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Difficulty: EasyAnxiety, OCD, and Trauma-Related Disorders

A 22-year-old law student schedules an appointment at the university health center due to severe distress regarding his upcoming moot court arguments. He explains that whenever he has to speak in front of a panel of judges, he experiences intense palpitations, a prominent hand tremor, and a trembling voice. These symptoms begin roughly 30 minutes before he is scheduled to speak and severely impair his performance. He does not experience this anxiety during written exams, while studying in groups, or in everyday social interactions. He is otherwise healthy, exercises regularly, and takes no daily medications. His pulse is 78/min and blood pressure is 118/76 mm Hg. Which of the following is the most appropriate initial pharmacotherapy to manage this patient's symptoms?

  1. PropranololAnswer
  2. B
    Sertraline
  3. C
    Clonazepam
  4. D
    Buspirone
  5. E
    Quetiapine

Answer

Propranolol
The patient's presentation is highly characteristic of social anxiety disorder (SAD), performance-only specifier. This condition involves intense fear and physiologic arousal specifically linked to public speaking or performing. The most appropriate initial pharmacotherapy for performance-only SAD is an as-needed beta-blocker, such as propranolol, taken 30 to 60 minutes before the stressful event. Beta-blockers effectively blunt the peripheral autonomic symptoms of anxiety, such as tachycardia and tremor, without causing cognitive impairment.

Step-by-Step Solution

1
Analyze the clinical presentation.
The patient experiences intense autonomic anxiety symptoms (tremor, palpitations) exclusively triggered by public speaking, without generalized social fears.
To establish the diagnosis of Social Anxiety Disorder, performance-only specifier.
2
Determine the treatment goals for performance-only anxiety.
The goal is to suppress peripheral autonomic arousal on an as-needed basis without impairing the patient's cognitive sharpness during the performance.
To select the most appropriate pharmacological class.
3
Identify the standard first-line medication.
Beta-blockers (like propranolol) administered 30-60 minutes before the event are the standard of care.
They effectively block beta-adrenergic receptors, stopping tremor and tachycardia, while leaving cognitive function intact.

Key Concept

The first-line pharmacologic treatment for performance-only Social Anxiety Disorder is an as-needed beta-blocker (e.g., propranolol).
Estimated Time:45s
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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