1 . The first known case description of anxiety disorder appeared in
| A) | | the Hippocratic Corpus. |
| B) | | Charles Darwin's works. |
| C) | | the International Classification of Diseases (ICD). |
| D) | | the Diagnostic and Statistical Manual of Mental Disorders (DSM). |
The first known clinical case description of an anxiety
disorder appeared in the medical corpus of the Ancient Greek physician Hippocrates. The
description tells of Nicanor, a man who developed an extreme fear of a "flute girl" whom he
encountered one night at a drinking party and who haunted him every night for many years. Five
hundred years after this case description, the Ancient Roman Stoic philosophers Seneca the
Younger and Cicero addressed the topic of anxiety at length, recognizing both its benefits and
harms, depending on the severity and circumstances of the anxiety [1]. These texts reveal a sophisticated
understanding of fear and anxiety among these ancient authors, even by modern medical
standards. It was not until the 19th century that Charles Darwin noted essential similarities
in the expression of fear and anxiety in mammals, reinforcing Seneca's notion that fear and
anxiety are ultimately adaptive traits [2]. In
its normal state, anxiety facilitates the management of potential future hazards [3,4,5]. In its extreme state,
the individual regards it as excessive or distressing or it can cause impairment in the
individual's daily life, thus constituting a disorder [6,7].
2 . Anxiety is a(n)
| A) | | adaptive trait that facilitates the detection and management of threats. |
| B) | | maladaptive trait that is a leading cause of mental distress and impairment. |
| C) | | Both A and B |
| D) | | None of the above |
The analogy of a smoke detector demonstrates the adaptive and
maladaptive aspects of anxiety [8,9]. Just as the function of a smoke detector is
to signal potential fires so that one can take action to prevent harm, the function of anxiety
is to signal any potential hazards so that preventive actions can be taken. In this analogy,
an anxiety disorder is an extreme that renders the individual more sensitive to threat signals
[10]. Although those with higher anxiety
experience more false alarms (signals for a threat that does not occur), this is advantageous
to the extent that it reduces the risk of a fatal miss. In other words, the costs associated
with false alarms and misses are not equal: over-reacting to non-threats is generally less
costly than failing to detect one danger. Nonetheless, living in a chronic state of high
anxiety can take a long-term toll on an individual's health and quality of life, and in these
cases, intervention is warranted.
3 . António Egas Moniz was awarded the 1949 Nobel Prize for treating mental disorders with
| A) | | leukotomy. |
| B) | | psychotherapy. |
| C) | | holistic medicine. |
| D) | | pharmacotherapy. |
In 1949, the Nobel Prize in Medicine was awarded to António
Egas Moniz for his discovery of "a simple operation, always safe, [and] which may prove to be
an effective surgical treatment in certain cases of mental disorder" [11]. Specifically, Moniz
discovered the prefrontal leukotomy as a treatment for mental disorders, including anxiety
disorders [12]. Since then, studies have found that damage to the ventromedial prefrontal
cortex produces resistance against anxiety and depression [13; 14; 15; 16]. Despite the
effective reduction of anxiety in these patients, it took many decades until research began to
address the harms imposed by damage to the prefrontal cortex. For example, in addition to
reducing anxiety, damage to the ventromedial prefrontal cortex also impairs self-regulation
and decision-making and can induce sociopathic behaviors [17; 18; 19; 20; 21]. Similar
patterns of anxiety reduction were also observed in one patient with focal bilateral lesions
to the amygdalae who showed a similar pattern of impairment in her daily life as those with
damage to the prefrontal cortex [22]. Although the prefrontal cortex and amygdala are critical
structures in a neural network that is necessary for anxiety, these findings highlight the
fact that damage to these structures comes with unintended consequences. These findings also
highlight the more general point that, in treating anxiety disorders, it is also important to
not abolish otherwise useful traits as it is to reduce the anxiety to a manageable
level.
4 . Two neural structures that are necessary for anxiety responses are the
| A) | | temporal pole and amygdala. |
| B) | | temporal pole and hippocampus. |
| C) | | ventromedial prefrontal cortex and amygdala. |
| D) | | ventromedial prefrontal cortex and hippocampus. |
In 1949, the Nobel Prize in Medicine was awarded to António
Egas Moniz for his discovery of "a simple operation, always safe, [and] which may prove to be
an effective surgical treatment in certain cases of mental disorder" [11]. Specifically, Moniz
discovered the prefrontal leukotomy as a treatment for mental disorders, including anxiety
disorders [12]. Since then, studies have found that damage to the ventromedial prefrontal
cortex produces resistance against anxiety and depression [13; 14; 15; 16]. Despite the
effective reduction of anxiety in these patients, it took many decades until research began to
address the harms imposed by damage to the prefrontal cortex. For example, in addition to
reducing anxiety, damage to the ventromedial prefrontal cortex also impairs self-regulation
and decision-making and can induce sociopathic behaviors [17; 18; 19; 20; 21]. Similar
patterns of anxiety reduction were also observed in one patient with focal bilateral lesions
to the amygdalae who showed a similar pattern of impairment in her daily life as those with
damage to the prefrontal cortex [22]. Although the prefrontal cortex and amygdala are critical
structures in a neural network that is necessary for anxiety, these findings highlight the
fact that damage to these structures comes with unintended consequences. These findings also
highlight the more general point that, in treating anxiety disorders, it is also important to
not abolish otherwise useful traits as it is to reduce the anxiety to a manageable
level.
5 . Two main subtypes of panic disorder diverge between individuals with
| A) | | suicidality and non-suicidality. |
| B) | | mental and physical symptoms. |
| C) | | comorbidity and multimorbidity. |
| D) | | respiratory and non-respiratory symptoms. |
Two main subtypes of panic disorder have been observed,
diverging between individuals with respiratory and non-respiratory symptoms [23,24,25]. Determining the
subtype may be informative for treatment purposes. Older adults with panic disorder
experience fewer symptoms of panic compared with younger adults, and their panic attacks are
also reported to be less intense and shorter in duration [26,27,28,29].
6 . The standard for anxiety disorder assessment is the
| A) | | ICD. |
| B) | | DSM. |
| C) | | structured interview. |
| D) | | semi-structured interview. |
The standard procedure for anxiety disorder assessment is
the structured diagnostic interview, which is administered by a trained professional. The
structured interview consists of pre-determined questions that assess for relevant symptoms
based on diagnostic criteria. For example, an interview for GAD would start by asking the
individual questions about the presence of worry symptoms over the past six months. If the
interviewee answers this question affirmatively, the interviewer would then ask the
individual about the presence of secondary symptoms associated with the worry (e.g., sleep,
irritability). If the individual responds affirmatively to the minimum number of secondary
symptoms required for a diagnosis of GAD, the individual would then be queried about the
presence of distress or impairment due to the worry. The key advantage of the structured
interview is its standardized administration, procedure, and scoring, which minimize bias
and error in assessment. Two commonly used structured interviews for the assessment of
mental disorders are the Diagnostic Interview Schedule (DIS) and the Composite International
Diagnostic Interview (CIDI) [56,57]. In addition, the Anxiety Disorders
Interview Schedule (ADIS) is a structured diagnostic interview that was developed
specifically for anxiety disorder assessment [58]. These interviews are regularly updated along with diagnostic criteria,
as for example with new editions of the DSM. Structured interviews rely essentially on
self-report; in addition to being administered by clinicians, they may also be conducted by
trained lay persons and/or computer-assisted technology (as in epidemiologic
surveys).
7 . The Overall Anxiety Severity and Impairment Scale (OASIS) consists of
| A) | | two items. |
| B) | | five items. |
| C) | | 12 items. |
| D) | | 25 items. |
The Overall Anxiety Severity and Impairment Scale (OASIS)
is a brief, transdiagnostic screening tool designed to assess for the severity of anxiety
in the past week of the individual's life [69]. There are five items, each rated on a five-point scale (0 to 4),
yielding a total possible score of 20. A raw score of 8 or greater indicates the presence
of anxiety disorder based on validation against anxiety disorder diagnosis using the
psychiatrist-administered SCID [70]. Raw
scores of 10 and 12 indicate the presence of marked and severe anxiety, respectively,
based on validation against the clinician-rated Clinical Global Impression-Severity
(CGI-S) scale in a sample of individuals with any anxiety disorder ascertained using the
Mini International Neuropsychiatric Interview (MINI) [71].
8 . Informant report is effective for assessing what types of anxiety symptoms?
| A) | | Physical but not mental symptoms |
| B) | | Objective but not subjective symptoms |
| C) | | Observable but not unobservable symptoms |
| D) | | All of the above |
Compared with younger adults, older adults report fewer
and less concrete anxiety symptoms across anxiety subtypes [40,41,42,43,45]. In addition to this, age-related neurocognitive impairment makes
self-reporting a more difficult method of assessment [55]. For example, those with memory impairment can experience stressors
that evoke negative effects without leaving memory traces [22,80]. Although informant report can be a way of effectively gathering
information about observable (e.g., physical) symptoms, it is ineffective for identifying
unobservable (i.e., subjective) symptoms [81].
9 . What is the most prevalent type of mental disorder in older adults?
| A) | | Mood disorder |
| B) | | Anxiety disorder |
| C) | | Substance disorder |
| D) | | Trauma and stress-related disorder |
Anxiety disorders are the most prevalent mental
disorders in older adults [54,84]. The most prevalent subtypes are, in
descending order, specific phobia, GAD, social anxiety disorder, and panic disorder.
Table 5 displays the one-year prevalence of anxiety
disorders, both overall and by subtype, in the NESARC and the Collaborative Psychiatric
Epidemiology Surveys (CPES) of the United States. The prevalence of anxiety disorders is
higher among women relative to men, and the prevalence of all anxiety subtypes decreases
among persons 75 years of age or older. Previous studies have also reported ethnic
differences in prevalence, such that Native and White Americans have the highest prevalence,
and Hispanic and Asian Americans have the lowest prevalence of anxiety disorders [85]. Black Americans have a higher or lower
prevalence of anxiety disorders depending on subtype; specific phobias and GAD are more
prevalent, comparable to Native and White Americans, whereas panic disorder and social
anxiety disorder are less prevalent, closer to levels observed in Hispanic and Asian
Americans. The prevalence of anxiety disorders does not vary substantially by educational
attainment or marital status.
10 . The most prevalent anxiety disorder subtype in older adults is
| A) | | panic disorder. |
| B) | | specific phobia. |
| C) | | social anxiety disorder. |
| D) | | generalized anxiety disorder. |
Anxiety disorders are the most prevalent mental
disorders in older adults [54,84]. The most prevalent subtypes are, in
descending order, specific phobia, GAD, social anxiety disorder, and panic disorder.
Table 5 displays the one-year prevalence of anxiety
disorders, both overall and by subtype, in the NESARC and the Collaborative Psychiatric
Epidemiology Surveys (CPES) of the United States. The prevalence of anxiety disorders is
higher among women relative to men, and the prevalence of all anxiety subtypes decreases
among persons 75 years of age or older. Previous studies have also reported ethnic
differences in prevalence, such that Native and White Americans have the highest prevalence,
and Hispanic and Asian Americans have the lowest prevalence of anxiety disorders [85]. Black Americans have a higher or lower
prevalence of anxiety disorders depending on subtype; specific phobias and GAD are more
prevalent, comparable to Native and White Americans, whereas panic disorder and social
anxiety disorder are less prevalent, closer to levels observed in Hispanic and Asian
Americans. The prevalence of anxiety disorders does not vary substantially by educational
attainment or marital status.
11 . Which of the following groups of older adults (55 years of age or older) has the highest prevalence of any anxiety disorder according to data from the NESARC?
| A) | | Women |
| B) | | Persons with a Bachelor's degree |
| C) | | Adults 75 years of age and older |
| D) | | Those who are married or cohabitating |
ONE-YEAR PREVALENCE OF ANXIETY DISORDER AMONG ADULTS 55 YEARS OF AGE AND OLDER IN TWO
NATIONAL SAMPLES
| Population | Specific Phobia | Social Anxiety Disorder | Generalized Anxiety Disorder | Panic Disorder | Any Anxiety Disorder |
|---|
| NESARC | CPESa | NESARC | CPES | NESARC | CPES | NESARC | CPES | NESARC | CPESb |
|---|
| Total | 5% | 6% | 2% | 3% | 1% | 3% | 1% | 2% | 9% | 6% |
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| Education | | Less than high school | | Completed high school | | Some college | | Bachelor's degree |
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| Marital status | | Married or cohabiting | | Widowed, divorced or separated | | Never married |
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| aSpecific phobia was assessed in a sub-sample
of 9,282 respondents from the NCS-R. | | bSpecific phobia was not included in the
overall anxiety disorder estimate for the CPES. |
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12 . The most persistent anxiety disorder subtype in older adults is
| A) | | panic disorder. |
| B) | | specific phobia. |
| C) | | social anxiety disorder. |
| D) | | generalized anxiety disorder. |
The chronicity of a disease refers to its persistence.
Persistence is defined here as the percentage of respondents who meet diagnostic criteria
for an anxiety disorder at baseline and who then meet criteria again at follow-up. Data from
the NESARC indicate that approximately 30% of older adults (55 years of age and older) have
persistent cases of anxiety disorder, or chronicity, assessed over a three-year follow-up
period. The most persistent subtypes were specific phobia (25%) and GAD (20%), followed by
social anxiety disorder (16%) and panic disorder (10%) [31].
13 . Compared with those without anxiety disorder, the mortality rate of older adults with anxiety disorders is
| A) | | lower. |
| B) | | higher. |
| C) | | similar. |
| D) | | fluctuating. |
Importantly, the findings of a 2016 systematic review and
meta-analysis of prospective, longitudinal studies suggest that a diagnosis of any anxiety
disorder at baseline is not associated with increased risk of all-cause mortality at
follow-up [5]. In fact, in a population
study of Norwegians, high anxiety symptoms were associated with lower mortality among
individuals with depression [103]. In a
population study of a 1946 UK birth cohort, individuals who demonstrated lower levels of
trait anxiety in adolescence were associated with higher risk of accident mortality at
follow-up [104]. Thus, low anxiety (but not
high anxiety) is associated with increased mortality risk, and some degree of anxiety is
beneficial for survival. Some anxiety likely encourages individuals to engage in preventive
health behaviors. For example, women who worry about the possibility of breast cancer are
more likely to seek routine screenings, people who are more worry-prone are more likely to
vaccinate than those who worry less, and smokers with higher worries about their health have
been found to be more likely to quit [105,106,107].
14 . The two biggest demographic risk factors for late-life anxiety disorders are
| A) | | age and sex. |
| B) | | age and education. |
| C) | | age and marital status. |
| D) | | education and marital status. |
The two strongest risk factors for anxiety disorders
among older adults are female sex and younger age [84,108,109]. However, other risk factors have also
been identified. Cigarette smoking is shown to be a major risk factor of anxiety disorder
onset, while smoking cessation is associated with reduced anxiety, suggesting that smoking
interventions would have a significant effect on anxiety disorder onset [110,111]. Another important risk factor of anxiety disorder onset in longitudinal
studies is the occurrence of adverse life events, such as the ending of a relationship or
the injury, illness, or death of a loved one [112,113,114].
15 . The most significant modifiable risk factor for anxiety disorder is
| A) | | age. |
| B) | | education. |
| C) | | adverse events. |
| D) | | cigarette smoking. |
The two strongest risk factors for anxiety disorders
among older adults are female sex and younger age [84,108,109]. However, other risk factors have also
been identified. Cigarette smoking is shown to be a major risk factor of anxiety disorder
onset, while smoking cessation is associated with reduced anxiety, suggesting that smoking
interventions would have a significant effect on anxiety disorder onset [110,111]. Another important risk factor of anxiety disorder onset in longitudinal
studies is the occurrence of adverse life events, such as the ending of a relationship or
the injury, illness, or death of a loved one [112,113,114].
16 . The prevalence of anxiety disorder is substantially lower in medical versus community settings.
The prevalence of anxiety disorder is substantially higher
in medical versus community settings, and there is a particularly high prevalence of anxiety
disorder in individuals with Parkinson disease and among caregivers of older adults [51,61,122,123,124,125]. Studies have
demonstrated that, in part, the psychological distress (e.g., anxiety and depression)
experienced by caregivers is linked to their patients' overall cognitive well-being, patient
functional ability, and the reported caregiver burden [126,127,128,129].
17 . Which class(es) of pharmacotherapy is the most effective in the treatment of social anxiety disorder?
| A) | | MAOIs |
| B) | | SSRIs and SNRIs |
| C) | | Benzodiazepines |
| D) | | Tricyclic antidepressants |
Individual CBT was found to be effective for acute
treatment compared with waitlist control groups. Pharmacologic interventions included
anticonvulsants, benzodiazepines, monoamine oxidase inhibitors (MAOIs), noradrenergic and
serotonergic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and selective
norepinephrine reuptake inhibitors (SNRIs). SSRIs and SNRIs were found to be the most
effective class of pharmacological treatment compared with placebo control groups [133].
18 . The treatment of choice for specific phobias is
| A) | | cortisol. |
| B) | | lithium. |
| C) | | D-cycloserine. |
| D) | | exposure therapy. |
Exposure therapy is the treatment of choice for specific
phobias [139,140]. This includes in vivo (real-life) and
virtual reality exposure to phobic stimuli or situations. Virtual reality exposure therapy
was introduced in the 1990s, and although it may have some treatment benefit, it has not
been found to have strong efficacy [141]. A
one-session exposure therapy treatment for specific phobias was pioneered more than 30 years
ago with a suggested duration of two hours and was subsequently used to treat various
specific phobia subtypes [142,143,144,145]. More recent
studies suggest that one session does not always turn out to be adequate and that multiple
sessions are generally more efficacious [140,146]. However, there may be some cases
where the single-session approach is viable.
19 . Pharmacotherapy is a common treatment for specific phobias.
Pharmacotherapy is not a common treatment for specific
phobias. However, studies have sought to supplement exposure therapy using pharmacologic
approaches. One such intervention administers cortisol to augment exposure therapy due to
its role in interfering with memory for fearful scenarios [147,148]. Although this treatment shows some efficacy, it does not seem to be
particularly advantageous relative to exposure therapy alone. A second form of pharmacologic
augmentation for exposure therapy, introduced more than 20 years ago, is the antibiotic
D-cycloserine, which is thought to facilitate fear extinction due to its role as an
N-methyl D-aspartate (NMDA) receptor agonist [149,150]. D-cycloserine has also been used to augment exposure therapy for social
anxiety disorder, with studies suggesting that this antibiotic can produce a marginal
benefit for treating specific phobias and social anxiety disorder when combined with
exposure therapy [151]. However, while these
studies mention that the antibiotic is of a low dosage, they do not mention that this
marginal benefit needs to be traded off against the risk of accelerating antibiotic
resistance, which is a pressing global public health challenge. Computational studies
suggest that increasing administration of low doses of antibiotics (as these studies suggest
doing in conjunction with exposure therapy) accelerates resistance [152,153].
20 . The clinician's principal objective in treating anxiety is to
| A) | | remove distress completely. |
| B) | | eradicate the anxiety completely. |
| C) | | make the individual's life happier. |
| D) | | reduce the anxiety to a manageable level. |
Given that anxiety itself is an adaptive trait, anxiety
disorders are better seen as poorly regulated defenses than as defects. As decades of lesion
studies indicate, a lack of anxiety may also create non-trivial problems for individuals'
lives. Low levels of anxiety are associated with higher mortality risk, and those who report
greater worries about particular health problems are likely to seek medical care and take
preventative or corrective action [39,103,104,105,106,107]. If some degree of anxiety is advantageous, then insufficient and
excessive anxiety can both be considered maladaptive.
