Dipiro GAD

A 26-year-old student nurse is diagnosed with panic disorder and is prescribed fluoxetine. Which of the following is a key component of patient education that should be provided to the student? A. Minimize intake of nicotine and caffeine B. Antidepressant medication should be taken at nighttime C. Breathing into a paper bag is a helpful coping mechanism when having a panic attack D. Cognitive behavioral therapy is unlikely to be beneficial while prescribed medication

A. A key component of education provided to patients with anxiety disorders is to minimize intake of nicotine and caffeine. Both of these drugs are stimulants that can increase symptoms of anxiety, especially in panic disorder. Fluoxetine should be taken in the morning because it is activating. Breathing into a paper bag during a panic attack has been shown to make panic worse and breathing exercises are more appropriate. Cognitive behavioral therapy is a very helpful psychological treatment for panic disorder in conjunction with medication therapy.

A 27-year-old patient is newly diagnosed with generalized anxiety disorder in the outpatient clinic. The medical resident would like to prescribe escitalopram. What daily starting dose would you recommend? A. 10 mg B. 12.5 mg C. 20 mg D. 50 mg

A. The starting dose of escitalopram for generalized anxiety disorder is 10 mg daily. The other doses are too high for an initial dose.

A 42-year-old factory worker is starting pharmacotherapy for generalized anxiety disorder. The patient is very concerned about any sedation or cognitive impairment from medications that might interfere with employment. Which of the following medications should be avoided in this patient case? A. Diazepam B. Fluoxetine C. Duloxetine D. Buspirone

A. In comparing class of medications for anxiety disorders, they have distinctive adverse effects. In this case, the patient needs to avoid medications that may cause sedation and cognitive impairment. Therefore, diazepam (benzodiazepine) would not be appropriate treatment for generalized anxiety. Fluoxetine, duloxetine or buspirone would be appropriate treatment choices.

A patient with social anxiety disorder has been treated successfully with venlafaxine extended-release 150 mg daily for 6 months. The patient inquires about discontinuation of therapy. Which of the following is the most appropriate plan for discontinuation of venlafaxine extended-release? A. Continue therapy for 6 more months, then attempt to taper the venlafaxine over 4 to 6 months B. Add lorazepam to the regimen and attempt to taper venlafaxine extended-release over 2 months C. Continue therapy for 3 more months, then attempt to taper venlafaxine extended-release by decreasing the dose 25% weekly D. Convert venlafaxine to fluoxetine, then discontinue fluoxetine after 6 months of therapy

A. Since the patient has been taking the venlafaxine extended-release for 6 months with good response, and the minimum duration of treatment is 12 months, the medication should be continued for 6 more months and then tapered over 4 to 6 months to avoid discontinuation syndrome and recurrence of symptoms. There is no need to add a benzodiazepine or change the venlafaxine to fluoxetine.

A 62-year-old patient with diabetes, depression, hyperlipidemia, and peptic ulcer disease presents with symptoms of anxiety including trembling, irritability, and palpitations. The patient's medication regimen includes metformin, bupropion, rosuvastatin, and famotidine. Which medication is most likely to contribute to symptoms of anxiety? A. Metformin B. Bupropion C. Rosuvastatin D. Famotidine

B. Bupropion is the most likely medication to cause anxiety of those that the patient is taking. Metformin, rosuvastatin, and famotidine are not associated with anxiety.

A 45-year-old patient presents with generalized anxiety disorder. The patient is not interested in pharmacotherapy but is agreeable to nonpharmacologic methods of treatment. If nonpharmacologic methods are recommended, which of the following types of psychotherapy would be most appropriate? A. Psychological debriefing B. Cognitive behavioral therapy C. Dialectical behavioral therapy D. Eye movement desensitization and reprocessing

B. Cognitive behavioral therapy is the psychological therapy recommended for generalized anxiety disorder. Psychological debriefing and eye movement densitization and reprocessing are used to treat anxiety related to trauma. Dialectical behavioral therapy is used primarily with personality disorders

A 30-year-old patient presents to the clinic complaining of feeling anxious. The patient endorses feeling on edge and their mind going blank which are interfering with their job as a salesperson. These symptoms have been occurring nearly every day for the past 7 months and are difficult to control. The presence of which of the following symptoms would indicate that the patient meets the Diagnostic and Statistical Manual Version 5 criteria for generalized anxiety disorder? A. Suicidal ideation, guilt, weight loss B. Fear of dying, paresthesias, chest pain C. Fatigue, muscle tension, sleep disturbance D. Fear of being humiliated, blushing, sweating

C. Fatigue, muscle tension, and sleep disturbance are symptoms of generalized anxiety disorder. Suicidal ideation, guilt, and weight loss are symptoms of depression. Fear of dying, paresthesias, and chest pain are consistent with panic disorder. Fear of being humiliated, blushing, sweating are symptoms of social anxiety disorder.

Which of the following neurotransmitters is a major inhibitory neurotransmitter in the central nervous system and is involved in the pathophysiology of anxiety? A. Dopamine B. Norepinephrine C. Gamma-aminobutyric acid D. Corticotropin-releasing factor

C. Gamma-aminobutyric acid is the major inhibitory neurotransmitter in the central nervous system. Norepinephrine is involved in implanting the fear response, while the roles of dopamine and serotonin in anxiety are not as well defined. Corticotropin-releasing factor is a peptide hormone that is released in response to stress.

A 22-year-old college student with social anxiety disorder has been treated with sertraline 100 mg daily. The student has responded well to the sertraline in the acute phase of treatment and asks how long the sertraline should be continued. The sertraline should be continued for at least how many months? A. 1 B. 3 C. 6 D. 12

D. Generalized anxiety disorder, social anxiety disorder, and panic disorder should all be treated for a minimum of 12 months after resolution of symptoms to avoid relapse and recurrence of symptoms.

A 55-year-old transgender (female-to-male) patient with a 25-year history of generalized anxiety disorder, a 10-year history of alcohol use disorder, and hepatic impairment presents to the outpatient clinic complaining of significant anxiety related to recent break up of a relationship and loss of their job. The patient is currently on no medication. Which of the following anxiolytics would be the safest to prescribe? A. Duloxetine 30 mg PO once daily B. Clonazepam 0.5 mg PO twice a day C. Alprazolam 0.5 mg PO three times a day D. Hydroxyzine 25 mg PO four times a day

D. Hydroxyzine is the best choice because it is an antihistamine and lacks the risk of misuse and dependence in this patient with a history of alcohol use disorder. Clonazepam and alprazolam should be avoided because this patient is at risk of misusing these benzodiazepines. Duloxetine should not be used in patients with hepatic impairment because of reports of hepatitis and elevated hepatic enzymes; rare cases of hepatic failure have been reported.

A patient has been treated with alprazolam 1 mg three times daily for panic disorder for 12 months. Upon discontinuation of therapy, the alprazolam should be tapered over how many weeks to minimize withdrawal and reduce the chance for relapse? A. 2 B. 4 C. 6 D. 12

D. Long-term use of benzodiazepines (ie, 1 year or longer) requires a 2- to 4- month slow taper. Since this patient has been treated for 12 months, a taper of 12 weeks (3 months) would be most appropriate. See section on "Benzodiazepine Discontinuation."

Which of the following drugs interacts with alprazolam to reduce alprazolam concentrations? A. Ritonavir B. Mirtazapine C. Fluvoxamine D. St. John's Wort

D. St. John's Wort is a CYP3A4 inducer that can reduce alprazolam plasma concentration and concurrent use should be avoided. Ritonavir and fluvoxamine are both CYP3A4 inhibitors and concurrent use with alprazolam would be expected to increase alprazolam plasma concentrations. There is not a pharmacokinetic interaction between mirtazapine and alprazolam, but combined use can result in increased central nervous system depression.

A 45-year-old patient with generalized anxiety disorder has been on paroxetine 20 mg daily for 2 weeks and returns today for a follow-up appointment. In addition to asking the patient questions to determine efficacy, emergence of adverse effects, and adherence, which of the following items would provide an objective measure of the antianxiety efficacy? A. Sheehan Disability Scale (SDS) B. Brief Panic Disorder Screen (BPDS) C. Patient Health Questionnaire-9 (PHQ-9) D. Hamilton Anxiety Rating Scale (HAMD)

D. The Hamilton Anxiety Rating Scale is the best scale for measuring the efficacy of medication for generalized anxiety disorder and it is a clinician-rated scale. The Sheehan Disability Scale is a self-rated scale that assesses the impact of a disorder on a patient's life; it is not sensitive for medication effects. The Brief Panic Disorder Screen is used to screen patients for panic disorder. The Patient Health Questionnaire 9 is used for assessing and monitoring depression severity.

You are discussing goals and objectives of pharmacotherapy of anxiety disorders with your learning team. Which of the following is the long-term goal of therapy in the treatment of each of the anxiety disorders? A. Few to minimal core symptoms B. Partial response after 12 weeks C. Ability to taper adjunctive agent D. Complete remission of symptoms

D. The long-term goal of generalized anxiety disorder, panic disorder, and social anxiety disorder is complete remission of symptoms. While having few to minimal core symptoms, response to medication, and decreased need for adjunctive agents are desirable, the long-term goal should always be complete remission of the disorder

A patient with panic disorder has failed therapy with fluoxetine and escitalopram. Based on evidence-based treatment guidelines, which of the following medications would be preferred for the next trial of pharmacotherapy? A. Bupropion B. Pregabalin C. Mirtazapine D. Venlafaxine

D. When a patient has failed 1 or 2 trials with a selective serotonin reuptake inhibitor, treatment with venlafaxine, a serotonin norepinephrine reuptake inhibitor, is most appropriate. Bupropion has the potential to make anxiety worse, pregabalin has not been studied in panic disorder, and mirtazapine is not a first-line treatment option.