Chapter 01 Quiz
Neuroscience and Nosology of Anxiety Disorders
5 clinical cases · 20 questions
Each case presents a clinical scenario followed by board-style questions. Select your answer and submit to see the rationale.
Gemma, Age 34
Gemma, a 34-year-old woman, presents to the emergency department for the third time in two months with tachycardia, diaphoresis, chest tightness, and an overwhelming conviction that she is having a heart attack. Cardiac workup is again negative. Between episodes, she constantly monitors her heartbeat and interprets normal rate fluctuations as evidence of cardiac disease.
Q1. Which brain region most directly explains Gemma's misinterpretation of normal cardiac sensations as dangerous?
Q2. You explain to Gemma that during her episodes, her body produces real physical symptoms while her rational mind simultaneously recognizes no actual danger exists. Which theoretical framework best accounts for this dissociation between physical response and conscious awareness?
Q3. Gemma is started on sertraline 50 mg daily. At her one-week follow-up, she reports feeling more anxious than before starting the medication. She asks whether the medication is making her worse. Which receptor mechanism best explains this initial worsening?
Q4. At Gemma's follow-up, her husband asks: "Can't she just learn to relax when she feels a panic attack coming on? It seems like she's making it worse by focusing on it." Which neurobiological finding most directly explains why this advice is insufficient?
Caleb, Age 4
Caleb, a 4-year-old boy, is brought to his pediatrician for a well-child visit. His mother mentions that he "completely shuts down" in new situations. At a recent birthday party, he clung to her leg for the entire two hours and refused to interact with other children. At preschool drop-off, he cries intensely every morning. His heart rate during the office visit is elevated at 112 bpm. His mother asks whether she should worry, noting that her own mother "was always anxious" and she herself takes sertraline for generalized anxiety disorder.
Q5. Caleb's pattern of extreme caution, withdrawal from novelty, and elevated physiological arousal in unfamiliar situations is most consistent with which temperamental construct?
Q6. Caleb's pediatrician asks what specific disorder she should monitor for as he grows older. Based on longitudinal research, behavioral inhibition in preschool-age children most strongly predicts development of which condition?
Q7. The pediatrician refers Caleb's family to a parent-directed prevention program for preschool-age children with behavioral inhibition who do not yet meet diagnostic criteria for an anxiety disorder. Which intervention has demonstrated reduced anxiety diagnoses at 3-year follow-up in a randomized controlled trial for this specific population?
Q8. Caleb's mother asks whether he will "grow out of" his fearfulness. Which pattern best characterizes the natural course of untreated childhood anxiety disorders across longitudinal studies?
Vera, Age 48
Vera, a 48-year-old high school principal, presents to a new psychiatrist after relocating. She reports 15 years of persistent, diffuse worry about work, finances, health, and her adult children's safety. She cannot identify a specific trigger. She describes chronic muscle tension, difficulty sleeping, and an inability to "shut her brain off." Her previous psychiatrist diagnosed her with generalized anxiety disorder (GAD). However, a psychologist she recently consulted told her she has "adjustment disorder with anxiety" and does not meet GAD criteria. Vera is frustrated by the contradictory diagnoses.
Q9. Vera describes constant worry without a specific trigger, chronic hypervigilance, and an inability to identify what she is afraid of. Which neural structure is most likely driving this sustained, context-independent anxiety pattern?
Q10. Vera received a GAD diagnosis from one clinician and an adjustment disorder diagnosis from another, both using standard unstructured interviews. Which factor most directly accounts for this contradiction?
Q11. To resolve the diagnostic disagreement, the psychiatrist decides to use a structured diagnostic tool. For an adult with a suspected anxiety disorder, which instrument provides the strongest diagnostic reliability?
Q12. Vera also reports intrusive thoughts about accidentally leaving her stove on and returns home from work to check it multiple times daily, which temporarily reduces her distress. Which neurobiological distinction best explains why OCD is classified separately from the core anxiety disorders?
Soren, Age 16
Soren, a 16-year-old boy, is referred for cognitive-behavioral therapy (CBT) after being diagnosed with social anxiety disorder. He avoids the school cafeteria, declines invitations to social gatherings, and has dropped out of his school's debate team. Before entering any social situation, he takes lorazepam 0.5 mg that his mother's psychiatrist prescribed "for emergencies." He reports that the lorazepam "works great" and attributes his ability to attend family gatherings to it.
Q13. Soren's therapist plans to use exposure therapy. What is the primary therapeutic goal of each individual exposure exercise?
Q14. Before beginning exposure work, the therapist identifies Soren's PRN lorazepam use as a clinical priority. From the perspective of inhibitory learning, what is the primary concern about Soren carrying lorazepam during social exposures?
Q15. After eight weeks of successful exposure therapy, Soren is eating in the cafeteria and attending debate practice. Three months later, he relapses after his family moves to a new city. He is surprised and distressed, telling his therapist "I thought I was cured." Which mechanism of relapse best explains his symptom return?
Q16. Soren's new therapist in the new city proposes restarting exposure therapy. The prescribing psychiatrist suggests adding a standing benzodiazepine prescription to "take the edge off" during exposures. Based on the neuroscience of extinction learning, what is the primary concern about concurrent benzodiazepine use during active exposure therapy?
Dina, Age 32
Dina, a 32-year-old woman, presents for evaluation of panic disorder and generalized anxiety that have been treatment-resistant to two adequate SSRI trials. She has a history of severe childhood physical abuse from ages 2 to 5. Her biological mother had panic disorder, and her maternal grandmother was hospitalized for "nervous breakdowns." Dina brings results from a direct-to-consumer genetic test that identified her as carrying the "short" allele of the serotonin transporter gene (5-HTTLPR). She asks whether this explains her anxiety and her poor treatment response.
Q17. Dina asks whether her 5-HTTLPR result explains her anxiety. Regarding the clinical utility of 5-HTTLPR testing for anxiety risk prediction, which statement best reflects the current evidence?
Q18. Dina's severe early childhood abuse occurred during preschool years. Her clinician explains that adversity during early development can leave lasting molecular changes in gene expression without altering the DNA sequence. Which epigenetic mechanism is best characterized as mediating stress-induced changes to anxiety vulnerability?
Q19. Dina's laboratory workup shows a morning cortisol level of 8.2 mcg/dL (reference range 6.0-18.0 mcg/dL). She says: "See, my cortisol is normal. Maybe my anxiety isn't as bad as I think." Which physiological phenomenon best explains why a normal cortisol level does not rule out a chronic stress disorder?
Q20. Dina asks: "My mother had panic disorder, my grandmother was hospitalized. Is my daughter doomed to have anxiety too?" Which counseling statement most accurately reflects the heritability of anxiety disorders?