A 20-year-old college student comes to the office due to anxiety. She is very worried because she has an important presentation coming up in a few weeks and is afraid that "everyone will see how anxious I am." The patient reports that she had to leave in the middle of her last presentation because her heart suddenly began racing, her voice started to crack, and her face turned bright red. The patient says school has been stressful due to a heavy class load. She recently ended a relationship with her boyfriend of 6 months but feels supported by her friends. She drinks alcohol and uses marijuana socially. Family history is significant for anxiety, depression, and alcohol dependence in her mother. Blood pressure is 134/82 mm Hg, pulse is 86/min, and respirations are 12/min. Physical examination is unremarkable. Mental status examination shows an initially tense patient who relaxes as the interview progresses. The patient requests medication to help with her symptoms. Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 20-year-old college student comes to the office due to anxiety.  She is very worried because she has an important presentation coming up in a few weeks and is afraid that "everyone will see how anxious I am."  The patient reports that she had to leave in the middle of her last presentation because her heart suddenly began racing, her voice started to crack, and her face turned bright red.  The patient says school has been stressful due to a heavy class load.  She recently ended a relationship with her boyfriend of 6 months but feels supported by her friends.  She drinks alcohol and uses marijuana socially.  Family history is significant for anxiety, depression, and alcohol dependence in her mother.  Blood pressure is 134/82 mm Hg, pulse is 86/min, and respirations are 12/min.  Physical examination is unremarkable.  Mental status examination shows an initially tense patient who relaxes as the interview progresses.  The patient requests medication to help with her symptoms.  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d803_d7b0_bc81_a371feeb645f_MD0003_00 This patient has performance anxiety, which is classified in DSM-5 as social anxiety disorder, performance-only. Individuals with performance-only social anxiety disorder do not fear nonperformance social situations and are not socially avoidant in general. The pharmacologic treatment of performance-only social anxiety disorder includes as-needed beta blockers or benzodiazepines rather than maintenance medication. Beta blockers (eg, propranolol) on an as-needed basis help control the associated autonomic response (eg, tremors, tachycardia, diaphoresis). Due to their addictive potential, benzodiazepines (eg, diazepam, lorazepam) are generally avoided in patients with a personal or family history of substance use disorder. In addition, they are not preferred when performance could be impaired by sedation and cognitive side effects (eg, giving a presentation, as in this case) (Choices B and C). Cognitive-behavioral therapy is an effective nonpharmacologic approach. (Choice A) Buspirone is used to treat generalized anxiety disorder, not social anxiety disorder. (Choices D and F) Selective serotonin reuptake inhibitors (eg, paroxetine) and serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine) are used in the treatment of social anxiety disorder that is not limited to performance situations (ie, generalized) or if there is comorbid depression. It would be inappropriate to prescribe a daily medication to this patient because her anxiety is limited to performance situations and she has no depression. Educational objective: Performance anxiety is classified as performance-only social anxiety disorder in DSM-5. Pharmacologic treatments include as-needed beta blockers or benzodiazepines. Benzodiazepines should be avoided in patients with a personal or family history of substance use disorder or when cognitive and sedative side effects could impair performance. References: Non-antidepressant treatment of social anxiety disorder: a review. (http://www.ncbi.nlm.nih.gov/pubmed/23438729)

A 20-Year-Old College Student Comes to the Office Due to Anxiety