GAD PollEv Questions

A patient comes to clinic complaining of fatigue, insomnia, difficulty concentrating, and muscle tension. How long must the patient have these symptoms to be diagnosed with GAD?

a. 4 weeks

b. 6 weeks

c. 4 months

d. 6 months

d. 6 months

[Has to have ≥3 of the six DSM-5-TR criteria]

Men have a greater risk of developing generalized anxiety disorder versus women: T/F?

False

[Women have 2x the risk]

Which of the following medications may cause symptoms of anxiety?

a. propranolol

b. prednisone

c. hydroxyzine

d. hydrochlorothiazide

b. prednisone

[Propranolol is the opposite and may help with short-term performance anxiety; hydroxyzine is the opposite and is used in treatment of GAD; hydrochlorothiazide is an exception to the fact that antihypertensives do cause anxiety]

Which area of the brain is associated with fear and which area is associated with worry, respectively?

a. nigrostriatal, tuberoinfundibulum

b. amygdala, CSTC

c. mesocortical, mesolimbic

d. prefrontal cortex and hypothalamic pituitary

b. amygdala (fear), CSTC (worry)

You drink one beer and feel disinhibited. Your friend drinks a 6-pack of beer and it doesn’t seem to have an affect on them. This is an example of:

a. tolerance

b. dependance

c. disinhibition

d. withdrawal

a. tolerance

Match the definition to the term below: decrease in the response of a drug due to frequent administration

a. Receptor desensitization

b. Receptor supersensitivity

c. Receptor withdrawal

d. Receptor dependence

a. Receptor desensitization

What kind of half-life does midazolam have?

a. Long acting

b. Short acting

c. Intermediate acting

d. Ultra short acting

d. Ultra short acting

What kind of half-life does diazepam have:

a. Long acting

b. Short acting

c. Intermediate acting

d. Ultra short acting

a. Long acting

What kind of half-life does lorazepam have?

a. Long acting

b. Short acting

c. Intermediate acting

d. Ultra short acting

c. Intermediate acting

What kind of half-life does oxazepam have?

a. Long acting

b. Short acting

c. Intermediate acting

d. Ultra short acting

b. Short acting

How long should hydroxyzine be used to treat anxiety?

a. 2 months

b. 4 months

c. 6 months

d. Indefinitely

b. 4 months

Why do references state that hydroxyzine use should be limited to four months?

a. Individuals on hydroxyzine adapt to it and no longer have a response after 4 months

b. Abuse of hydroxyzine is common after 4 months

c. Use longer than 4 months can cause discontinuation syndrome

d. No studies show that it works any longer than 4 months

d. No studies show that it works any longer than 4 months

[Studies longer than 4 months on hydroxyzine have not been completed, so the drug cannot be recommended for longer than 4 months.]

What is paradoxical about using an antidepressant for treating anxiety?

a. Antidepressants cause anxiety

b. Antidepressants cause depression

c. Antidepressants cause fatigue and insomnia which are symptoms of anxiety

d. Antidepressants aren’t studied for anxiety

a. Antidepressants cause anxiety

[Antidepressants can initially make anxiety worse, which is why for treatment of anxiety we start at 1/4 to 1/2 of the depression dose]

How do you initiate sertraline to treat anxiety?

a. Use one-half to one-quarter of the dose

b. Use the same dose as you would use to initiate depression

c. You could start at the depression maintenance dose

d. Don’t use sertraline to treat anxiety

a. Use one-half to one-quarter of the dose

Benzodiazepenes’ sedative properties occur at:

a. Higher doses

b. Lower doses

c. Longer half-lives

d. Shorter half-lives

a. Higher doses

[Some benzos are used specifically for sedation!]

Benzodiazepines are anxiolytic:

a. When used at higher doses

b. When used at lower doses

c. When long half-life agents are used

d. When short half-life agents are used

b. When used at lower doses

[Benzos are the most widely prescribed anxiolytics… but they really shouldn’t be because they’re only meant to be used short-term as a “bridge” to help with impaired functioning until SSRIs/SNRIs start working]

Which anxiety scale is self-rated?

a. Zung Rating Scale

b. Hamilton Anxiety Scale

c. Generalized Anxiety Scale

d. Beck Anxiety Scale

a. Zung Rating Scale

AND

c. Generalized Anxiety Scale

AND

d. Beck Anxiety Scale

What is a barrier to using buspirone as an anxiolytic?

a. It leads to dependence

b. Perception that it lacks efficacy

c. Pharmacokinetics

d. Adverse effects

b. Perception that it lacks efficacy

[Therapeutic effects take 4-6 weeks]

You are on rotation in the Emergency Room (ER) when a patient arrives after overdosing on a bottle of benzodiazepines. What should you do first?

a. Doctors should give naloxone to reverse effects

b. Give midazolam to reverse effects

c. Admit the patient and monitor for adverse effects

d. Give flumazenil to reverse effects

d. Give flumazenil to reverse effects

[Flumazenil is the only benzo. reversal agents on the market!!!]

Which adverse effect is caused by using benzodiazepines during pregnancy?

a. Spina bifida

b. Cardiac defect

c. Cleft lip and palate

d. Floppy baby syndrome

c. Cleft lip and palate

[Avoid benzos early in pregnancy for this reason. Meanwhile paroxetine causes atrial septal defects in fetuses!!!]

Which antidepressants cause an initial increase in anxiety?

a. SSRIs

b. SNRIs

c. vilazodone

d. vortioxetine

ALL!!!!!

a. SSRIs

b. SNRIs

c. vilazodone

d. vortioxetine

[Vilazodone and vortioxetine cause anxiety like SSRIs and SNRIs (which cause it initially) b/c of their mixed serotinergic effects. Bupropion also causes significant anxiety!!!]

Which of the following treatments for GAD is a 5-HT1A partial agonist?

a. fluoxetine (Prozac)

b. venlafaxine (Effexor)

c. buspirone (Buspar)

d. clonazepam (Klonopin)

c. buspirone (Buspar)

Which of the following treatments for anxiety is an SSRI?

a. fluoxetine (Prozac)

b. venlafaxine (Effexor)

c. buspirone (Buspar)

d. clonazepam (Klonopin)

a. fluoxetine (Prozac)

Which of the following treatments for anxiety is an SNRI?

a. fluoxetine (Prozac)

b. venlafaxine (Effexor)

c. buspirone (Buspar)

d. clonazepam (Klonopin)

b. venlafaxine (Effexor)

[Remember venlafaxine XR is used for anxiety b/c the IR needs to be dosed TID, which lowers adherence]

Which of the following treatments for anxiety is a GABA-A receptor agonist?

a. fluoxetine (Prozac)

b. venlafaxine (Effexor)

c. buspirone (Buspar)

d. clonazepam (Klonopin)

d. clonazepam (Klonopin)

[Note the specific receptor on one of GABA-A’s subunits (Alpha-2,3 (α2,3​)) that is the target of benzos!!!!]

A patient with anxiety is taking lorazepam 12 mg daily. Calculate the equivalent dose of diazepam.

a. 15 mg

b. 20 mg

c. 30 mg

d. 60 mg

d. 60 mg

[Use the “approximate equivalent dose” column of the cart; 1 mg lorazepam = 5 mg diazepam, so 12 mg lorazepam = 60 mg diazepam.]

Which benzodiazepine is rapidly and completely absorbed, and which is erratically absorbed, when given IM?

a. lorazepam, diazepam

b. clonazepam, chlorazepam

c. temazepam, buspirone

d. diazepam, lorazepam

a. lorazepam, diazepam

[Lorazepam is completely absorbed after IM administration and so preferred for quick control of anxiety. Diazepam takes a long time to dissolve in propylene glycol and is therefore slowly and erratically absorbed after IM administration.]

A 45-year-old is diagnosed with GAD that is significant enough that he cannot get to work and he is at risk of losing his job. When he was 21 he went to rehab for drinking too much alcohol, but he has not used any in 20 years. How would you treat?

a. Treat with a benzodiazepine for 12 months, then discontinue

b. Treat with a high dose long acting benzodiazepine for 6 months, then discontinue

c. Treat this gentleman with buspirone daily

d. Treat with an SSRI and use a benzodiazepine for couple of weeks until SSRI starts to work

d. Treat with an SSRI and use a benzodiazepine for couple of weeks until SSRI starts to work

[Benzo is used as a “bridge” to deal with function impairment that comes with anxiety symptoms until SSRI starts to work; SSRIs take a few weeks to months for anxiolytic effects to start taking place.]

[Ideally we don’t want to give a patient with a h/o substance use disorder a benzo, but…

• Benzo use will be brief (~2-3 weeks, no more than 6 weeks!!)

• We will monitor patient while he’s on benzo

• Substance use disorder was a long time ago

… so we can use it!]

[Note: ALL BENZOS CAUSE DEPRESSION!!!!]

Mr. Jackson, 68, started diazepam five weeks ago and his wife takes him to the ER and states that he got confused and started falling down over the weekend. Why?

a. Symptoms are due to dementia

b. Symptoms are due to a drug interaction

c. Symptoms are due to diazepam accumulation related to the patient’s age

d. Symptoms are due to generalized anxiety disorder

c. Symptoms are due to diazepam accumulation related to the patient’s age

[Most benzos are metabolized by CYP450 enzyme system, which begins to fail with age and lead to benzo accumulation in body, which then leads to delirium or rapid cognitive decline. Additionally, diazepam itself already lasts several days.]

[The benzos that are NOT metabolized by the CYP450 enzymes system, but rather directly undergo glucuronidation, are: lorazepam, oxazepam, temazepam, “LOT”

• If giving benzos to elderly, use these; since they are not metabolized by the CYP450 system and conjugation is fine even after aging, so the LOT benzos are still properly metabolized even in the elderly.]

Which of the following is true of initiating SSRIs in patients with generalized anxiety disorder?

a. If used at antidepressant doses, anxiety symptoms will get worse before they get better

b. Start low, go slow

c. Use 1/4 to 1/2 of the antidepressant dose when initiating treatment

d. Guidelines state to start with a benzodiazepine first line, and if that doesn’t work, use an SSRI

a. If used at antidepressant doses, anxiety symptoms will get worse before they get better

AND

b. Start low, go slow

AND

c. Use 1/4 to 1/2 of the antidepressant dose when initiating treatment

According to the DSM, which symptoms are associated with GAD?

a. Delusions, hallucinations, paranoia

b. Insomnia, fatigue, irritability

c. Poor appetite, distractibility, hyperactivity

d. Sedation, low sex drive, poor concentration

b. Insomnia, fatigue, irritability

A patient comes to your clinic and you think that he has GAD. A Beck Anxiety Scale shows he has a score of 24. Four weeks later his score is 8. How would you explain the change in score?

a. Severe to moderate

b. Severe to mild

c. Moderate to mild

d. Moderate to minimal

c. Moderate to mild

[24 is moderate; 8 is mild.]

You have noticed that Ms. Brown runs out of her diazepam every 3 weeks. She says she had to increase her dose to treat her GAD. What concept does this refer to?

a. Misuse

b. Withdrawal

c. Dependence

d. Tolerance

d. Tolerance

Which pharmacokinetic parameter makes a benzodiazepine have higher misuse potential?

a. Longer half-life

b. Longer time to peak

c. Shorter time to peak

d. Shorter half-life

c. Shorter time to peak

[Quick peak —> rapid onset of “high” feeling, which means greater abuse potential]

Are rating scales subjective or objective data?

Objective

[The score itself is considered an objective piece of data!!!]

Which medication is associated with causing anxiety?

a. fluoxetine

b. albuterol

c. caffeine

d. pseudoephedrine

ALL!!!!

a. fluoxetine (SSRI)

b. albuterol (SABA)

c. caffeine

d. pseudoephedrine

Which disease state is associated with anxiety?

a. asthma

b. diabetes

c. irritable bowel syndrome

d. seizures

ALL!!!!

a. asthma

b. diabetes

c. irritable bowel syndrome

d. seizures

Drinking too much caffeine in the form of coffee, energy drinks, or soda can potentially increase anxiety: T/F?

True

A patient in your patient education group does not speak English. What do you do to help provide education to your patient?

a. Ask patient to leave group

b. Provide a translator for your patient

c. Treat the patient like the other patients in the group by providing materials in English

d. Have a special class just for this patient

b. Provide a translator for your patient

What symptoms would a patient describe if they have anxiety and their antidepressant is initiated at too high of a dose?

a. Patient describes having fatigue and not feeling rested

b. Patient describes feeling jittery, like they are coming out of their skin

c. Patient describes their mind going blank at the worst times

d. Patient is more irritable than usual

b. Patient describes feeling jittery, like they are coming out of their skin

[“Like I’m coming out of my skin” is a widely-observed phrase used by patients initiated on too high an antidepressant dose for their anxiety!!!]

[Effect seen with SSRIs and SNRIs, both of which can initially make anxiety worse]

The Hamilton Anxiety Scale (HAM-A) is a good rating scale to use in a patient that has which of the following:

a. Difficulty reading

b. Non-English speaking

c. Uses benzodiazepines

d. Likes to do things independently

a. Difficulty reading

[The only anxiety rating scale that is clinician-administered and rated]

Which Beck Anxiety rating scale score is associated with moderate anxiety?

a. 10

b. 20

c. 30

d. 60

b. 20

[Beck scoring:

• 0-7: minimal

• 8-15: mild

• 16-25: moderate

• 26-63: severe anxiety]

Health literacy is a barrier to care for patients who:

a. Take their medication intermittently to save money

b. Keep their medication in their car on a hot day

c. Take their medication as directed

d. Experience sedation from their medication

a. Take their medication intermittently to save money

AND

b. Keep their medication in their car on a hot day

[B/c they don’t understand that they have to take their medication regularly for it to work properly; and that heat can damage medications and stop them from working properly]

Guidelines recommend which of the following as first line treatment for GAD?

a. SSRIs

b. Benzodiazepines

c. Propranolol

d. Pregabalin

a. SSRIs

How are benzodiazepines used for anxiety?

a. As a first-line treatment for anxiety

b. As a long-term treatment for insomnia caused by anxiety

c. As a bridge until antidepressants begin to work

d. Benzodiazepines should never be used for anxiety

c. As a bridge until antidepressants begin to work

What symptoms would a patient describe if they stop their SSRI too quickly?

a. They would feel jittery

b. They would feel like they are going to jump out of their skin

c. They would feel like something is zapping their brain with an electrical charge

d. They would feel like they had the flu

c. They would feel like something is zapping their brain with an electrical charge

AND

d. They would feel like they had the flu

[They would experience d/c syndrome in that case: key symptoms are “zapping in brain with electrical charge” and “flu-like”]

[D/c syndrome more common in antidepressants that affect serotonin and have a short half-life, e.g. paroxetine and venlafaxine. Rarely reported with bupropion.]

Which anxiety disorder medication should be avoided because of teratogenicity?

a. sertraline

b. paroxetine

c. diazepam

d. fluoxetine

b. paroxetine (SSRI)

AND

c. diazepam (benzo)

[Paroxetine affects fetus heart to have atrial septal defect. Diazepam, a benzo, is associated with cleft lip palate, so avoid in early pregnancy]

A patient with a history of substance use disorders has anxiety and the physician wants to use a benzodiazepine. What do you suggest?

a. Never use a benzodiazepine in a patient with substance use disorder

b. A benzodiazepine can be used in a patient with a current substance use disorder

c. A benzodiazepine can be used in a patient with a past substance use disorder if they are monitored carefully

d. An SSRI should be used as a bridge until a benzodiazepine starts to work

c. A benzodiazepine can be used in a patient with a past substance use disorder if they are monitored carefully

[Once again, we ideally want to avoid benzos in patients with a h/o substance use disorder, but if you have to… carefully monitor and use benzo only short-term (~2-3 weeks, no more than 6 weeks).]

[AVOID in patients with a recent or current substance abuse history.]

The prescription for anxiety medication you are giving to a patient requires that you provide patient education. When having the patient sign for the medication you realize that he cannot read. What kind of patient education do you provide the patient?

a. Provide the patient with a written summary of her medication

b. Provide the patient with the same guide that you provide all patients

c. Provide patient with a pictorial summary concerning his medication

d. Provide the patient with a written summary in Spanish

c. Provide patient with a pictorial summary concerning his medication