A 45-year-old woman comes to the office for evaluation of "muscle tightness." The patient reports having stiffness and muscle pain in her neck and shoulders for the past few months. She was previously a stay-at-home mom but started a new job as a receptionist 6 months ago and spends most of her time seated at a desk. The patient notes feeling increasingly stressed and fatigued since she started working and cannot get through the day without feeling overwhelmed. The patient finds herself thinking about "anything but work," including whether her son will get into college and if her husband will get a raise. She often texts her kids to check-in with them throughout the day and calls at 4 PM to make sure they arrived home safely. When she gets home in the evenings, she prefers to spend time alone because she tends to get easily irritated by her family. Medical history is noncontributory. The patient takes no medications. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?

Question

A 45-year-old woman comes to the office for evaluation of "muscle tightness."  The patient reports having stiffness and muscle pain in her neck and shoulders for the past few months.  She was previously a stay-at-home mom but started a new job as a receptionist 6 months ago and spends most of her time seated at a desk.  The patient notes feeling increasingly stressed and fatigued since she started working and cannot get through the day without feeling overwhelmed.  The patient finds herself thinking about "anything but work," including whether her son will get into college and if her husband will get a raise.  She often texts her kids to check-in with them throughout the day and calls at 4 PM to make sure they arrived home safely.  When she gets home in the evenings, she prefers to spend time alone because she tends to get easily irritated by her family.  Medical history is noncontributory.  The patient takes no medications.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d2a4_69c2_bc81_b39dd8cf950f_MD0003_00 This patient's ≥6-month history of feeling overwhelmed by anxious thoughts (eg, health, family, safety, finances), accompanied by symptoms of muscle tension, irritability, impaired concentration, and fatigue, is consistent with generalized anxiety disorder (GAD). Patients with GAD experience chronic and pervasive anxiety and worry excessively about everyday matters. They often describe lifelong anxiety but frequently experience worsening symptoms during periods of increased stress, such as this patient's starting a new job. Symptoms of GAD may also include feeling restless/on edge and sleep disturbance characterized by difficulty falling and staying asleep. Patients with GAD frequently seek medical attention in the primary care setting for physical symptoms related to muscle tension or for concerns about fatigue or poor sleep. This patient's neck and shoulder pain is a common presentation. (Choice A) In adjustment disorder, emotional and behavioral symptoms develop within 3 months in response to an identifiable stressor and do not meet the criteria for any other mental disorder. This patient's anxiety has persisted ≥6 months and is consistent with GAD due to her excessive worry about multiple topics and associated physical symptoms. (Choice C) There is significant symptom overlap between major depressive disorder and GAD (eg, fatigue, insomnia, impaired concentration). However, this patient's lack of key depressive symptoms (ie, sadness, decreased interest, anhedonia) and prominent, overwhelming anxiety make GAD the more accurate diagnosis. (Choice D) Although this patient is preoccupied with anxious thoughts, she lacks the intrusive, unwanted obsessions and repetitive, ritualistic, compulsive acts required for diagnosis of obsessive-compulsive disorder (OCD). Patients with GAD tend to seek reassurance directly (eg, calling home to check on children), whereas compulsive behaviors in OCD are often unrealistically connected to preventing a feared outcome (eg, repeatedly counting to a certain number to prevent illness in a child). (Choice E) Anxiety about physical symptoms occurs in both GAD and somatic symptom disorder (SSD). However, in contrast to SSD, patients with GAD typically have multiple worries about everyday concerns and are not exclusively focused on medically unexplained symptoms. Educational objective: Generalized anxiety disorder is characterized by overwhelming and pervasive anxiety lasting ≥6 months. Associated symptoms include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. References: Generalized anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/30934083)

A 45-Year-Old Woman Comes to the Office for Evaluation of "Muscle