Examkin

Question

Difficulty: MediumAnxiety, OCD, and Trauma-Related Disorders

A 20-year-old college sophomore presents to the student health clinic reporting intense fear and physical distress regarding an upcoming mandatory oral presentation scheduled in four days. He describes experiencing severe palpitations, visible hand tremors, and a "knot in his stomach" whenever he thinks about standing in front of his classmates. He states, "I know my fear is irrational, but I am terrified they will see me shaking and think I am incompetent." He has no anxiety in social gatherings, on dates, or in other academic settings. His medical history is significant for moderate persistent asthma, which is well-controlled with a daily fluticasone-salmeterol inhaler and albuterol as needed. He does not use illicit substances or alcohol. Vital signs are within normal limits. Which of the following is the most appropriate pharmacological intervention to manage his symptoms for the upcoming presentation?

  1. Prescription for lorazepam to be taken prior to the presentationAnswer
  2. B
    Prescription for propranolol to be taken prior to the presentation
  3. C
    Initiation of daily sertraline therapy
  4. D
    Initiation of daily buspirone therapy
  5. E
    Recommendation to use the albuterol inhaler prior to the presentation

Answer

The most appropriate management is a prescription for a short-acting benzodiazepine, such as lorazepam, to be taken prior to the presentation.
The correct answer provides a safe and effective immediate treatment. The patient presents with performance-only social anxiety disorder (SAD). While beta-blockers are generally the first-line targeted pharmacotherapy for this condition, this patient's history of asthma represents a strict contraindication to non-selective beta-blockers like propranolol due to the risk of severe bronchospasm. In cases where beta-blockers cannot be used and there is no history of substance abuse, a short-acting benzodiazepine (such as lorazepam or clonazepam) taken occasionally before the triggering event is the most appropriate alternative to suppress the autonomic and psychological symptoms of acute anxiety.

Step-by-Step Solution

1
Diagnose the primary psychiatric condition based on the patient's specific symptom triggers.
The patient experiences intense autonomic arousal strictly associated with public speaking, consistent with performance-only social anxiety disorder.
Accurate subtyping of social anxiety disorder is required to select the correct pharmacological pathway.
2
Identify the standard first-line treatment for this specific diagnosis.
Beta-blockers, such as propranolol, are typically the treatment of choice for managing the acute autonomic symptoms of performance anxiety.
Establishing the standard of care provides a baseline for management decisions.
3
Evaluate the patient's medical history for contraindications to the standard treatment.
The patient has moderate persistent asthma. Non-selective beta-blockers like propranolol are strictly contraindicated due to the high risk of inducing severe bronchospasm.
Patient safety requires recognizing systemic medical comorbidities that preclude standard psychiatric therapies.
4
Select the most appropriate, safe alternative therapy for the acute event.
A short-acting benzodiazepine (e.g., lorazepam) taken as needed prior to the performance is the safest alternative to achieve rapid anxiolysis.
Benzodiazepines provide targeted symptom relief without exacerbating airway resistance.

Key Concept

Management of performance-only social anxiety disorder in patients with contraindications to beta-blockers
Estimated Time:1m 15s
Rate this question

Topics

Anxiety, OCD, and Trauma-Related Disorders

More questions from this topic