Selection from: Generalized Anxiety Disorder With Comorbid Depression

The following test-and-teach case is an educational program modeled on the interactive grand rounds approach. The questions are designed to test your current knowledge. After each question, you will be able to see whether you answered the question correctly. The author will then present referenced information to support the most appropriate answer choice. Please note that these questions are designed to challenge you, and you are not penalized for answering the questions incorrectly. Case 1: Patient History and Introduction Susan G. is a 38-year-old financial services representative with a history of long-standing anxiety and recurrent depressive symptoms. She has had a history of anxiety dating back to childhood with separation anxiety and shyness manifesting in kindergarten. Since that time, she has had ongoing and apparently excessive worries about her performance in school (although she did well) and the safety of her family members (although they were in good health). She relates a series of marked fears that she experienced as she was growing up including fears of the dark and lightning, most of which disappeared by the time she reached adulthood except for a persistent fear of snakes. After entering college at age 18, her anxiety became more persistent and increased in intensity. She received care at the school counseling center, where she met occasionally with a therapist and received a prescription for lorazepam, which she used on an "as needed" basis during periods of increased anxiety such as examinations over the next few years. She experienced her first major depressive episode following a failed romantic relationship, for which she was prescribed imipramine, which she took for a couple of months but then discontinued because of intolerable side effects (dry mouth and weight gain). She saw a therapist regularly during this period, and the depression gradually resolved over the next 4 months. Since then Susan has experienced continuous feelings of anxiety, with associated insomnia, fatigue, irritability, tension, and irritable bowel. She is a self-described "worry queen" and notes she is "always anxious about something," whether it be her children's health, her job performance, or her family's financial situation -- all without evidence of problems in these areas. She is concerned that her children notice her anxiety and that she is "making my kids nervous"; further, her frequent need for reassurance is creating a strain in her marriage. Although she receives good reviews at work, her supervisors have told her that she has not been promoted to a managerial position because her obvious anxiety would interfere with her ability to lead others. Over the past 20 years, she has also had at least a half a dozen episodes of major depression lasting anywhere from 3 months to over a year, some spontaneous, and others associated with situational stressors, including 2 that were postpartum. Since college she has continued taken benzodiazepines intermittently (eg, lorazepam 1-2 mg) on an "as-needed" basis when her anxiety has increased, rather than regular daily doses, because of her concerns about becoming "addicted." About 7 years ago her primary care physician (PCP) started her on fluoxetine 20 mg/d, but she discontinued it within a week because it made her tremulous and exacerbated her anxiety. She has been in supportive therapy episodically over the years, which she has found helpful in dealing with situational stressors, but which has not has not relieved her overall level of anxiety. Her physical health has been generally good, although she has presented on multiple occasions to her PCP for a variety of somatic symptoms including headaches, muscle aches, chest pain, and dizziness for which no clear etiology could be determined. Thyroid testing, electrocardiogram (ECG), hematologic and chemistry screens have been normal. Her menstrual periods are generally regular although she notes marked premenstrual worsening of her anxiety and irritability. She has smoked a pack of cigarettes per day for more than 15 years, despite numerous attempts to quit. She cites the transient sense of decreased tension accompanying use of a cigarette and the increased anxiety experienced during quitting as factors in her inability to stop smoking. She will have 1or 2 glasses of wine during social occasions and occasionally on weekends; she has no history of alcohol abuse or dependence but monitors her use carefully, worrying that she will become an alcoholic because the alcohol makes her feel less anxious for awhile. She smoked marijuana twice in college but it made her feel more anxious and she has not used any illicit drugs since. Social and Family History Susan met her husband through a mutual friend, a few years after college. She was drawn to his sense of calm and strength and he found her dependence on him "endearing." They had 3 children over the next 10 years. After the births of her second and third children, postpartum depression developed; each episode lasted for almost a year; her anxiety also worsened during these periods. She did not seek treatment; her mother came to stay with her during those periods and helped her take care of the children. She tears up when noting that her youngest child "is just like I was -- he's afraid of everything." She grew up "generally happy" although troubled by anxiety starting early in life, in a middle class home, the younger of 2 children. There was no history of physical or sexual abuse. Her father died a number of years ago, and her mother, although still alive, has significant medical problems and the patient is worried about her health. Both her parents were "nervous people" although without formal diagnosis or treatment; a maternal aunt had a history of depression.