79 Questions
What is the minimum number of symptoms required for a major depressive episode?
5
What is the median age of onset for Major Depressive Disorder?
30
Which of the following is a risk factor for Major Depressive Disorder?
Female gender
What is the increased risk of all-cause mortality for individuals with Major Depressive Disorder?
52%
What is the purpose of the PHQ-9 screening tool?
Screening for depression
What is the percentage of individuals with Major Depressive Disorder who progress to schizophrenia-spectrum disorders?
5-30%
What is the severity of GAD associated with a GAD-7 score of 10-14?
Moderate
What is the increased risk of suicide for individuals with Major Depressive Disorder?
25X
What is the primary difference between Major Depressive Disorder and Minor Depressive Episode?
Number of symptoms experienced
What is Dysthymia also known as?
Persistent Depressive Disorder
What is the essential symptom that must be present in a major depressive episode?
Dysphoria
What is the primary difference between a panic attack and panic disorder?
Presence of persistent concern about having another panic attack
Which of the following is NOT a symptom of Depression?
Energized mood
What is the median age of onset for Panic Disorder?
24 years
What is the primary characteristic of Type II Bipolar Disorder?
Mild depression and hypomania
What is the term for an anxiety disorder characterized by a fear of being in situations where escape might be difficult or help wouldn't be available?
Agoraphobia
What is the comorbidity rate between Panic Disorder and Major Depressive Disorder?
50%
What is the term for 'markedly diminished interest or pleasure most of the day' in Depression?
Anhedonia
What is the term for 'recurrent thoughts of death or suicide, or suicide attempt' in Depression?
Suicidality
What is the purpose of the PHQ-PD screening tool?
To screen for Panic Disorder
What is the primary goal of management for Panic Disorder?
To improve patient education
Which of the following is a characteristic of Normal Bereavement?
No impairment of daily life
What is the term for 'loss of confidence, thoughts of worthlessness or hopelessness' in Depression?
I'm a failure
Which of the following medications can induce anxiety in patients?
All of the above
What is the primary criterion for diagnosing Major Depressive Disorder?
Establish presence of depressive symptoms
Which of the following symptoms is NOT a criterion for diagnosing depression?
Thoughts of grandiosity
What is the minimum duration required for depressive symptoms to be considered persistent?
2 weeks
Which of the following is a symptom of depression?
Loss of confidence
Which of the following conditions is characterized by fears focusing on primal themes and compulsions that are ritualistic or 'rule-driven'?
Obsessive-compulsive disorder
What is the term for markedly diminished interest or pleasure most of the day?
Anhedonia
Which of the following is NOT a step in diagnosing Major Depressive Disorder?
Conduct a physical exam
A patient presents with symptoms of anxiety, and a physical examination reveals a rapid heart rate. Which of the following laboratory tests would be most useful in ruling out an organic cause of the symptoms?
Urinary normetanephrine and platelet norepinephrine
What is the term for recurrent thoughts of death or suicide, or suicide attempt?
Suicidality
Which of the following is a key feature that distinguishes depression from anxiety?
Character of worry tends to be self-criticism of previous events and/or circumstances
A patient is diagnosed with anxiety disorder, and the treating physician wants to rule out any underlying medical conditions that may be contributing to the symptoms. Which of the following tests would be most useful in this scenario?
Serum TSH
Which of the following is NOT a distinguishing feature of adjustment disorder with anxiety?
Presence of suicidal thoughts
A patient presents with symptoms of anxiety and a history of shortness of breath. Which of the following tests would be most useful in ruling out an underlying medical condition?
Spirometry
Which of the following is a key feature of panic disorder?
Presence of unexpected or paroxysmal panic attacks
A patient presents with symptoms of anxiety and a history of fatigue. Which of the following tests would be most useful in ruling out an underlying medical condition?
Serum ferritin
What is the time frame within which the onset of emotional or behavioural symptoms must occur in response to an identifiable stressor?
Within 3 months
What is a characteristic of symptoms of Adjustment Disorder?
Distress that is disproportionate to the severity or intensity of the stressor
Which of the following is NOT a type of Mood Disorder?
Anxiety Disorder
What is dysphoria?
A mood state characterized by feelings of sadness, despair, anxiety, emptiness, discouragement, or hopelessness
Which of the following is an organic cause of depressive symptoms?
Vitamin B12 Deficiency
What is the primary difference between Adjustment Disorder with Depressed Mood and Major Depressive Disorder?
Presence of identifiable stressor
Which of the following is a characteristic of symptoms of Adjustment Disorder with Depressed Mood?
Significant impairments in social, occupational or other domains of functioning
What is the primary distinction between Mood Disorders and Anxiety Disorders?
Type of symptoms
What is the primary difference between fear and phobia?
Fear is a normal response, while phobia is an excessive response.
Which of the following is NOT a type of anxiety disorder?
Hyperthyroidism
What is the primary characteristic of acute stress disorder?
It is a response to a single, discrete event.
Which of the following medications can induce anxiety in patients?
Corticosteroids
What is the primary difference between anxiety and fear?
Fear is a response to a specific object or situation, while anxiety is a response to a general situation.
What is the primary characteristic of agoraphobia?
A fear of being in situations where escape might be difficult or help wouldn't be available
Which of the following is NOT an organic cause of anxiety?
Generalized anxiety disorder
What is the primary characteristic of stressor-related disorders?
A response to a single, discrete event or multiple events or ongoing problems.
What is the laboratory test that is most useful in diagnosing Addison disease?
Cortisol and aldosterone levels
Which of the following medications can cause persistently depressed or irritable mood?
All of the above
What is the most useful diagnostic test for diagnosing Multiple Sclerosis?
Magnetic Resonance Imaging (MRI)
What is the laboratory test that is most useful in diagnosing Pernicious anemia?
Serum B12 levels
What is the most useful diagnostic test for diagnosing Coronary artery disease?
All of the above
What is the laboratory test that is most useful in diagnosing Renal failure?
Serum creatinine levels
What is the most useful diagnostic test for diagnosing Stroke?
All of the above
What is the most useful diagnostic test for diagnosing Fibromyalgia?
All of the above
What is the primary purpose of assessing the natural history of a disease in medical decision making?
To understand the prognosis if left untreated
What is the primary benefit of using screening tools like GAD-7 and PHQ-9 in medical practice?
To assess the severity of disease and functional capacity
What is the primary difference between the objective and subjective data in a medical case?
Objective data is collected through physical exam and MSE, while subjective data is collected through patient history
What is the primary purpose of assessing the functional capacity of a patient in medical practice?
To understand the impact of disease on daily life activities
What is the primary benefit of using sensitivity, specificity, and likelihood ratios in medical decision making?
To influence the threshold model of medical decision making
What is the primary purpose of conducting a physical exam and MSE in a medical case?
To collect objective data about the patient's condition
What is the primary benefit of using the MSE in a medical case?
To evaluate the patient's mental status
What is the primary purpose of assessing the onset of symptoms in a medical case?
To understand the epidemiology of the disease
What is the primary diagnostic criterion for Generalized Anxiety Disorder (GAD) according to the DSM-5?
Excessive anxiety and worry occurring more days than not for at least 6 months
Which of the following symptoms is NOT a characteristic of GAD?
Hypervigilance
What is the primary purpose of the GAD-7 screening tool?
To assess the severity of GAD
What is the estimated risk of developing major depression in individuals with GAD?
40-43%
What is the primary difference between GAD and other anxiety disorders?
Excessive worry about everyday circumstances
What is the primary goal of management for individuals with GAD?
To reduce anxiety symptoms
What is the most common demographic characteristic of individuals with GAD?
Female gender
What is the estimated increased risk of suicide in individuals with GAD?
20-25%
Study Notes
Generalized Anxiety Disorder (GAD)
- GAD-2 screening tool has a sensitivity of 86% and a likelihood ratio (LR+) of 5.0, and an LR- of 0.17.
- GAD-7 screening tool has a sensitivity of 97% and an LR+ of 2.2, and an LR- of 0.05.
- GAD-7 screening tool with a score of ≥10 has a sensitivity of 89% and an LR+ of 5.1, and an LR- of 0.13.
- Mild GAD is characterized by more than half of the time experiencing anxiety, minor functional impairment, and a GAD-7 score of 5-9.
- Moderate GAD is characterized by most of the time experiencing anxiety, marked functional impairment, and a GAD-7 score of 10-14.
- Severe GAD is characterized by all the time experiencing anxiety, marked functional impairment, and a GAD-7 score of 15+.
Panic Disorder (PD)
- Panic attack is a sudden onset of intense discomfort, anxiety, or fear that reaches a peak within minutes and is accompanied by somatic and/or cognitive symptoms.
- Panic disorder is characterized by repeated panic attacks followed by at least 1 month of persistent concern about having another panic attack, worry about the possible implications or consequences of the attacks, or a significant behavioral change related to the attacks.
- Agoraphobia is an anxiety disorder characterized by a fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong.
- Prevalence of PD is 4.7% (4-8% in primary care) with a median age of onset of 24 years.
- Risk factors for PD include genetic, female (2X), increased stress, and those who suffer from asthma.
- Diagnosis of PD is made through interview according to DSM-5 criteria, and screening via PHQ-PD or ANS.
Depression
- Symptoms of depression include depressed mood, energy loss, pleasure lost, retardation or excitation, eating changed, sleep changed, suicidality, feeling of being a failure, only me to blame, and no concentration.
- Major depressive disorder is characterized by a history of one or more major depressive episodes and no history of mania/hypomania.
- Prevalence of major depressive disorder is 5-10% (primary care) and 2-4% (community) with a median age of onset of 30 years.
- Risk factors for major depressive disorder include female (2-3X), genetic, history of anxiety, substance use, and adverse life events.
- Diagnosis of major depressive disorder is made through clinical interview according to DSM-5 criteria, and screening by PHQ-9.
Differentiating Anxiety vs. Other Conditions
- Anxiety vs. depression: characterized by self-criticism of previous events and/or circumstances, early morning awakening, diurnal variation in mood, marked guilty preoccupations, and suicidal thoughts more commonly present in depression.
- Anxiety vs. panic disorder: characterized by the presence of unexpected or paroxysmal panic attacks in panic disorder.
- Anxiety vs. adjustment disorder with anxiety: characterized by the presence of an identifiable stressor or stressors occurring within three months of the onset of symptoms in adjustment disorder.
- Anxiety vs. organic disease: distinguished via history, physical exams, and labs, including hyperthyroidism, pheochromocytoma, heart failure, arrhythmias, asthma, COPD, anemia, and others.
- Anxiety vs. medication: patients using certain medications can present with anxiety, including alcohol, cannabis, amphetamines, analgesics, and others.
Anxiety Disorders
- Fear: an emotional, physical, and behavioral response to an immediately recognizable external threat (within normal or typical range)
- Phobia: an excessive fear response to a specific object or situation that is out of proportion to the actual danger (can occur with no danger present) and cause significant dysfunction due to avoidance behavior
- Anxiety: a distressing, unpleasant emotional state of nervousness and unease; causes are less clear and timing is less tied to a threat (anticipatory, persistent, none identifiable)
Generalized Anxiety Disorder (GAD)
- Excessive worry about everyday issues and situations almost daily for a duration of 6 months or greater, with multiple somatic symptoms
- Prevalence: 8-31.2% (Primary Care)
- Mean age of onset: 30 years
- Risk factors: dysregulation of worry, genetics/family history, female (2X), adverse life events
- Diagnosis: by clinical interview (according to DSM-5 criteria), screening tool: GAD-7
- Management: patient education, referral to psychotherapy, psychiatry
- Prognosis: 43% may develop major depression; 20-25% increased risk of suicide
GAD - DSM-5 Diagnostic Criteria
- Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities
- Difficulty controlling the worry
- Anxiety and worry are associated with 3 (or more) of the following:
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance (difficulty falling asleep, or restless, unsatisfying sleep)
- Anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The disturbance is not attributable to the physiological effects of a substance or another medical condition (e.g., hyperthyroidism)
- The disturbance is not better explained by another mental disorder
Mood Disorders
- Depression (aka. Major Depressive Disorder)
- Bipolar Disorder
- Adjustment Disorder with Depressed Mood (e.g., grief)
- Seasonal Affective Disorder (SAD)
- Premenstrual Dysphoric Disorder or Postpartum/Peripartum-onset Depression
- Substance/Medication-Induced Mood Disorder (including alcohol, cannabis, etc.)
- Borderline Personality Disorder
Considerations
- Trauma- and stressor-related disorders: Stress, not elsewhere classified, Adjustment Disorder, Acute Stress Disorder
- Organic causes of anxiety:
- Endocrine: Hyperthyroidism, Pheochromocytoma, Hyperparathyroidism
- Cardiopulmonary: Heart failure, Arrhythmias, Asthma or Chronic obstructive pulmonary disease (COPD)
- Neurologic: Temporal lobe epilepsy or Transient Ischemic Attacks (TIAs)
- Medication: corticosteroids, cocaine, amphetamines, caffeine; withdrawal
Putting it into Practice
- Subjective history: clinical syndrome, epidemiology, timing
- Objective data: physical exam, MSE, screening tool, labs, and imaging
- Pretest probability (or prevalence)
- Natural history (prognosis if left untreated)
Assessment
- Assessing severity of disease as well as functional capacity
- Impact of mental health on:
- Living independently
- Learning
- Working
- Socializing
- Self-care
Learn about the screening tools and likelihood ratios for identifying Generalized Anxiety Disorder (GAD), as well as assessing its severity levels.
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