A 43-year-old man comes to the office due to worsening insomnia, dysphoria, and anxiety. Symptoms began yesterday and have steadily worsened. The patient has felt restless and on edge throughout the day and has had difficulty concentrating at work. He has a history of major depressive disorder and generalized anxiety disorder successfully treated with fluoxetine and lorazepam for the last 2 years. The patient's other medical issues include asthma treated with an albuterol inhaler, which he uses twice a week, and osteoarthritis of his left knee joint, for which he takes ibuprofen. Two days ago, he discontinued fluoxetine and lorazepam after his boss was critical of his "tired" appearance during a presentation to important clients. The patient does not use alcohol or illicit drugs. Examination shows an alert and oriented man with a tense, strained affect and an anxious, irritable mood. He is tremulous and shifts uneasily in his seat. He is worried about his ability to perform at work and receiving further criticism from his boss. Which of the following is the most likely explanation for this patient's new symptoms?

Question

A 43-year-old man comes to the office due to worsening insomnia, dysphoria, and anxiety.  Symptoms began yesterday and have steadily worsened.  The patient has felt restless and on edge throughout the day and has had difficulty concentrating at work.  He has a history of major depressive disorder and generalized anxiety disorder successfully treated with fluoxetine and lorazepam for the last 2 years.  The patient's other medical issues include asthma treated with an albuterol inhaler, which he uses twice a week, and osteoarthritis of his left knee joint, for which he takes ibuprofen.  Two days ago, he discontinued fluoxetine and lorazepam after his boss was critical of his "tired" appearance during a presentation to important clients.  The patient does not use alcohol or illicit drugs.  Examination shows an alert and oriented man with a tense, strained affect and an anxious, irritable mood.  He is tremulous and shifts uneasily in his seat.  He is worried about his ability to perform at work and receiving further criticism from his boss.  Which of the following is the most likely explanation for this patient's new symptoms?

Quizplus · Accepted Answer

This patient's acute onset of worsening anxiety, insomnia, tremor, psychomotor agitation, and dysphoria 2 days after discontinuing lorazepam are suggestive of benzodiazepine withdrawal. Following abrupt discontinuation of benzodiazepines, early rebound effects of insomnia and increased anxiety are common, sometimes making it difficult to distinguish benzodiazepine withdrawal from a return of the underlying psychiatric disorder. Benzodiazepine withdrawal may also present with psychosis and seizures and may be life-threatening in severe cases. Onset and severity of benzodiazepine withdrawal depend on the half-life of the drug, with shorter-acting drugs (eg, alprazolam, lorazepam) producing earlier and more severe symptoms. Strategies for managing withdrawal include using a longer half-life benzodiazepine (eg, diazepam) and gradually tapering it over several months. (Choice A) This patient is concerned about his job performance, which may be a significant stressor for him. However, his acute onset of symptoms following lorazepam discontinuation is more likely due to withdrawal. An adjustment disorder should not be diagnosed when a patient's symptoms are better explained by substance use or withdrawal. (Choice B) Abrupt discontinuation of antidepressants may be associated with a withdrawal syndrome that includes anxious and depressive exacerbations; symptoms are more severe in antidepressants with a short half-life (eg, paroxetine). Fluoxetine's long half-life (ie, 4-6 days with chronic use) makes it unlikely to cause clinically significant withdrawal after only 2 missed doses, whereas lorazepam may produce withdrawal symptoms within 1-2 days (due to its half-life of 12 hours). (Choice C) This patient's asthma appears to be stable and is therefore unlikely to be the cause of his new symptoms. (Choice E) The patient's generalized anxiety disorder (GAD) was previously well controlled. The time course of abrupt onset of symptoms following lorazepam discontinuation makes benzodiazepine withdrawal more likely than reemergence of GAD. (Choice F) This patient has an insufficient number of symptoms and duration to diagnose a recurrent major depressive episode. His insomnia, dysphoria, and impaired concentration are more likely due to benzodiazepine withdrawal. Educational objective: Abrupt discontinuation of a benzodiazepine can result in a potentially life-threatening withdrawal syndrome, characterized by anxiety, insomnia, tremors, psychosis, and seizures. In patients with anxiety disorders, mild withdrawal may be difficult to distinguish from reemergence of the underlying disorder. References: Benzodiazepine harm: how can it be reduced? (http://www.ncbi.nlm.nih.gov/pubmed/22882333) Sedative-hypnotic drug withdrawal syndrome: recognition and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28186869)

A 43-Year-Old Man Comes to the Office Due to Worsening