A 35-year-old man comes to the office for increasing anxiety associated with public speaking. The patient previously worked in product development but was recently promoted to a leadership sales position that requires leading daily team meetings and frequent public speaking. When speaking before a group of people, the patient becomes extremely anxious; his face turns bright red; he starts to sweat profusely; and he feels that his heart is racing. He also becomes acutely aware that other people notice his anxiety and judge him negatively. The patient reports that he has been uncomfortable in large groups and while meeting new people since he was a teenager. His new job has been very stressful as he can no longer avoid these situations. He recognizes that his anxiety and fear of public speaking are excessive. The patient has no depression and is otherwise healthy.
Blood pressure is 118/68 mm Hg and pulse rate is 86/min. BMI is 23 kg/m². The remainder of the physical examination is unremarkable.
Which of the following is the most appropriate pharmacologic treatment in management of this patient?

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11ec193a_98c6_1a94_853d_b51326b76a94_MD0002_00 This patient's excessive anxiety in social situations in which he fears scrutiny and embarrassment is consistent with social anxiety disorder (SAD). Patients with SAD experience extreme distress in social situations, leading to avoidance behavior. In this case, the patient's job promotion has resulted in increased demands for public speaking and social interactions, thereby exacerbating his social anxiety that has been present since adolescence. Treatment of SAD includes cognitive-behavioral psychotherapy and pharmacotherapy. Selective serotonin reuptake inhibitors (SSRIs) such as sertraline and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line medications. Benzodiazepines are reserved for patients who have an inadequate response to SSRI/SNRIs and should be used only in patients with no history of substance use disorder. Patients whose anxiety is restricted to performance situations (ie, performance-only subtype) and who have rarely recurring performance situations can be treated on an as-needed basis with beta blockers or benzodiazepines. (Choices A and C) Benzodiazepines (eg, alprazolam, clonazepam) have demonstrated efficacy in SAD but are generally used as second-line agents due to their potential for tolerance, abuse, and dependence. Adverse effects of sedation and impaired concentration may also be problematic when mental clarity is important for performance. (Choice B) Buspirone is ineffective in SAD. It has been used to treat generalized anxiety disorder. (Choice D) Beta blockers such as propranolol have been used as needed for the performance-only subtype of SAD (eg, propranolol 10 mg, an hour before a performance or speech). However, this patient shows evidence of more generalized social anxiety and encounters stressful social situations and performance situations on a daily basis. SSRIs/SNRIs would be preferred. Educational objective: Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line pharmacotherapy for social anxiety disorder. Benzodiazepines can be considered for poor responders without a history of substance use. Beta blockers can be used as needed for rarely occurring performance situations. __________ References: The evidence-based pharmacotherapy of social anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22436306) Social anxiety disorder in DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/24395386)

A 35-Year-Old Man Comes to the Office for Increasing Anxiety