A 35-year-old woman comes to the office due to worsening fatigue and tension headaches over the past year. She describes always feeling "on edge" and lies awake at night worrying about various issues such as whether she is good at her job, whether her grown children like her, if she will get cancer one day, and whether her house will be broken into. During the day she feels tired and her shoulders and neck ache; she has difficulty concentrating on her work and has become increasingly concerned about losing her job. The patient has no medical or psychiatric history. Physical examination and routine laboratory studies, including thyroid function tests, are normal. The patient's anxiety has never been treated, but she once took a tablet of alprazolam offered by a friend. This lowered her anxiety, but the effect did not last long. The patient drinks a glass of wine on rare social occasions and does not use illicit drugs. Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 35-year-old woman comes to the office due to worsening fatigue and tension headaches over the past year.  She describes always feeling "on edge" and lies awake at night worrying about various issues such as whether she is good at her job, whether her grown children like her, if she will get cancer one day, and whether her house will be broken into.  During the day she feels tired and her shoulders and neck ache; she has difficulty concentrating on her work and has become increasingly concerned about losing her job.  The patient has no medical or psychiatric history.  Physical examination and routine laboratory studies, including thyroid function tests, are normal.  The patient's anxiety has never been treated, but she once took a tablet of alprazolam offered by a friend.  This lowered her anxiety, but the effect did not last long.  The patient drinks a glass of wine on rare social occasions and does not use illicit drugs.  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

This patient's excessive and chronic worry, feeling on edge, muscle tension, and insomnia are characteristic of generalized anxiety disorder (GAD). Patients with GAD have multiple worries about everyday issues (eg, work, health, finances, safety of family members) that cause significant distress and functional impairment. GAD is treated with cognitive behavioral psychotherapy and/or antidepressant medication. Selective serotonin reuptake inhibitors (SSRIs) such as citalopram or serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line treatment. This patient's insomnia should improve as the medication takes effect and her anxiety decreases. Although this patient experienced acute relief with alprazolam, benzodiazepines are less preferred in the treatment of chronic anxiety. Benzodiazepines (eg, alprazolam, clonazepam, diazepam) are considered second-line therapy due to the risks of dependence and tolerance, and the potential for rebound and withdrawal syndromes with abrupt discontinuation (Choices A, D, and E). Benzodiazepines can be used on a limited basis to manage acute anxiety while waiting for SSRIs or SNRIs to take effect. However, they should be avoided in patients with a history of substance use disorder. (Choice B) Bupropion is a norepinephrine dopamine reuptake inhibitor approved for the treatment of major depressive disorder and smoking cessation. It is not a first-line agent for GAD and may worsen symptoms due to its activating effects. Bupropion should not be confused with buspirone, a non-benzodiazepine anxiolytic that is another second-line treatment option for GAD. (Choice F) Propranolol, a beta-adrenergic blocker, can be used as needed for the performance subtype of social anxiety disorder and in the prophylactic treatment of migraine headaches. Beta blockers are not a first-line treatment for GAD. This patient's headaches are related to muscle tension, which should improve as her anxiety is treated. Educational objective: Serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line medications for generalized anxiety disorder. Benzodiazepines should be limited to short-term use while antidepressants take effect and avoided in patients with a history of substance abuse. __________ References: Pharmacotherapy of generalized anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25225022) Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. (http://www.ncbi.nlm.nih.gov/pubmed/30056792)

A 35-Year-Old Woman Comes to the Office Due to Worsening