A 28-year-old man comes to the office with a 6-month history of extreme nervousness, irritability, restlessness, muscle tension, and insomnia. He fears making mistakes in his job as an attorney and often worries that he has said something wrong. The patient dreads the possibility of not being offered a position as partner in the law firm despite being reassured many times by his superiors. As a result, he finds himself unable to concentrate well or perform his duties efficiently. He is also engaged to be married and spends sleepless nights thinking about the responsibilities of married life. He worries that he will not be a good husband or father. The patient says that he has no previous history of alcohol intake but has been drinking 2 beers on weekends for the past month to escape his distressing thoughts. He is reluctant to start psychotherapy due to his busy schedule. Which of the following medications is most appropriate for this patient?

Question

A 28-year-old man comes to the office with a 6-month history of extreme nervousness, irritability, restlessness, muscle tension, and insomnia.  He fears making mistakes in his job as an attorney and often worries that he has said something wrong.  The patient dreads the possibility of not being offered a position as partner in the law firm despite being reassured many times by his superiors.  As a result, he finds himself unable to concentrate well or perform his duties efficiently.  He is also engaged to be married and spends sleepless nights thinking about the responsibilities of married life.  He worries that he will not be a good husband or father.  The patient says that he has no previous history of alcohol intake but has been drinking 2 beers on weekends for the past month to escape his distressing thoughts.  He is reluctant to start psychotherapy due to his busy schedule.  Which of the following medications is most appropriate for this patient?

Quizplus · Accepted Answer

11ec25c8_d7ca_77f6_bc81_c71cb49c68a5_MD0003_00 This patient's 6-month history of excessive worry and anxiety, restlessness, irritability, difficulty concentrating, muscle tension, and sleep disturbance is consistent with generalized anxiety disorder (GAD). In GAD, the anxiety is chronic, excessive, and difficult to control, and as a result it causes significant distress or impairment. Treatment of GAD includes cognitive-behavioral therapy, medication, or a combination of both. First-line medications for GAD include selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine. No antidepressant has been shown to be superior, and so medication selection is based on side effect profile and the patient's treatment history. SSRIs/SNRIs are also effective in treating depression, a common comorbidity. Benzodiazepines are also effective but are considered second-line treatments due to the risks of abuse, dependence, tolerance, and potential for withdrawal syndromes and rebound effects with abrupt discontinuation (Choices B and C). Benzodiazepines can be used when antidepressants are ineffective or poorly tolerated, but they should be avoided in patients with a history of substance abuse or significant comorbid depression. They can also be used as an adjunct to manage acute anxiety while waiting for SSRIs or SNRIs to take effect. Buspirone, an FDA-approved non-benzodiazepine anxiolytic, has also been used to treat GAD in patients without comorbid depression or panic symptoms. Although it has a slower onset of action and weaker anxiolytic effects than benzodiazepines, it can be helpful in patients with a high risk of benzodiazepine abuse. (Choice A) Bupropion is a nonserotonergic antidepressant that inhibits the reuptake of norepinephrine and dopamine. It is not effective in GAD and may worsen insomnia and anxiety due to its activating effects. (Choice D) The beta blocker propranolol is effective in treatment of the performance subtype of social anxiety disorder, but it is not used in the treatment of GAD. (Choice E) Second-generation antipsychotics such as quetiapine should not be used as first-line treatment for GAD. They have been used in treatment-resistant patients but have significant adverse effects (eg, sedation, metabolic effects). (Choice G) Zolpidem is a sedative hypnotic that could target the patient's insomnia but would not address his other GAD symptoms. Educational objective: Serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line medications for treating generalized anxiety disorder that can also potentially treat comorbid major depression. Benzodiazepines should be reserved for nondepressed patients without a history of substance abuse who fail to respond to or cannot tolerate antidepressants. References: Pharmacological treatment of generalized anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/21950420)

A 28-Year-Old Man Comes to the Office with a 6-Month