Anxiety Disorders on the Physician Assistant Exam

Anxiety is a very broad term that is covered on the Physician Assistant Exam (PANCE). Generally, it concerns how people react to stress. Everyone has anxiety from time to time in response to a particular stressor. Examples include anxiety brought on by the loss of a job, financial worries, or an upcoming certification exam. You may see both physical and emotional symptoms of anxiety.

Panic attacks

A panic disorder involves an anxiety-evoked response to a perceived fear. People with a panic disorder experience many of the following symptoms in the form of panic attacks: nausea, stomachache, palpitations, tension, hypertension, fatigue, weak muscles, headache, chest pain, and/or shortness of breath.

Profound diaphoresis and tachycardia often accompany a panic attack, and many times, the person experiencing a panic attack thinks that he or she is having a heart attack because of the overlapping symptoms. A full medical evaluation is necessary to exclude other “organic” causes of the symptoms, such as acute coronary syndrome and hyperthyroidism.

Panic attacks can occur spontaneously. Often, a noticeable change in behavior accompanies the recurrent attacks.

Panic disorder may occur with agoraphobia, which literally means “fear of the market” or “public place fear.” The person worries about future panic attacks and therefore avoids places or events where escape would be embarrassing or impossible.

You’re evaluating a 45-year-old woman for a possible panic disorder. Which of the following medical conditions can be associated with panic disorder?

(A) Hypothyroidism
(B) Hypercalcemia
(C) Mitral valve prolapse (MVP)
(D) Hyperglycemia
(E) Hypokalemia

The answer is Choice (C) — mitral valve prolapse can be associated with panic disorder.

Generalized anxiety disorder

Generalized anxiety disorder is literally being anxious about everything for a long time. The symptoms can overlap many of the symptoms of a panic disorder. Tension, fatigue, nausea, trouble sleeping, feeling “pain all over” — all of these can be related to anxiety. Usually, for a diagnosis of generalized anxiety disorder, the symptoms have to have been occurring for about 6 months or more.

As with panic disorder, the treatment for generalized anxiety disorder is mainly behavior-based therapy, although medications such as the “benzos” (benzodiazepines) often need to be used in conjunction. Causes of generalized anxiety disorder are often difficult to pinpoint.

For the PANCE, you need to know about the side effects of medications commonly prescribed for generalized anxiety disorder, including the benzodiazepines. Examples include clonazepam and lorazepam. Here are a few key points about benzodiazepines in general:

  • They can cause sedation and lethargy as side effects. You need to be careful of the dosing in someone who has liver disease or cirrhosis, because these conditions increase the half-life of many benzodiazepines.

  • Stopping benzodiazepines abruptly can cause a withdrawal reaction. Withdrawal reactions cause the opposite symptoms of what the medication is supposed to do. For the benzos, this can mean agitation and excitability. Physical manifestations can include tachycardia and even hypertension.

  • A person can become so sedated on a benzo that it can cause respiratory depression. The antidote for a benzodiazepine overdose is flumazenil.

Other anxiety disorders

The following brief descriptions get you into the world of anxiety disorders. It’s by no means complete, because a person can develop a fear of practically anything at any time, and medical science may then discover and report it. Here are a few anxiety disorders you’re likely to see on the test:

  • Post-traumatic stress disorder: Anyone can develop PTSD after a traumatic experience. You see the condition more than ever in soldiers returning home from war. Examples of traumatic events include war, rape, domestic violence, a devastating illness, a major accident, natural disasters, the sudden death of someone close, or seeing someone else severely hurt or killed. The symptoms can occur as early as a few months after the traumatic event.

    The person with PTSD keeps reliving parts of the traumatic event over and over. Experiencing momentary flashbacks is not uncommon. The affected person often has trouble sleeping. In addition, he or she seeks to avoid potential triggers for those bad memories. The person becomes angry and anxious and can exhibit physical signs of extreme anxiety, including sweating, palpitations, and tachycardia.

  • Obsessive-compulsive disorder (OCD): Here, the affected person develops obsessions and compulsions to deal with anxiety.

  • Separation anxiety disorder (SAD): Separation anxiety disorder is the name for recurring distress when a person fears separation from parents, children, a significant other, or home. Note that this SAD isn’t the same as another SAD — seasonal affective disorder.

Phobias

Phobia is the Greek word for “fear.” Fear is a healthy emotional response to a perceived danger. Fearing a charging lion is quite rational. By contrast, look at the phobias. A fear of bananas isn’t rational and surely isn’t healthy.

A phobia is a fear of something that isn’t thought to be a danger. Phobias can be significant enough to interfere with a person’s social functioning, and they often don’t go away without therapy.

Here are some common ones you should know:

  • Agoraphobia literally means “public place fear.” It’s a fear of places or events where escape would be embarrassing or impossible.

  • Acrophobia is an irrational fear of heights.

  • Arachnophobia is an irrational fear of spiders and other arachnids, such as scorpions.

  • Nyctophobia, fear of the dark, is a common fear. It’s right up there with fear of monsters under the bed and fear of monsters in the closet. Fear of the dark is common among children and can be seen in adults to varying degrees.

  • Pedophobia is an irrational fear of infants or children.

Various lists put forth 179 different phobias. The diagnostic criteria for phobias are outlined in the DSM-IV-TR in sections on social and specific phobias. In general for the diagnosis, look for a “marked and persistent fear that is excessive or unreasonable.” Treatments are highly varied.

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