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Self-Assessment Questions


Evaluation and Treatment of Anxious Patients: Review Questions

Julia B. Frank, MD

Dr. Frank is Associate Professor of Psychiatry and Behavioral Sciences,
George Washington University School of Medicine, Washington, DC.

Choose the single best answer for each question.

Questions 1 and 2 refer to the following case study.

A 32-year-old married woman seeks evaluation for rapid heartbeat, dizziness, and pressure in her chest. The symptoms cluster and are associated with a feeling of doom. She also describes shortness of breath and trembling. The episodes, which began in her late 20s after she was fired from a job, vary in frequency from daily to a few times per month. The episodes begin suddenly and resolve in approximately 20 minutes, but she describes feeling tired for hours afterwards. She associates some episodes with feeling trapped (eg, being in a long line, being in a car in traffic) but says they are unrelated to exertion. Her vital signs are normal, and cardiovascular examination is normal except for a midsystolic click, suggestive of mitral valve prolapse (MVP). MVP is subsequently confirmed by echocardiogram.

1. Which of the following factors must be present to establish a diagnosis of panic disorder?

  1. Intense restlessness with the attacks
  2. A family history negative for heart disease
  3. Excessive worry about having future episodes
  4. Episodes that wake the patient from sleep
  5. A family history of mental illness
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2. Further evaluation of this patient should include which of the following tests?

  1. A 24-hour urine screen for catecholamine metabolites
  2. Thyroid function tests
  3. Ventilation-perfusion scan
  4. A 5-hour glucose tolerance test
  5. All of the above
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Questions 3 and 4 refer to the following case study.

A 40-year-old man who is undergoing a contested divorce requests medication for anxiety. He says that for the past 2 months, he has been worried and can’t fall asleep until approximately 2 am. His work has suffered because of daytime fatigue. He has trouble “catching his breath,” sighs excessively, and feels constant tension in his back and neck. He sometimes feels angry when he has contact with his wife. He denies excessive consumption of alcohol according to the CAGE questionnaire. He describes himself as a man prone to worry about money and work demands prior to the divorce but cannot recall having similar symptoms that lasted more than 1 or 2 days. He denies any past abuse of his wife or any current intention to hurt her.

3. What is the most likely diagnosis in this patient?

  1. Generalized anxiety disorder
  2. Acute stress disorder
  3. Adjustment disorder with anxiety
  4. Panic disorder without agoraphobia
  5. Posttraumatic stress disorder
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4. All of the following treatments might be helpful to this patient EXCEPT:

  1. A benzodiazepine, especially at bedtime
  2. Brief psychodynamic psychotherapy
  3. Cognitive behavioral psychotherapy
  4. Buspirone
  5. Propranolol
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