A 27-year-old man comes to the office due to daily anxiety and poor sleep that have been worsening over the last year. He has particular difficulty sleeping on the nights leading up to his weekly staff meeting due to worry that he will say something stupid or embarrassing. He says, "It's just so difficult for me to relax at those meetings even though I am always well prepared. I'm also worried about having to attend a family reunion next month." Although the patient's work performance is good, he recently turned down a promotion that would have required him to interact more regularly with clients. He is experiencing no depression, difficulty concentrating, or appetite disturbance. The patient formerly used alcohol daily to calm his nerves but now drinks once a week. Medical history is insignificant. Blood pressure is 110/70 mm Hg, pulse is 82/min, and respirations are 18/min. On mental status examination, the patient sighs frequently and has a tense appearance and poor eye contact. He is reluctant to consider psychotherapy and requests medication to help him relax. Which of the following is the most appropriate pharmacotherapy?

Question

A 27-year-old man comes to the office due to daily anxiety and poor sleep that have been worsening over the last year.  He has particular difficulty sleeping on the nights leading up to his weekly staff meeting due to worry that he will say something stupid or embarrassing.  He says, "It's just so difficult for me to relax at those meetings even though I am always well prepared.  I'm also worried about having to attend a family reunion next month."  Although the patient's work performance is good, he recently turned down a promotion that would have required him to interact more regularly with clients.  He is experiencing no depression, difficulty concentrating, or appetite disturbance.  The patient formerly used alcohol daily to calm his nerves but now drinks once a week.  Medical history is insignificant.  Blood pressure is 110/70 mm Hg, pulse is 82/min, and respirations are 18/min.  On mental status examination, the patient sighs frequently and has a tense appearance and poor eye contact.  He is reluctant to consider psychotherapy and requests medication to help him relax.  Which of the following is the most appropriate pharmacotherapy?

Quizplus · Accepted Answer

11ec25c8_d804_25d1_bc81_97c96f89a366_MD0003_00 This patient's extreme anxiety in multiple social situations and fears of scrutiny and negative evaluation are consistent with social anxiety disorder. His fear of saying something embarrassing and his anticipatory anxiety about meetings with coworkers and parties (both work-related and social) are characteristic of the disorder. His refusal of a job promotion is an example of the resulting functional impairment. Self-medication with alcohol is a common complication of social anxiety. Selective serotonin reuptake inhibitors (SSRIs) (eg, sertraline) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are used as first-line medication for social anxiety disorder. Cognitive-behavioral therapy is considered a first-line nonpharmacological treatment. Techniques include social skills training, cognitive reframing of anxious thoughts, and systematic desensitization. (Choices A and C) Both buspirone and mirtazapine (an alpha-2 antagonist) have limited evidence for the treatment of social anxiety disorder and are not considered first-line pharmacotherapy. (Choice B) Benzodiazepines such as clonazepam have a role in the treatment of the performance-only type of social anxiety disorder and as augmentation in patients with inadequate response to SSRIs/SNRIs. They are less preferred in patients who have anxiety in nonperformance social situations and a history of self-medication with alcohol, as in this case. (Choice D) Beta blockers are indicated for performance-only social anxiety disorder. They are used on an as-needed basis and are most useful for patients with prominent physiological symptoms such as tachycardia or tremor. This patient's social anxiety occurs daily, is not limited to performance situations, and manifests in multiple social situations (eg, work, personal). (Choice F) Zolpidem is a nonbenzodiazepine sedative hypnotic that would treat only the patient's insomnia, not his underlying social anxiety disorder. The patient's difficulty sleeping is related to his social anxiety and will likely improve when treated with an SSRI/SNRI. Educational objective: Social anxiety disorder is characterized by anxiety and fear of scrutiny in social situations, resulting in avoidance, distress, and social-occupational dysfunction. The preferred pharmacological treatment is a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor. Cognitive-behavioral therapy can also be used as a first-line nonpharmacological treatment. References: Pharmacotherapy for social anxiety disorder (SAnD). (http://www.ncbi.nlm.nih.gov/pubmed/29048739) Update on the efficacy of pharmacotherapy for social anxiety disorder: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25284086) The evidence-based pharmacotherapy of social anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22436306)

A 27-Year-Old Man Comes to the Office Due to Daily