separation of an idea or memory from its attached feeling tone. Dissociation is an unconscious defense mechanism involving the segregation of any group of mental or behavioral processes from the rest of the person's psychic activity. Table 16.1 describes a more current view of seven of the psychodynamic themes in phobias.

16.19. 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)

ANS: D A high prevalence of generalized anxiety disorder (not panic disorder) symptoms has been reported in patients with Sjo ̈gren's syndrome. Sjo ̈gren's syndrome is a chronic autoimmune dis- ease 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 med- ical condition can be identical to those of the primary anxiety disorders. A syndrome similar to panic disorder is the most com- mon clinical picture. Patients who have cardiomyopathy may have the highest incidence of panic disorder secondary to a gen- eral medical condition. Cardiomyopathy is a disease of the heart muscle (myocardium). One study reported that 83 percent of pa- tients 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 symp- toms 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 dis- order characterized by paroxysmal brain dysfunction caused by excessive neuronal discharge), particularly when focus is in the right parahippocampal gyrus.

16.9. 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

ANS: D According to current conceptualizations, PTSD is associated with objective measures of physiological arousal. This includes elevated baselines heart rate, increased blood pressure, and ex- cessive 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 con- sistent with the hypothesis of tonic sympathetic nervous system arousal in PTSD. Disturbance in autonomic nervous system ac- tivity in individuals with PTSD is characterized by increased sympathetic and decreased parasympathetic tone. Preliminary evidence suggests that this autonomic imbalance can be normal- ized with selective serotonin reuptake inhibitor treatment. There is no change in blood level of thyroxine in those with PTSD.

49.5. An 8-month-old infant who is separated from his mother for the first time goes through three well-defined sequential stages. In order, they are A. despair, protest, and detachment B. detachment, despair, and protest C. detachment, protest, and despair D. protest, despair, and detachment E. protest, detachment, and despair

ANS: D Attachment disorder of the anaclitic type may be seen in any infant between the ages of 6 and 36 months of age. The primary symptoms consist of depressive-anxious affect and the dropping out of attachment behaviors that had been achieved before separation from the mother. The infant's reaction to such a loss occurs in several well-defined stages after the age of 6 months. In order, these stages are protest, despair, and detachment. The attitude of detachment refers to the infant's failure to make new attachments after the loss of the mother; detachment occurs generally a few days after such a loss. Other major symptoms include psychosocial retardation, avoidance of others, gastrointestinal disturbances without organic cause, and depressive withdrawal.

49.9. Which of the following is not a common physical symptom of generalized anxiety disorder in children? A. Gastrointestinal distress B. Headaches C. Heart palpitations D. Bed wetting E. Restlessness

ANS: D Bed wetting is not a common physical symptom of GAD in children. Common physical symptoms include headaches, tension, restlessness, gastrointestinal distress, and heart palpi- tations. Cognitive characteristics of GAD include negative think- ing errors such as catastrophizing (i.e., expecting the worst possi- ble outcome) or overestimation of the likelihood that something undesirable will occur. Generalized worries cover a range of ev- eryday issues, such as being on time, upcoming activities, failure of loved ones or friends to meet basic expectations, or whether unexpected events (e.g., inclement weather) will change daily plans or schedules. Children and adolescents with GAD are of- ten described as perfectionistic and overly sensitive.

16.17. 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

ANS: D Buspirone (Buspar) is a serotonin receptor partial agonist and is most likely effective in 60 to 80 percent of patients with gen- eralized 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 evi- dent in contrast to the almost immediate anxiolytic effects of the benzodiazepines.

16.26. 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

ANS: 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-syntactic in that they do not recognize the unreasonable nature of their behaviors.

49.1. Which of the following is not a true statement about the genetics of OCD? A. There is an increased risk of OCD in first degree relatives. B. Subclinical syndromes occur in family pedigrees. C. OCD is related to Tourette's disorder. D. There is a linkage to chromosome 21. E. Tics are highly correlated to OCD.

ANS: D OCD is a heterogeneous disorder that has been recognized for decades to run in families. Family studies have documented an increased risk of at least fourfold in the first-degree relatives of early-onset OCD. In addition, the presence of subclinical symp- tom constellations in family members appears to breed true. Molecular genetic studies have suggested linkage to regions of chromosomes 2 and 9 (not 21) in certain pedigrees with multiple members exhibiting early-onset OCD. Candidate gene studies have been inconclusive thus far. Family studies have pointed to a relationship between OCD and tic disorders such as Tourette's disorder. OCD and tic disorders are believed to share suscepti- bility factors. The concept of a broader "obsessive-compulsive spectrum" including eating disorders, and somatoform disorders may account for the expression of repetitive and stereotyped symptoms.

16.12. 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.

ANS: 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 obses- sions as "persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate," causing distress. Obsessions provoke anxiety, which accounts for the categoriza- tion of OCD as an anxiety disorder. However, they must be differ- entiated from excessive worries about real-life problems and as- sociated 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.

49.11. Childhood PTSD was officially recognized as a psychiatric disorder in what year? A. 1978 B. 1979 C. 1980 D. 1981 E. 1982

ANS: D PTSD, which is defined as a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma, was officially recognized as a psychiatric disorder in 1980 with the publication of DSM-III. Childhood PTSD was not recognized until the publication of the DSM-III-R, which was published in 1981.

16.15. 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

ANS: 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 pe- ripheral nervous system symptoms that may be induced by hy- perventilation and hypocapnia. Increased blood flow to the basal ganglia has not been noted in patients with panic disorder.

16.16. 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

ANS: 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.

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

ANS: E (all) Disorders that may enhance the risk for the development of anxi- ety 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 associ- ation between anxiety disorders and allergies, high fever, im- munological diseases and infections, epilepsy, and connective tissue diseases. Likewise, prospective studies have revealed that the anxiety disorders may comprise risk factors for the develop- ment of some cardiovascular and neurological diseases, such as ischemic heart disease and migraine.

49.4. Separation anxiety in children is characterized by A. fears that a loved one will be hurt B. fears about getting lost C. irritability D. animal and monster phobias E. all of the above

ANS: E (all) Morbid fears, preoccupations, and ruminations are characteristic of separation anxiety in children. Children become fearful that someone close to them will be hurt or that something terrible will happen to them when they are away from important caring figures. Many children worry that accidents or illness will befall their parents or themselves. Fears about getting lost and about being kidnapped and never again finding their par- ents are common. Young children express less specific, more generalized concerns because their immature cognitive development precludes the formation of well-defined fears. In older children, fears of getting lost may include elaborate fantasies around kidnappings, being harmed, being raped, or being made into slaves. Animal and monster phobias are common, as are concerns about dying. When threatened with separation, children may become fearful that events related to muggers, burglars, car accidents, or kidnapping may occur. When separation from an important figure is imminent, children show many premonitory signs; irritability, difficulty in eat- ing, and complaints such as vomiting and headaches are common when separation is anticipated or actually happens. These diffi- culties increase in intensity and organization with age because older children are able to anticipate anxiety in a more structured fashion. Thus, there is a continuum between mild anticipatory anxiety before a threatened separation and pervasive anxiety after the separation has occurred.

49.13. In the differential of PTSD, the clinician should consider which of the following conditions? A. Bereavement B. Disruptive behavior disorder C. Obsessive-compulsive disorder D. Social phobia E. All of the above

ANS: E (all) OCD, phobias, bereavement, and disruptive behavior disorder all have to be considered in children who are being worked up for posttraumatic stress disorder (PTSD) because many of the symptoms overlap. OCD is an anxiety disorder that is characterized by the per- sistent recurrence of obsessions and compulsions. A phobia is the persistent, pathological, unrealistic, intense fear of an object or situation; a person with a phobia may realize that the fear is irrational but is nonetheless unable to dispel it. Some examples are acrophobia (high places), agoraphobia (open places, leav- ing familiar setting of home), algophobia (pain), claustrophobia (closed or confined places), and zoophobia (animals). Bereavement is the feeling of grief or desolation, especially at the death or loss of a loved one. Disruptive behavior disorder is characterized by inattention, overaggressiveness, delinquency, destructiveness, hostility, feel- ings of rejection, negativism, or impulsiveness. Finally, the clinician should remember that PTSD can be superimposed on any of the above disorders.

16.21. 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

ANS: 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 no- radrenergic 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 stud- ies revealed that patients with panic disorder have abnormally brisk cerebrovascular responses to stress, showing greater vaso- constriction during hypocapnic respiration than normal control subjects.

16.4. 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 agora- phobia than men. E. All of the above

ANS: E (all) 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, gen- eralized anxiety disorder, agoraphobia, and simple phobia com- pared 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 anxi- ety 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.

16.20. 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

B Specific phobia is usually easily distinguished from anxiety stem- ming 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 dif- ferentiated from a number of medical conditions that produce similar symptomatology. Panic attacks are associated with a va- riety of endocrinologic disorders, including hypo- and hyper- thyroid states, hyperparathyroidism, and pheochromocytomas. Episodic hypoglycemia associated with insulinomas can also produce panic-like states, as can primary neuropathologic pro- cesses. These include seizure disorders, vestibular dysfunction, neoplasms, and the effects of both prescribed and illicit sub- stances 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 dis- orders that are associated with basal ganglia diseases, such as Sydenham's chorea and Huntington's disease. It should be noted that OCD frequently develops before age 30 years, and new-onset OCD in 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 child- hood OCD in 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 contr