Chapter review

Fitzgerald PMHNP board review. ch09. Anxiety Disorders. This is drive 1 of 7. When I say Pause. Answer. wait, then I will give the answer. New section. Anxiety disorders: criteria, timelines, and look-alikes. Topic. Symptom Differentiation (Figure 9-1). FITZGERALD CH09: Anxiety Disorders. Anxiety Disorders: Criteria, Timelines, and Look-Alikes. Symptom Differentiation (Figure 9-1). Anxiety presents across two distinct clinical domains: psychological symptoms and physiological symptoms. Psychological symptoms represent the cognitive and emotional experiences of the patient, including **apprehension**, **fear**, and **obsession**. Physiological symptoms represent autonomic nervous system activation, manifested as **muscle tension**, **tachycardia** (increased heart rate), **tachypnea** (increased respiration rate), **chest tightness**, **stomach discomfort**, and **restlessness**. Evaluating anxiety requires applying a two-step diagnostic branching logic to differentiate adaptive human stress from clinical pathology. When anxiety occurs as a reasonable response to a real external threat and remains proportional to that threat, it is classified as **normal anxiety**. Conversely, when anxiety arises without an obvious external threat, or when the response is excessive relative to the stimulus, AND causes demonstrable functional impairment in social, occupational, or daily activities, it is classified as an **anxiety disorder**. **Safety alert**: Autonomic anxiety symptoms like chest tightness, shortness of breath, and tachycardia overlap significantly with life-threatening medical emergencies. Clinicians must rule out acute cardiovascular events like **myocardial infarction**, respiratory compromise like **pulmonary embolism** or **COPD**, and endocrine surges like **hypoglycemia** or **pheochromocytoma** before diagnosing a primary anxiety disorder. **Board trap**: Assuming that severe physical complaints like chest pain or dyspnea are purely psychiatric without checking vital signs, physical status, and medical history. On board exams, physical stability and medical rule-outs always precede psychiatric diagnoses. **First-line**: Perform a systematic history, physical examination, and basic laboratory workup (including **TSH**, **blood glucose**, and ECG when indicated) as the initial step for any patient presenting with new-onset or severe physiological anxiety symptoms. Bottom Line Summary. - Anxiety symptoms manifest in two domains: psychological (**apprehension**, **fear**, **obsession**) and physiological (**muscle tension**, **tachycardia**, **tachypnea**, **chest tightness**, **stomach discomfort**, **restlessness**). - **Normal anxiety** is defined as a proportional response to a real external threat that does not impair daily function. - **Anxiety disorders** (pathological anxiety) are defined by excessive responses or threat-free onset combined with significant functional impairment. - Medical conditions that mimic anxiety symptoms span cardiovascular (**myocardial infarction**), respiratory (**COPD**, **pulmonary embolism**), and metabolic (**hypoglycemia**, **pheochromocytoma**) systems. - Pharmacological triggers of anxiety include **stimulants**, **sympathomimetics**, **theophylline**, **diphenhydramine** (paradoxical excitation in older adults), **levodopa**, and **antipsychotic-induced akathisia**. - Generalized anxiety disorder requires excessive worry on most days for at least **6 months** plus 3 of 6 physical/cognitive symptoms in adults (1 in children), whereas panic attack surges peak within **10 minutes**. Figure 9-1 Teaching: Symptom and Diagnostic Mapping. Figure 9-1 organizes anxiety manifestations and maps them directly to the diagnostic decision gate. Psychological symptoms group together as cognitive-emotional distress: **apprehension**, **fear**, and **obsession**. Physiological symptoms group together as autonomic hyperarousal: **muscle tension**, **tachycardia**, **tachypnea**, **chest tightness**, **stomach discomfort**, and **restlessness**. Comparing the two diagnostic endpoints reveals the core threshold: **normal anxiety** requires both a real external threat and a proportional reaction, whereas an **anxiety disorder** is defined by an absent threat or excessive reaction coupled with functional impairment. Sample Test Questions for This Leaf. Question 2. Which of the following symptoms is not consistent with a panic attack? - A. Sensation of shortness of breath - B. Chest pain - C. Fear of dying - D. Fatigue Pause. Answer: D. Why it is correct: Fatigue is a chronic diagnostic criterion for generalized anxiety disorder under the WATCHERS criteria. In contrast, panic attacks represent acute autonomic surges peaking within 10 minutes that feature shortness of breath, chest pain, and fear of dying. Why the other choices are wrong: - A. Sensation of shortness of breath is a classic physical symptom of an acute panic attack. - B. Chest pain is a characteristic physiological symptom during a panic attack. - C. Fear of dying is one of the three core psychological symptoms of a panic attack. Question 4. A 68-year-old man presents with symptoms of anxiety. He provides a list of medications he is currently taking. Which of the following is least likely to contribute to his anxiety symptoms? - A. Theophylline - B. Diphenhydramine - C. Methotrexate - D. Levodopa Pause. Answer: C. Why it is correct: Methotrexate is an immunosuppressant disease-modifying agent that does not cause central autonomic stimulation or anxiety symptoms. Conversely, theophylline, diphenhydramine, and levodopa are established medication triggers for anxiety, agitation, or paradoxical excitation. Why the other choices are wrong: - A. Theophylline is a bronchodilator sympathomimetic that frequently induces tremor, tachycardia, and anxiety symptoms. - B. Diphenhydramine can trigger paradoxical excitation, agitation, and anxiety symptoms, particularly in older adults. - D. Levodopa increases central dopamine levels and can precipitate acute anxiety, agitation, or psychosis. Question 7. Medical conditions associated with anxiety-like symptoms include all of the following, except: - A. Chronic obstructive pulmonary disease (COPD) - B. Myocardial infarction - C. Hypoglycemia - D. Hyperglycemia Pause. Answer: D. Why it is correct: Hyperglycemia does not typically present with an acute sympathetic surge or anxiety-like symptoms. In contrast, acute hypoglycemia triggers epinephrine release causing sweating, tachycardia, and tremor, while COPD and myocardial infarction directly provoke severe physiological anxiety symptoms. Why the other choices are wrong: - A. COPD causes acute hypoxia and dyspnea, directly triggering physiological anxiety. - B. Myocardial infarction presents with chest tightness, diaphoresis, and an impending sense of doom that mimic panic and severe anxiety. - C. Hypoglycemia triggers an acute autonomic surge (adrenergic release) that directly mimics physiological anxiety symptoms. Next. Topic. The Diagnostic Pivot Logic. Bottom Line Summary. * Normal anxiety is a reasonable, adaptive response to a real external threat, whereas **anxiety disorder** requires an excessive response or no external threat plus demonstrable functional impairment. * **Gate 1 (Medical Rule-Out)**: Always rule out physiological mimics first, including **hyperthyroidism**, **pheochromocytoma**, **COPD**, **pulmonary embolism**, **myocardial infarction**, and **hypoglycemia**. * **Gate 2 (Substance Rule-Out)**: Evaluate for symptoms starting within **1 month** of substance use, intoxication, or withdrawal. Key culprits include **theophylline**, **diphenhydramine**, **levodopa**, stimulants, and withdrawal from alcohol or benzodiazepines. * **Gate 3 (Stressor Timeline)**: Symptoms emerging within **3 months** of an identified stressor that resolve within **6 months** after termination represent **adjustment disorder**. * **Gate 4 (Trauma Pivot)**: Symptoms developing after severe trauma lasting **3 days to 1 month** are **acute stress disorder (ASD)**; symptoms persisting **greater than 1 month** become **post-traumatic stress disorder (PTSD)**. * **Gate 5 (Primary Chronic Disorders)**: **Generalized anxiety disorder (GAD)** requires excessive worry on most days for **6 months or more** with 3 or more **WATCHERS** symptoms (1 symptom in children). **Panic disorder** requires recurrent, **unexpected** attacks peaking within **10 minutes**, followed by **1 month** of anticipatory worry or behavioral change. The Diagnostic Pivot Framework. The diagnostic pivot logic establishes a step-by-step filter to prevent premature psychiatric labeling and ensure patient safety. Step 1: Normal vs. Pathological Anxiety. Evaluate presenting features against three diagnostic criteria: * Is there an actual external threat? * Is the autonomic and emotional response proportional to the threat? * Is there significant impairment in social, occupational, or personal functioning? If the threat is real and the response is proportional, the condition is normal anxiety. If there is no threat or the response is excessive, plus there is functional impairment, the patient has an anxiety disorder. Step 2: The 5-Gate Diagnostic Filter. **Safety alert**: Never diagnose a primary psychiatric anxiety disorder without running the patient through the systematic 5-gate filter. Missing an underlying medical crisis or drug toxicity can be fatal. 1. **Gate 1: Rule Out Medical Conditions** * Assess for medical mimics before considering primary psychiatric illness. * Endocrine and metabolic triggers: **hyperthyroidism**, **pheochromocytoma**, and **hypoglycemia** (which triggers sympathoadrenal epinephrine release). * Cardiopulmonary triggers: **myocardial infarction**, **COPD**, and **pulmonary embolism**. 2. **Gate 2: Rule Out Substance and Medication Triggers** * Assess if onset occurs within **1 month** of substance ingestion, intoxication, or withdrawal. * Medication culprits: **theophylline**, **diphenhydramine** (causes anticholinergic excitation in older adults), **levodopa** (dopaminergic stimulation), stimulants, and sympathomimetics. * Withdrawal triggers: abrupt cessation of alcohol or benzodiazepines, which can induce severe withdrawal, seizures, delirium, and death. 3. **Gate 3: Evaluate Stressor-Related Timelines** * Identify if emotional or behavioral distress developed within **3 months** of a specific stressor. * If symptoms do not meet criteria for another specific disorder and resolve within **6 months** after the stressor ends, diagnose **adjustment disorder with anxious mood**. 4. **Gate 4: Apply the Trauma Duration Pivot** * Confirm exposure to actual or threatened death, serious injury, or sexual violence. * If symptom duration is **3 days to 1 month** post-trauma, diagnose **acute stress disorder**. * If symptom duration is **greater than 1 month** post-trauma, pivot the diagnosis to **post-traumatic stress disorder**. 5. **Gate 5: Distinguish Primary Chronic Anxiety Disorders** * **First-line** intervention for primary anxiety disorders includes **SSRIs** or **CBT**, whereas **psychotherapy** (such as trauma-focused CBT or EMDR) is primary for **PTSD**. * **Social anxiety disorder**: Fear of social scrutiny lasting **6 months or more**. * **Panic disorder**: Recurrent, **unexpected** panic attacks peaking within **10 minutes**, followed by **1 month** of worry about future attacks. * **Obsessive-compulsive disorder**: Obsessions or compulsions taking **greater than 1 hour per day**. * **Generalized anxiety disorder**: Excessive worry for **6 months or more** with 3 **WATCHERS** symptoms. Compare and Distinguish. **Normal Anxiety vs. Anxiety Disorder** * Think: Normal anxiety is adaptive and proportional; anxiety disorder is excessive and disabling. * Priority: Differentiate real external threat from pathologically generated hyperarousal. * Boards are testing: Functional impairment as the defining threshold for psychiatric diagnosis. **Acute Stress Disorder vs. Post-Traumatic Stress Disorder** * Think: The 1-month calendar cutoff determines the diagnostic label. * Priority: Symptom duration following a traumatic event. * Boards are testing: **3 days to 1 month** is ASD; **greater than 1 month** is PTSD. **Expected Panic vs. Unexpected Panic** * Think: Expected panic occurs with a known trigger (phobia); unexpected panic comes out of the blue. * Priority: Identifying whether panic attacks are spontaneous. * Boards are testing: **Panic disorder** requires recurrent, **unexpected** attacks. Expected attacks point to specific phobias or social anxiety. **Board trap**: Test writers love presenting an older adult with acute anxiety who was recently started on **diphenhydramine** or **theophylline**, or a patient with new-onset panic who is actually experiencing **hypoglycemia** or **hyperthyroidism**. Selecting a primary anxiety disorder or prescribing an **SSRI** before completing Gate 1 and Gate 2 medical and medication rule-outs is a classic distractor trap. Board Practice Question Bank. Question 1. A 68-year-old man presents for evaluation reporting new-onset severe anxiety and restlessness over the past two weeks. He brings his current medication list. Which of the following medications is least likely to contribute to his anxiety symptoms source 1? A) Theophylline B) Diphenhydramine C) Methotrexate D) Levodopa **Pause.** **Answer**: C **Why It Is Correct**: **Methotrexate** is an immunosuppressive disease-modifying antirheumatic agent that does not cause central nervous system stimulation or autonomic hyperarousal, making it least likely to induce anxiety symptoms source 1. **Why the Other Choices Are Wrong**: * **A**: **Theophylline** is a xanthine bronchodilator with central stimulant properties that commonly causes tachycardia, tremors, and severe anxiety source 1. * **B**: **Diphenhydramine** has significant anticholinergic effects that frequently trigger paradoxical central nervous system excitation, restlessness, and anxiety in older adults source 1. * **D**: **Levodopa** increases central dopamine levels, which routinely causes agitation, anxiety, and neuro-psychiatric side effects source 2. Question 2. When applying the diagnostic filter for a patient presenting with acute anxiety symptoms, which of the following general medical conditions is least likely to be the underlying physiological cause source 3? A) Chronic obstructive pulmonary disease B) Myocardial infarction C) Hyperglycemia D) Hypoglycemia **Pause.** **Answer**: C **Why It Is Correct**: **Hyperglycemia** does not acutely stimulate the sympathoadrenal system to produce acute panic or autonomic anxiety symptoms, whereas **hypoglycemia** triggers an immediate catecholamine surge source 3. **Why the Other Choices Are Wrong**: * **A**: **Chronic obstructive pulmonary disease** causes acute hypoxia and hypercapnia, which directly trigger respiratory panic and intense autonomic anxiety source 4. * **B**: **Myocardial infarction** induces severe autonomic hyperarousal and acute apprehension, often described as a feeling of impending doom source 4. * **D**: **Hypoglycemia** triggers a massive epinephrine release, causing acute tachycardia, diaphoresis, tremors, and severe anxiety source 3. Question 3. Ashley, a 28-year-old female, presents for a psychiatric evaluation after two recent emergency department visits for acute panic attacks. Comprehensive medical workups were entirely normal. Which of the following statements by Ashley is least consistent with a diagnosis of panic disorder [5, 6]? A) My attacks always happen right after I have a bad argument with my boyfriend. B) During the episode I felt detached from myself, like I was not really present. C) The feeling came completely out of nowhere while I was driving and my heart started racing. D) I am terrified that another attack will happen so I avoid leaving my apartment alone. **Pause.** **Answer**: A **Why It Is Correct**: **Panic disorder** requires recurrent, **unexpected** panic attacks that occur spontaneously out of the blue. Attacks that occur predictably after a specific emotional argument are situational responses rather than unexpected panic source 6. **Why the Other Choices Are Wrong**: * **B**: Depersonalization and derealization are characteristic psychological symptoms during a panic attack [7, 8]. * **C**: Abrupt onset peaking within **10 minutes** out of the blue is the cardinal feature of unexpected panic attacks [8, 9]. * **D**: Persistent anticipatory worry and behavioral avoidance lasting **1 month or more** are core criteria for panic disorder [6, 10]. Question 4. A PMHNP evaluates a 35-year-old combat veteran who experienced a severe explosion 3 weeks ago. He reports persistent intrusive nightmares, hypervigilance, and severe distress. Which statement accurately reflects the diagnostic pivot logic for this patient [11-13]? A) The patient should be diagnosed with post-traumatic stress disorder because the trauma involved combat. B) The patient meets duration criteria for acute stress disorder because symptoms have lasted between 3 days and 1 month. C) The patient should be diagnosed with adjustment disorder because symptoms began within 3 months of the stressor. D) The diagnosis cannot be made until symptoms have persisted for at least 6 months. **Pause.** **Answer**: B **Why It Is Correct**: Symptoms occurring between **3 days and 1 month** following exposure to a severe traumatic event meet the specific time frame for **acute stress disorder** [11, 13]. **Why the Other Choices Are Wrong**: * **A**: The diagnosis of **post-traumatic stress disorder** requires symptoms to persist for **greater than 1 month**, regardless of trauma severity or type [11, 12]. * **C**: **Adjustment disorder** is used for non-trauma stressors or trauma reactions that do not meet full symptom criteria for ASD or PTSD source 14. * **D**: **PTSD** can be diagnosed as soon as symptom duration exceeds **1 month**; waiting 6 months is unnecessary [11, 15]. 💡 *Would you like to move on to the next leaf in Chapter 9, or drill down into GAD diagnostic criteria and the WATCHERS mnemonic?* Next. Topic. Diagnostic Branching Hierarchy (Figure 9-2). Diagnostic Branching Hierarchy (Figure 9-2). Bottom Line. * **Gate 1 Medical Rule-Out**: Before diagnosing a primary psychiatric disorder, rule out medical conditions such as **hyperthyroidism**, **pheochromocytoma**, **COPD**, **pulmonary embolism**, **myocardial infarction**, and **hypoglycemia**. * **Gate 2 Substance Rule-Out**: **Substance-induced anxiety disorder** is diagnosed when symptoms occur within **1 month** of substance ingestion, intoxication, or withdrawal. Key offending agents include **sympathomimetics**, **stimulants**, **theophylline**, **levodopa**, **diphenhydramine**, and withdrawal from **alcohol** or **benzodiazepines**. * **Gate 3 Adjustment Disorder**: **Adjustment disorder with anxious mood** requires symptom onset within **3 months** of an identifiable stressor and resolution within **6 months** after the stressor or its consequences end. * **Gate 4 Trauma Timeline**: Trauma-related symptoms lasting **3 days to 1 month** after exposure represent **acute stress disorder**. Symptoms persisting for greater than **1 month** represent **post-traumatic stress disorder** (**PTSD**). * **Gate 4 GAD Criteria**: **Generalized anxiety disorder** (**GAD**) requires excessive, uncontrollable worry on most days for at least **6 months**, accompanied by at least **3** of the **WATCHERS** physical/cognitive symptoms (only **1** symptom required in children). * **Gate 4 Panic Disorder Criteria**: **Panic disorder** requires recurrent, unexpected panic attacks peaking within **10 minutes**, followed by at least **1 month** of persistent concern about additional attacks or significant maladaptive behavior change. * **Gate 4 OCD Criteria**: **Obsessive-compulsive disorder** (**OCD**) requires intrusive obsessions or repetitive compulsions that are time-consuming, taking up at least **1 hour per day**, or cause severe functional impairment. * **First-Line Pharmacotherapy**: First-line medication across **GAD**, **panic disorder**, **social anxiety disorder**, **OCD**, and **PTSD** consists of **SSRIs** (such as **sertraline** or **fluoxetine**) and **SNRIs** (such as **duloxetine** or **venlafaxine**). High-Yield Concept Map: Diagnostic Branching Hierarchy. Step 1: Primary Medical Assessment (Gate 1). * **What it is**: Evaluating whether physical illness or altered lab parameters directly cause the anxiety presentation. * **Must know criteria**: Check **TSH** for **hyperthyroidism**, **EKG** and cardiac enzymes for **myocardial infarction**, blood glucose for **hypoglycemia**, and urinary catecholamines for **pheochromocytoma**. * **Safety alert**: Never assume acute anxiety or panic in an older adult or new-onset case is primary psychiatric without obtaining vital signs, physical exam, and basic lab work. * **Board trap**: Mistaking physical symptoms of hypoxia or respiratory distress from **COPD** or **pulmonary embolism** for a primary panic attack. Step 2: Substance and Medication Assessment (Gate 2). * **What it is**: Identifying anxiety caused by exogenous substances, prescriptions, or withdrawal. * **Timelines**: Symptoms occur within **1 month** of substance use, intoxication, or discontinuation. * **Common offending drugs**: **theophylline**, **bronchodilators**, **levodopa**, **diphenhydramine**, OTC decongestants, **caffeine**, **amphetamines**, and abrupt withdrawal from **benzodiazepines** or **alcohol**. * **Safety alert**: Abrupt discontinuation of **alprazolam** or **lorazepam** can precipitate severe withdrawal seizures, delirium, and autonomic crisis. * **Board trap**: Attributing new-onset agitation in a Parkinson patient to worsening anxiety instead of **levodopa** toxicity or **akathisia** from antipsychotics. Step 3: Stressor and Adjustment Assessment (Gate 3). * **What it is**: Evaluating emotional or behavioral reactions to identifiable psychosocial stressors. * **Timelines**: Onset occurs within **3 months** of the stressor. Symptoms must resolve within **6 months** once the stressor or its consequences end. * **Must know criteria**: Distress is out of proportion to the stressor severity and causes functional impairment, but does not meet full criteria for another primary disorder. Step 4: Primary Anxiety and Related Disorders Screening (Gate 4: The Big Five). * **Trauma spectrum**: * **Acute stress disorder**: Symptoms emerge within **3 days to 1 month** following exposure to actual or threatened death, serious injury, or sexual violence. * **Post-traumatic stress disorder**: Symptoms persist for greater than **1 month** post-trauma, spanning intrusion, avoidance, negative mood/cognitions, and hyperarousal. * **First-line**: **SSRIs** (**sertraline**, **paroxetine**) or **SNRIs** plus trauma-focused psychotherapy. **Prazosin** (**3 to 15 mg**) at bedtime targets trauma nightmares. Avoid **benzodiazepines** in **PTSD**. * **Social and phobic spectrum**: * **Social anxiety disorder**: Marked fear of scrutiny or embarrassment in social or performance situations lasting at least **6 months**. * **First-line**: **SSRIs** for generalized social anxiety. For performance-only anxiety, use beta-blockers such as **propranolol** (**20 to 40 mg**) or **atenolol** (**50 to 100 mg**) taken **1 hour** prior to the event. * **Panic spectrum**: * **Panic attack**: Abrupt surge of intense fear peaking within **10 minutes**, requiring at least **4** physical symptoms and **1** psychological symptom. * **Board trap**: A **panic attack** is a specifier, not a standalone DSM-5-TR diagnosis. * **Panic disorder**: Recurrent, unexpected panic attacks followed by **1 month** or more of persistent worry or behavioral changes. * **First-line**: **SSRIs** starting at **half the usual initial dose** (for example, **12.5 mg** of **sertraline**) to avoid initial activation or paradoxical panic. * **Obsessive spectrum**: * **Obsessive-compulsive disorder**: Presence of obsessions (intrusive thoughts) or compulsions (repetitive behaviors/mental acts) taking at least **1 hour per day**. * **First-line**: High-dose **SSRIs** (such as **fluoxetine** up to **80 mg** daily) plus **CBT** with exposure and response prevention. * **Generalized worry spectrum**: * **Generalized anxiety disorder**: Excessive, uncontrollable worry on most days for at least **6 months**, plus at least **3** **WATCHERS** symptoms (**1** in children). * **First-line**: **SSRIs**, **SNRIs**, or **buspirone**. Short-term **benzodiazepine** bridge for **2 to 3 weeks** may be used during **SSRI** initiation. Step 5: Unspecified Classification (Gate 5). * **What it is**: Used when anxiety symptoms cause significant functional impairment but fail to meet full diagnostic thresholds for any specific primary disorder. Compare and Distinguish. Acute Stress Disorder vs Post-Traumatic Stress Disorder. * **Think**: ASD is short-term post-trauma reaction; PTSD is chronic persistent trauma disorder. * **Priority**: Assess time elapsed since the traumatic event. * **Boards are testing**: The **1 month** timeline pivot. Symptoms lasting **3 days to 1 month** indicate ASD. Symptoms persisting beyond **1 month** indicate PTSD. * **Classic distractor**: Diagnosing PTSD 2 weeks after a motor vehicle accident. Panic Attack vs Panic Disorder. * **Think**: Panic attack is an acute episodic symptom building within minutes; panic disorder is a chronic syndrome of recurrent unexpected attacks with persistent anticipatory fear. * **Priority**: Differentiate specifier from primary diagnosis. * **Boards are testing**: Panic attack requires **10 minutes** peak and at least **4** physical symptoms; panic disorder requires unexpected attacks plus **1 month** of anticipatory worry or behavioral changes. * **Classic distractor**: Selecting panic attack as the primary Axis I diagnosis. Substance-Induced Anxiety vs Primary Anxiety Disorder. * **Think**: Substance-induced is directly linked to drug ingestion, toxicity, or withdrawal; primary anxiety occurs independently of substance use. * **Priority**: Rule out recent chemical ingestion or withdrawal before starting psychotropics. * **Boards are testing**: Onset within **1 month** of substance use or withdrawal defines substance-induced anxiety. * **Classic distractor**: Diagnosing GAD in a patient actively withdrawing from alcohol or taking high-dose **theophylline**. Social Anxiety Disorder vs Generalized Anxiety Disorder. * **Think**: Social anxiety is fear of judgment/scrutiny in social settings; GAD is pervasive worry across multiple everyday life domains. * **Priority**: Identify the trigger stimulus. * **Boards are testing**: Social anxiety centers on embarrassment and scrutiny; GAD centers on uncontrollable worry about finances, health, family, and performance over **6 months**. * **Classic distractor**: Calling social performance anxiety GAD because the patient reports somatic symptoms like sweating and tachycardia. Sample Test Questions. Question 1. A 68-year-old man presents with new-onset symptoms of generalized anxiety and restlessness. He provides a list of his current outpatient medications. Which of the following medications is least likely to contribute to his anxiety symptoms? A. Theophylline B. Diphenhydramine C. Methotrexate D. Levodopa Pause. Answer. C Why it is correct: **Methotrexate** is a disease-modifying antirheumatic drug and immunosuppressant that does not stimulate the central nervous system or trigger autonomic sympathomimetic activation. **Theophylline**, **diphenhydramine** (via anticholinergic toxicity or withdrawal/paradoxical excitation in older adults), and **levodopa** (via dopaminergic overstimulation) are well-known pharmacological causes of anxiety-like symptoms. Why the other choices are wrong: * **A**: **Theophylline** is a methylxanthine bronchodilator with stimulant properties that frequently induces tachycardia, jitteriness, and anxiety. * **B**: **Diphenhydramine** can cause anticholinergic side effects, **akathisia**, paradoxical excitation, and withdrawal anxiety in elderly patients. * **D**: **Levodopa** increases central dopamine levels and routinely triggers anxiety, agitation, or hallucinosis in older adults. Test-taking pearl: When an older adult presents with new-onset anxiety, always apply Gate 2 of the diagnostic hierarchy and review the medication list for sympathomimetics, dopaminergics, and anticholinergics before diagnosing a primary psychiatric disorder. Question 2. Medical conditions associated with anxiety-like symptoms include all of the following, except: A. Chronic obstructive pulmonary disease (COPD) B. Myocardial infarction C. Hypoglycemia D. Hyperglycemia Pause. Answer. D Why it is correct: **Hyperglycemia** typically presents with polydipsia, polyuria, lethargy, or diabetic ketoacidosis rather than acute sympathoadrenal panic or anxiety symptoms. **Hypoglycemia** triggers acute epinephrine release resulting in diaphoresis, tremors, tachycardia, and severe anxiety. **COPD** and **myocardial infarction** directly trigger respiratory and cardiovascular alarm signals that mimic panic attacks. Why the other choices are wrong: * **A**: **COPD** causes hypoxia and hypercapnia, which generate intense air hunger and autonomic panic symptoms. * **B**: **Myocardial infarction** frequently presents with an impending sense of doom, chest tightness, and severe anxiety. * **C**: **Hypoglycemia** causes acute autonomic crisis with shakiness, diaphoresis, and anxiety due to sympathetic discharge. Test-taking pearl: Apply Gate 1 of the diagnostic branching hierarchy by ruling out acute medical emergencies like hypoglycemia, MI, and hypoxia before confirming a primary anxiety diagnosis. Question 3. Ashley, a 28-year-old female, presents for a psychiatric evaluation stating, "My doctor thought I might have panic disorder." She states that she has had two panic attacks that caused her to go to the emergency department, where a thorough medical workup revealed no physical abnormalities. Which of the following patient statements is least consistent with a diagnosis of panic disorder? A. "My attacks always happen right after I have a heated argument with my boyfriend." B. "During the attack, I felt a strange sense that I was not really present in my own body." C. "The attack came out of nowhere while I was driving, and my heart started pounding uncontrollably." D. "I am terrified that another attack will happen, so I am hesitant to leave my house alone." Pause. Answer. A Why it is correct: **Panic disorder** requires recurrent, unexpected panic attacks that occur out of the blue without an obvious situational trigger. Attacks that occur exclusively in response to a specific interpersonal conflict suggest an **adjustment disorder** or situational anxiety response rather than panic disorder. Why the other choices are wrong: * **B**: Depersonalization and derealization are classic psychological symptoms during a panic attack. * **C**: Unexpected onset from a calm or neutral state is the hallmark feature of panic disorder. * **D**: Persistent worry about future attacks or behavioral changes like agoraphobic avoidance supports the diagnosis of panic disorder. Test-taking pearl: Panic disorder requires unexpected attacks. If panic symptoms are always tied to a single specific trigger or conflict, look for another diagnosis on the branching tree. Question 4. Evan, a 26-year-old factory worker, reports intense anxiety and excessive worry whenever he is required to speak with his supervisor. He avoids approaching his coworkers because he feels intensely self-conscious and fears being judged or humiliated. He experiences a racing heart, shallow breathing, and chest tightness in these situations. His symptoms have persisted for 8 months and interfere with his job advancement. Which diagnosis best fits Evan's clinical presentation? A. Social anxiety disorder B. Generalized anxiety disorder C. Panic disorder with agoraphobia D. Post-traumatic stress disorder Pause. Answer. A Why it is correct: Evan displays marked fear and anxiety tied specifically to social and workplace interactions where he faces potential scrutiny or judgment by others. His symptoms persist for greater than **6 months** and cause functional impairment, meeting DSM-5-TR criteria for **social anxiety disorder**. Why the other choices are wrong: * **B**: **Generalized anxiety disorder** involves pervasive, uncontrollable worry across multiple everyday domains, not fear restricted to social scrutiny. * **C**: **Panic disorder** involves recurrent unexpected panic attacks out of the blue, whereas Evan's anxiety is predictably triggered by social exposure. * **D**: **PTSD** requires exposure to actual or threatened death, serious injury, or sexual violence, which is absent in Evan's history. Test-taking pearl: When anxiety is predictably triggered by performance or fear of negative evaluation by others, route down the social anxiety branch of the diagnostic tree. Question 5. A 35-year-old male is evaluated 2 weeks after surviving a major residential fire. He reports intrusive distressing memories, vivid nightmares, hypervigilance, and emotional numbness. He avoids walking near his burned home. Which diagnosis is most appropriate at this time? A. Acute stress disorder B. Post-traumatic stress disorder C. Adjustment disorder with anxious mood D. Normal stress reaction Pause. Answer. A Why it is correct: The patient exhibits classic post-trauma symptoms (intrusion, avoidance, negative mood, and hyperarousal) following a life-threatening event, and the symptom duration is **2 weeks** (between **3 days and 1 month**). This meets criteria for **acute stress disorder**. Why the other choices are wrong: * **B**: **PTSD** cannot be diagnosed until symptoms persist for greater than **1 month** (> 30 days) following the traumatic event. * **C**: **Adjustment disorder** is used when symptoms occur in response to a non-life-threatening stressor or do not meet full trauma criteria. * **D**: Symptoms cause significant distress and include severe intrusions and avoidance, exceeding a normal transient stress response. Test-taking pearl: Remember the **1-month** time boundary on the trauma branch: **3 days to 1 month** is acute stress disorder; greater than **1 month** is PTSD. 🧠 Would you like to proceed with a focused active recall drill or review another leaf from Fitzgerald Chapter 9? Next. Topic. Medical and Pharmacological Mimics (Table 9-1). FITZGERALD CH09 — Anxiety Disorders. Parent Section: Anxiety disorders: criteria, timelines, and look-alikes. Current Leaf: Medical and Pharmacological Mimics (Table 9-1). Bottom Line Summary. - Medical conditions and pharmacological agents must be systematically evaluated and ruled out before confirming a primary **anxiety disorder** diagnosis [1, 2]. - **Safety alert**: Suspect **pheochromocytoma** when a patient presents with paroxysmal episodes of severe hypertension, headache, diaphoresis, and sudden panic attacks due to catecholamine hypersecretion source 3. - **Board trap**: Distinguish medication-induced **akathisia** from worsening primary anxiety source 4. **Akathisia** is an extrapyramidal motor restlessness caused by dopamine-blocking **antipsychotics** or antiemetics that patients experience as extreme internal anxiety source 4. - **First-line**: Always order baseline laboratory work, including **TSH** to rule out **hyperthyroidism**, blood glucose to evaluate **hypoglycemia**, and a urine drug screen before initiating psychotropics [3, 5]. - Central stimulants such as **dextroamphetamine**, **methylphenidate**, **caffeine**, and OTC decongestants like **pseudoephedrine** directly provoke autonomic hyperarousal and acute anxiety symptoms source 4. - Severe cardiovascular and pulmonary conditions including **myocardial infarction**, **pulmonary embolism**, and **COPD** produce hypoxia and hypercapnia that directly mimic acute panic [3, 5]. - Abrupt withdrawal from **alcohol**, **benzodiazepines**, or sedatives triggers life-threatening autonomic hyperarousal, seizures, and severe anxiety within 1 to 2 days for short-acting agents or 5 to 10 days for long-acting agents [6, 7]. - Older adults taking anticholinergic medications like **diphenhydramine** or bronchodilators like **theophylline** frequently experience drug-induced restlessness, agitation, and anxiety symptoms [4, 8]. High-Yield Concept Breakdown: Medical and Pharmacological Mimics. Pharmacological Mimics of Anxiety. - Sympathomimetics and stimulants increase noradrenergic and dopaminergic neurotransmission source 4. **Dextroamphetamine**, **methylphenidate**, **cocaine**, **caffeine**, and **pseudoephedrine** stimulate alpha and beta receptors, producing tachycardia, tremors, diaphoresis, and acute fear source 4. - Central nervous system stimulants and dopaminergics alter central arousal pathways [4, 8]. **Theophylline** is a xanthine bronchodilator with a narrow therapeutic range that induces severe tremor, agitation, and central excitation [4, 8]. **Levodopa** increases dopamine synthesis, frequently precipitating central excitation, motor agitation, and anxiety [4, 8]. - Anticholinergics and sedating antihistamines produce paradoxical central effects [4, 8]. **Diphenhydramine** causes anticholinergic restlessness, cognitive disorientation, and paradoxical anxiety, particularly in geriatric patients [4, 8]. - Dopamine receptor antagonists induce motor restlessness source 4. **Akathisia** from **antipsychotics** or prokinetic antiemetics presents as subjective internal anxiety and objective motor inability to sit still source 4. - Sedative-hypnotic withdrawal causes severe rebound autonomic hyperactivity [7, 9]. Abrupt cessation of **alcohol** or **benzodiazepines** results in **GABA** hypofunction, producing tremors, severe anxiety, delirium, and seizures [7, 10]. Medical Condition Mimics by System. - Endocrine and metabolic disorders cause profound autonomic hyperarousal [3, 5]. **Hyperthyroidism** features suppressed **TSH** and elevated thyroid hormones, leading to palpitations, heat intolerance, fine tremors, and persistent anxiety source 3. **Hypoglycemia** triggers an immediate adrenal epinephrine surge, causing diaphoresis, tachycardia, shakiness, and acute panic source 5. **Pheochromocytoma** produces episodic catecholamine release, presenting with the classic triad of severe headache, diaphoresis, and marked hypertension source 3. - Cardiovascular conditions present with intense chest distress [3, 5]. **Myocardial infarction**, cardiac arrhythmias, angina, and heart failure cause autonomic hyperactivity, air hunger, and a profound feeling of impending doom [3, 5]. - Respiratory conditions induce hypoxia and hypercapnia [3, 5]. **COPD**, **pulmonary embolism**, and severe asthma trigger central fight-or-flight circuits due to impaired oxygenation [3, 5]. - Neurological conditions alter central anxiety networks source 3. **Delirium**, complex partial seizures, vestibular dysfunction, and stroke alter cerebral regulation, producing acute agitation, disorientation, and anxiety source 3. Fitzgerald Sample Test Questions for This Leaf. Question 4. A 68-year-old man presents with symptoms of anxiety source 11. He provides a list of medications he is currently taking [8, 11]. Which of the following is least likely to contribute to his anxiety symptoms source 8? A. **Theophylline** source 8 B. **Diphenhydramine** source 8 C. **Methotrexate** source 8 D. **Levodopa** source 8 Pause source 12. Answer: C source 8 Why It Is Correct: **Methotrexate** is an antimetabolite and immunosuppressive agent used primarily for autoimmune conditions and malignancies source 8. It does not stimulate central noradrenergic or dopaminergic pathways and does not cause autonomic hyperarousal, making it least likely to induce anxiety symptoms source 8. Why the Other Choices Are Wrong: - A: **Theophylline** is a xanthine bronchodilator with a narrow therapeutic range that acts as a direct central nervous system stimulant, frequently causing agitation, tremors, and anxiety [4, 8]. - B: **Diphenhydramine** possesses strong anticholinergic properties that routinely cause paradoxical excitation, motor restlessness, and cognitive anxiety in older adults [4, 8]. - D: **Levodopa** enhances central dopamine activity, which commonly precipitates central nervous system stimulation, motor agitation, and acute anxiety symptoms [4, 8]. Question 7. Medical conditions associated with anxiety-like symptoms include all of the following, except source 5: A. **Chronic obstructive pulmonary disease** (**COPD**) source 5 B. **Myocardial infarction** (**MI**) source 5 C. **Hyperglycemia** source 5 D. **Hypoglycemia** source 5 Pause source 12. Answer: C source 5 Why It Is Correct: **Hyperglycemia** typically leads to osmotic diuresis, dehydration, and lethargy rather than acute anxiety-like symptoms source 5. In contrast, **hypoglycemia** triggers an immediate counter-regulatory epinephrine release, producing acute autonomic anxiety symptoms including diaphoresis, tachycardia, tremors, and panic source 5. Why the Other Choices Are Wrong: - A: **Chronic obstructive pulmonary disease** (**COPD**) leads to hypoxia and hypercapnia, directly triggering autonomic fight-or-flight panic responses [3, 5]. - B: **Myocardial infarction** (**MI**) causes acute cardiovascular distress and sympathetic activation, generating a severe feeling of impending doom [3, 5]. - D: **Hypoglycemia** causes a rapid surge of epinephrine, resulting in sweating, palpitations, shaking, and acute panic-like symptoms source 5. 💡 **Next Study Nudge:** Would you like to review the next leaf in Chapter 9 on **Generalized Anxiety Disorder** diagnostic criteria and the **WATCHERS** mnemonic, or generate a 5-question rapid active-recall check on medical mimics? Next. End of this drive.