Quiz: Evaluation and Diagnosis

Petra, Age 38

Petra, a 38-year-old woman, has been treated for panic disorder for three years with sertraline 150 mg daily and 14 sessions of CBT including interoceptive exposure. Her therapist reports excellent treatment engagement and completion of all exposure assignments. Despite this, Petra continues to experience sudden-onset episodes of palpitations, diaphoresis, and lightheadedness occurring two to three times weekly. Episodes last 5 to 15 minutes and resolve spontaneously. Her previous psychiatrist increased sertraline to 200 mg, then augmented with buspirone, with no improvement. A resting ECG and 24-hour Holter monitor were both normal.

Q1. Given Petra's failure to respond to adequate pharmacotherapy and evidence-based CBT, what is the most appropriate next step?

Q2. Petra's 30-day event monitor captures paroxysmal supraventricular tachycardia during one of her episodes. She undergoes successful catheter ablation, and her episodes resolve completely without further psychiatric treatment. Her resolution most directly demonstrates that:

Q3. Reviewing Petra's case, the treatment team notes that her initial evaluation was conducted by a male cardiologist who documented "probable panic disorder, recommend psychiatry referral" after the normal resting ECG. Research shows women are twice as likely as men to have SVT-related cardiac symptoms attributed to psychiatric causes. How should this finding change the team's future clinical practice?

Ravi, Age 9

Ravi, a 9-year-old boy, is brought to his pediatrician for a well-child visit. His mother reports that he has been complaining of stomachaches every school morning for the past four months and has been asking to sleep in his parents' bed. His teacher describes him as "very quiet" but notes no behavioral problems. The pediatrician administers the Screen for Child Anxiety Related Disorders (SCARED), with both parent and child versions.

Q4. Ravi's parent-completed SCARED total score is 18 (below the clinical cutoff of 25), but his child self-report total score is 31. The most appropriate interpretation of this discrepancy is:

Q5. Ravi's positive screen triggers the primary care evaluation pathway. Before proceeding to treatment, the required components are:

Q6. Ravi's medical workup is normal. His pediatrician diagnoses generalized anxiety disorder and recommends an SSRI. Ravi's mother asks whether the potential benefits outweigh the risks for a 9-year-old. The pediatrician explains that across meta-analyses, SSRIs in pediatric anxiety have NNTs of 3-5, while the NNH for emergent suicidality from the FDA Black Box Warning is approximately 140. The most accurate interpretation of this risk-benefit ratio is:

Q7. Three months into sertraline 50 mg daily, Ravi's SCARED total has decreased from 31 to 22 (below the total cutoff of 25), but the GAD subscale remains at 10, above the subscale clinical cutoff of 9. The most appropriate measurement-based care response is:

Adela, Age 28

Adela, a 28-year-old graduate student, presents with difficulty concentrating, restlessness, and trouble completing her dissertation. She reports that she "can't focus on anything" and feels "driven by a motor." Her primary care physician referred her for ADHD evaluation. On interview, she describes constant worry about her academic performance, her relationship, and finances. She sleeps poorly because she "can't shut her brain off." She denies impulsive behavior and reports that she was an excellent student through college with no attention problems until graduate school.

Q8. Adela's inattention and restlessness could represent either anxiety or ADHD. Which symptom dimension most reliably discriminates ADHD from anxiety?

Q9. The evaluator asks Adela: "When you can't focus, is your mind drifting away because the task is boring, or is it locked onto worries?" She responds: "Definitely worry. I'm thinking about my dissertation failing, my advisor being disappointed, whether I'll get a job." This pattern is most consistent with:

Q10. Adela's evaluator determines that her symptoms are best explained by generalized anxiety disorder. She asks: "But the online ADHD quiz I took said I scored high. Doesn't that prove I have ADHD?" Which response best addresses the limitation of her self-assessment?

Hector, Age 52

Hector, a 52-year-old Dominican man, presents to the emergency department with chest tightness, trembling, and a sensation of "heat rising in my body." He describes these episodes as ataques, reporting they occur during family conflicts and are accompanied by uncontrollable crying and a feeling that he might "lose control." He denies prior psychiatric history. His ED physician administers the GAD-7, which scores 6 (below the clinical cutoff of 10). The physician tells Hector his anxiety is "mild" and refers him back to his primary care physician.

Q11. Hector describes culturally specific ataques de nervios, yet his GAD-7 scores below the clinical cutoff. Which clinical action should the ED physician have taken instead of relying on the GAD-7 score alone?

Q12. Hector follows up with his primary care physician, who recognizes his ataques de nervios as a potential culturally specific expression of anxiety. An open-ended interview reveals persistent worry about his family's safety, chronic muscle tension, difficulty sleeping, and avoidance of social situations for the past three years. In addition to the GAD-7, which screening instrument should be added to this evaluation?

Iris, Age 14

Iris, a 14-year-old girl, is evaluated for anxiety after her GAD-7 score of 17 (severe range) is flagged during a school-based screening program. Her parents express surprise, stating that Iris is "a great student" with "no problems at home." They question whether the screening result is accurate. The school psychologist notices that Iris has dropped all extracurricular activities, eats lunch alone in the library, and has not attended a single social event this academic year.

Q13. Iris's GAD-7 score is 17, yet her parents report no problems. Her school psychologist observes severe social withdrawal. The best explanation for why symptom screeners alone cannot predict functional status is that symptom severity and impairment are:

Q14. To assess Iris's functional impairment independently from her symptom severity, the school psychologist conducts an avoidance mapping exercise. Correct implementation requires documenting:

Q15. Iris begins missing school two to three days per week. Her parents initially allow her to stay home because she appears genuinely distressed. The school psychologist suspects anxiety-based school refusal. Which tool best identifies the maintaining function driving Iris's non-attendance?

Q16. Iris's SRAS-R results indicate that her school refusal is primarily maintained by escape from social and evaluative situations. The intervention most directly supported by this functional profile is:

Felix, Age 24

Felix, a 24-year-old man, presents to his primary care physician with new-onset panic attacks that began three weeks ago. He reports daily consumption of two large energy drinks (estimated total caffeine: 480 mg) and has been increasing his cannabis use (high-THC products, daily) over the past two months to "manage stress." He has no prior psychiatric history and no family history of anxiety disorders.

Q17. Felix consumes 480 mg of caffeine daily and uses high-THC cannabis daily, with panic attacks beginning one week after escalating both substances. Before establishing a primary anxiety disorder diagnosis, the most important initial step is:

Q18. Felix's physician confirms that his panic attacks began approximately one week after he increased to two energy drinks daily and started daily cannabis use. Following caffeine reduction to under 200 mg daily and cannabis cessation, how long should the physician observe for symptom resolution before considering a primary anxiety diagnosis?

Q19. After three weeks of abstinence from cannabis and caffeine reduction, Felix's panic attacks have completely resolved. He asks: "So I never actually had an anxiety disorder?" Which response most accurately reflects the diagnostic framework?

Q20. Six months later, Felix returns with recurrent panic attacks despite maintained caffeine reduction and cannabis abstinence. Unassisted GP detection rates for anxiety are 29% for GAD, 14% for panic, and 2.2% for social anxiety. Given these data, the most appropriate evaluation approach is:

Q21. Felix's evaluation confirms primary panic disorder. His physician recognizes that the prior correct SMIAD diagnosis could bias the current evaluation. The cognitive error most directly threatening diagnostic accuracy is:

Q22. Felix asks his physician how to interpret the fact that his anxiety was substance-induced six months ago but now appears to be a primary disorder. The relationship between these two episodes is best characterized as: