A 32-year-old man comes to the office due to anxiety that has intensified since he was promoted to a managerial position. Whereas he previously worked alone, his new position requires him to interact with a team of five employees and handle customer service complaints. The patient says he is anxious throughout the day and fears that he will say something embarrassing or that his coworkers and customers will notice his anxiety and think he is incompetent. He says he was very quiet and shy growing up and would always get anxious when meeting new people. He has a few friends with whom he socializes, but he typically has three or four alcoholic drinks before going out with them to feel more relaxed. The patient does not feel depressed, and his sleep and appetite are normal. A medication with which of the following mechanisms of action would be most appropriate for this patient?

Question

A 32-year-old man comes to the office due to anxiety that has intensified since he was promoted to a managerial position.  Whereas he previously worked alone, his new position requires him to interact with a team of five employees and handle customer service complaints.  The patient says he is anxious throughout the day and fears that he will say something embarrassing or that his coworkers and customers will notice his anxiety and think he is incompetent.  He says he was very quiet and shy growing up and would always get anxious when meeting new people.  He has a few friends with whom he socializes, but he typically has three or four alcoholic drinks before going out with them to feel more relaxed.  The patient does not feel depressed, and his sleep and appetite are normal.  A medication with which of the following mechanisms of action would be most appropriate for this patient?

Quizplus · Accepted Answer

11ec160b_3646_708d_9249_534a0e911f53_MD0001_00 This patient's marked anxiety in social situations is consistent with social anxiety disorder (SAD). His fears of saying something embarrassing and negative evaluation by others are characteristic of the disorder. SAD is a common anxiety disorder with typical onset in childhood or adolescence. If untreated, the disorder can cause major impairment in social and occupational functioning and is often complicated by depression and self-medication with alcohol. Drugs that inhibit the reuptake of serotonin are first-line medications for social anxiety disorder. Patients are commonly started on a selective serotonin reuptake inhibitor (SSRI) although there is also good evidence for the efficacy of serotonin-norepinephrine reuptake inhibitors (SNRIs). These medications work by blocking the serotonin transporter, causing an increase in the availability of serotonin in the synaptic cleft. (Choice A) Beta blockers have been used to treat performance-only social anxiety disorder. They are taken on an as-needed basis and are most useful for patients with prominent physiological symptoms such as tachycardia or tremor. A beta blocker would not be appropriate for this patient who is generally socially anxious (ie, anxiety not limited to performance situations) and who experiences impairing anxiety on a daily basis. (Choice B) Dopamine and serotonin receptor antagonism are the mechanisms of action of second-generation antipsychotics. These drugs are not indicated for SAD. (Choice C) GABA A receptor agonism is the mechanism of action of benzodiazepines. Benzodiazepines are effective in SAD but are generally used as second-line agents due to their potential for tolerance, abuse, and dependence. They should be avoided in this patient who has a history of self-medication with alcohol. (Choice D) Histamine receptor antagonism is the mechanism of action of antihistamines (eg, diphenhydramine). Although they have sedative effects, they are not effective in treating anxiety. (Choice E) Monoamine oxidase inhibitors are effective for SAD but are not used as a first-line treatment due to their side effect profile and dietary restrictions. Educational objective: Social anxiety disorder is characterized by anxiety and fear of scrutiny in social situations and can result in marked social-occupational impairment. Preferred pharmacotherapy is medication that inhibits serotonin reuptake (eg, SSRIs or SNRIs). __________ References: The evidence-based pharmacotherapy of social anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22436306) Pharmacotherapy for social anxiety disorder (SAnD). (http://www.ncbi.nlm.nih.gov/pubmed/29048739)

A 32-Year-Old Man Comes to the Office Due to Anxiety