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Difficulty: MediumAnxiety, OCD, and Trauma-Related Disorders

A 27-year-old female medical resident presents to the clinic due to overwhelming anxiety. She reports experiencing intense palpitations, sweating, and hand tremors whenever she has to orally present patient cases during morning rounds. She states, 'I am terrified that my attendings will think I am incompetent because I look so nervous.' This anxiety is strictly isolated to public speaking; she has no difficulty interacting with patients, attending social events, or talking to colleagues in casual settings. Her past medical history is notable for asthma, which is currently managed with an albuterol inhaler as needed. Her vital signs are within normal limits. Which of the following is the most appropriate next step in management for this patient's psychiatric symptoms?

  1. Cognitive-behavioral therapyAnswer
  2. B
    Propranolol therapy
  3. C
    Paroxetine therapy
  4. D
    Lorazepam therapy
  5. E
    Buspirone therapy

Answer

Cognitive-behavioral therapy
The patient's symptoms of intense autonomic arousal (palpitations, sweating, tremors) occurring exclusively in the context of public speaking confirm a diagnosis of social anxiety disorder, performance-only subtype. The first-line treatments for this condition are as-needed beta-blockers (such as propranolol) or cognitive-behavioral therapy (CBT). Because this patient has a history of asthma, non-selective beta-blockers are contraindicated as they antagonize beta-2 receptors in the lungs, potentially causing severe bronchoconstriction. Therefore, cognitive-behavioral therapy is the safest and most appropriate next step in management.

Step-by-Step Solution

1
Diagnose the specific psychiatric condition based on the clinical presentation.
The patient has social anxiety disorder, performance-only subtype.
Her symptoms are strictly limited to public speaking and do not occur in general social situations.
2
Identify the standard first-line treatment options for this specific subtype.
First-line therapies include as-needed beta-blockers (e.g., propranolol) or cognitive-behavioral therapy (CBT).
These modalities specifically target the autonomic arousal and cognitive distortions associated with performance situations without requiring chronic daily medication.
3
Evaluate the patient's medical history for any absolute or relative contraindications to the standard therapies.
The patient has a history of asthma.
Non-selective beta-blockers like propranolol can cause severe bronchoconstriction and are contraindicated in asthmatics.
4
Select the most appropriate remaining management strategy.
Cognitive-behavioral therapy is chosen.
It is a highly effective first-line alternative that avoids the risk of bronchospasm associated with beta-blockers.

Key Concept

Management of performance-only social anxiety disorder in patients with medical contraindications to beta-blockers.
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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