Family Medicine

29 year old man presents with new onset anxiety

john roberts on Dec 8, 2017

A 29-year-old single, Caucasian man presents to your clinic with the chief complaint of anxiety. He states that starting about a year ago, he started feeling increasingly anxious and irritable. He says that these symptoms have gotten worse over time and that recently he has had several episodes of feeling suddenly panicked, having difficulty breathing, a racing heart and a feeling of “the walls closing in around me.” He believes that his anxiety is related to his work but also mentions that he is concerned about his finances, his romantic struggles and over his parent’s health. Prior this year he states that worrying has not really been an issue with him. 

He denies any psychiatric history and adamantly states that he is not depressed. His past medical history is remarkable for migraines, asthma, diabetes. He has a family history of alcohol abuse in his father, grandfather and a few cousins. Socially, he is currently between apartments and is living at a friends place on a temporary basis. He reports that money is tight at the moment. He reports that he had been unemployed off and on for the past year but has recently started a new job as a waiter at a popular restaurant. He states that he smokes a pack of cigarettes a day, has 3-4 alcoholic drinks a day, has used marijuana daily for the past few years and that he drinks several cups of coffee a day. 

Physical exam and vitals are unremarkable. On mental status examination, the patient appears is well-groomed, well dressed and he is in no acute distress. His movement is normokinetic and he speech is mildly rapid. His mood is anxious and his affect is congruent. Thought process is linear and organized and thought content is without suicidal ideation or hallucinations. He is alert and oriented. He has good insight and judgment. 

Which of the following is the most appropriate initial medication choice?

Expand all answers
Buspirone
This is a good idea, however it would be more commonly used an an augmentive agent to another answer choice. Buspirone is a 5HTa partial agonist.


Desipramine
A TCA could be effective but they would not be tried as a first line agent due to their side effect profiles.


Sertraline
This is the best choice. SSRIs and SNRIs are the first line for the treatment of anxiety disorders.


Alaprazolam
Benzodiazepines are an effective and quick acting treatment for symptoms of anxiety, however they carry a risk for addiction. What are some features of this patient’s history that are cause for concern over starting a benzodiazepine?


After discussing your recommendation to begin an SSRI, the patient appears upset and expresses that he believes that this will not be enough. He tells of a close friend who had similar symptoms to his own who takes takes Xanax. He would prefer to try this first instead. Which of the following are “red flags” related to prescribing a benzodiazepine for the treatment of anxiety?

Select all that apply
Expand all answers
The patients alcohol use
Benzodiazepines works on the same GABA receptors as alcohol and can be especially dangerous if combined. His history is concerning for substance misuse and prescribing a controlled substance could cause more harm than good.


The patients marijuana use
His history is concerning for substance misuse and although more history is need in order to discern this, prescribing a controlled substance could cause more harm than good.


A patient aggressively insisting on a prescription
This could be a sign that the patient could be engaging in drug seeking behavior. This podcast produced by University of Michigan residents provides a framework for navigating the uncomfortable scenario of a patient demanding controlled substances http://www.learnpsychpodcast.com/2017/07/01/019-handling-drug-seeking-behaviors-part-1-with-dr-ed-jouney-and-dr-jenny-wang/


Chronic symptom course
Benzodiazepines are an effective and reliable solution for short term anxiety but are not a good long term solution due to their potential for abuse and tolerance development


The patients asthma history
Nope


You decide to start Sertraline at 25 mg a day with instructions to increase the dose eventually to 100 mg. Which of the following are side effects that you should council the patient on?

Select all that apply
Expand all answers
Autonomic instability
This is a feature of serotonin syndrome, which is not a concern give that the patient is not taking any other medications other than an SSRI. Watch for this if a patient is taking both an SSRI as well as a MAOI.


GI upset (nausea, diarrhea)
Yup. Classic. Of the SSRI's, Sertraline has the highest risk for GI upset


Increased anxiety
Yes. The anxiety can get worse before it gets better


Decreased libido
Yes. Often Buproprion (Wellbutrin) can be trailed if this is a concern of the patients


Dystonia
This would not occur from an SSRI, however watch for this in the use of neuroleptics


Regarding the patients acute bouts of anxiety: Which of the following must be ruled out before there can be a diagnosis of panic disorder?

Select all that apply
Expand all answers
Asthma
This is on the differential for the cause of the patients symptoms and should be further clarified before a diagnosis of panic disorder is made. This would be Anxiety Disorder Due to Another Medical Condition


Marijuana use
Yes, marijuana use can lead to his symptoms. It would be helpful to know if the symptoms occur soon after ingestion?


Cigarettes and caffeine use
– Yes, the patient’s simulant use can lead to his symptoms. It would be helpful to know if the symptoms occur soon after ingestion?


Alcohol intoxication
No, but alcohol withdrawal could cause this...


Diabetes
Yes this could cause his symptom. This would be Anxiety Disorder Due to Another Medical Condition


A 29-year-old single, Caucasian man presents to your clinic with the chief complaint of anxiety. He states that starting about a year ago, he started feeling increasingly anxious and irritable. He says that these symptoms have gotten worse over time and that recently he has had several episodes of feeling suddenly panicked, having difficulty breathing, a racing heart and a feeling of “the walls closing in around me.” He believes that his anxiety is related to his work but also mentions that he is concerned about his finances, his romantic struggles and over his parent’s health. Prior this year he states that worrying has not really been an issue with him. 

He denies any psychiatric history and adamantly states that he is not depressed. His past medical history is remarkable for migraines, asthma, diabetes. He has a family history of alcohol abuse in his father, grandfather and a few cousins. Socially, he is currently between apartments and is living at a friends place on a temporary basis. He reports that money is tight at the moment. He reports that he had been unemployed off and on for the past year but has recently started a new job as a waiter at a popular restaurant. He states that he smokes a pack of cigarettes a day, has 3-4 alcoholic drinks a day, has used marijuana daily for the past few years and that he drinks several cups of coffee a day. 

Physical exam and vitals are unremarkable. On mental status examination, the patient appears is well-groomed, well dressed and he is in no acute distress. His movement is normokinetic and he speech is mildly rapid. His mood is anxious and his affect is congruent. Thought process is linear and organized and thought content is without suicidal ideation or hallucinations. He is alert and oriented. He has good insight and judgment. 

Which of the following is the most appropriate initial medication choice?

Expand all answers
Buspirone
This is a good idea, however it would be more commonly used an an augmentive agent to another answer choice. Buspirone is a 5HTa partial agonist.


Desipramine
A TCA could be effective but they would not be tried as a first line agent due to their side effect profiles.


Sertraline
This is the best choice. SSRIs and SNRIs are the first line for the treatment of anxiety disorders.


Alaprazolam
Benzodiazepines are an effective and quick acting treatment for symptoms of anxiety, however they carry a risk for addiction. What are some features of this patient’s history that are cause for concern over starting a benzodiazepine?


After discussing your recommendation to begin an SSRI, the patient appears upset and expresses that he believes that this will not be enough. He tells of a close friend who had similar symptoms to his own who takes takes Xanax. He would prefer to try this first instead. Which of the following are “red flags” related to prescribing a benzodiazepine for the treatment of anxiety?

Select all that apply
Expand all answers
The patients alcohol use
Benzodiazepines works on the same GABA receptors as alcohol and can be especially dangerous if combined. His history is concerning for substance misuse and prescribing a controlled substance could cause more harm than good.


The patients marijuana use
His history is concerning for substance misuse and although more history is need in order to discern this, prescribing a controlled substance could cause more harm than good.


A patient aggressively insisting on a prescription
This could be a sign that the patient could be engaging in drug seeking behavior. This podcast produced by University of Michigan residents provides a framework for navigating the uncomfortable scenario of a patient demanding controlled substances http://www.learnpsychpodcast.com/2017/07/01/019-handling-drug-seeking-behaviors-part-1-with-dr-ed-jouney-and-dr-jenny-wang/


Chronic symptom course
Benzodiazepines are an effective and reliable solution for short term anxiety but are not a good long term solution due to their potential for abuse and tolerance development


The patients asthma history
Nope


You decide to start Sertraline at 25 mg a day with instructions to increase the dose eventually to 100 mg. Which of the following are side effects that you should council the patient on?

Select all that apply
Expand all answers
Autonomic instability
This is a feature of serotonin syndrome, which is not a concern give that the patient is not taking any other medications other than an SSRI. Watch for this if a patient is taking both an SSRI as well as a MAOI.


GI upset (nausea, diarrhea)
Yup. Classic. Of the SSRI's, Sertraline has the highest risk for GI upset


Increased anxiety
Yes. The anxiety can get worse before it gets better


Decreased libido
Yes. Often Buproprion (Wellbutrin) can be trailed if this is a concern of the patients


Dystonia
This would not occur from an SSRI, however watch for this in the use of neuroleptics


Regarding the patients acute bouts of anxiety: Which of the following must be ruled out before there can be a diagnosis of panic disorder?

Select all that apply
Expand all answers
Asthma
This is on the differential for the cause of the patients symptoms and should be further clarified before a diagnosis of panic disorder is made. This would be Anxiety Disorder Due to Another Medical Condition


Marijuana use
Yes, marijuana use can lead to his symptoms. It would be helpful to know if the symptoms occur soon after ingestion?


Cigarettes and caffeine use
– Yes, the patient’s simulant use can lead to his symptoms. It would be helpful to know if the symptoms occur soon after ingestion?


Alcohol intoxication
No, but alcohol withdrawal could cause this...


Diabetes
Yes this could cause his symptom. This would be Anxiety Disorder Due to Another Medical Condition


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