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Chapter 57. Anxiety Disorders

SB is a 55-year-old woman who reports excessive worrying, poor concentration, back and neck pain, and difficulty sleeping through the night. She constantly worries about losing her job as a data analyst despite the fact that she recently received a promotion. These symptoms have progressively worsened in the past 7 months and have negatively affected her relationships with friends. Previous medication trials include sertraline, fluoxetine, and venlafaxine extended release (ER). She has a history of atrial fibrillation, hypertension, alcohol use disorder, suicidal ideation, and medication nonadherence due to her busy work schedule. Her current medications include warfarin 2.5 mg PO daily, metoprolol succinate 25 mg PO daily, and lisinopril 10 mg PO daily. The psychiatrist is seeking a recommendation. Which medication has an FDA indication for generalized anxiety disorder and would be a reasonable option for SB?

a. Alprazolam

b. Amitriptyline

c. Bupropion

d. Buspirone

e) Fluvoxamine

Answer d is correct. Buspirone (Buspar) has an FDA indication for generalized anxiety disorder.

Answer a is incorrect. Alprazolam (Xanax) should be avoided given her history of alcohol use disorder.

Answer b is incorrect. Amitriptyline (Elavil) is only FDA-indicated for depression and should be avoided given her history of suicidal ideation. An overdose of tricyclic antidepressants (TCAs) can be lethal.

Answer c is incorrect. Bupropion (Wellbutrin) is only FDA-indicated for depression, depression associated with seasonal affective disorder, and smoking cessation. Bupropion can potentially worsen anxiety due to its activating side effects.

Answer e is incorrect. Fluvoxamine (Luvox) is only FDA-indicated for obsessive-compulsive disorder.

What is the mechanism of action of buspirone?

a. Dopamine 2A partial agonist

b. Selective serotonin reuptake inhibitor

c. Serotonin and norepinephrine reuptake inhibitor

d. Serotonin 1A partial agonist

e. Serotonin and dopamine antagonist

Answer d is correct. Buspirone works primarily as a serotonin 1A partial agonist.

Answers a, b, c, and e are incorrect. Buspirone has no action at dopamine or norepinephrine receptors and does not selectively inhibit the reuptake of serotonin.

Which of the following counseling points are correct for a patient picking up a prescription for buspirone? Select all that apply.

a. Buspirone may increase levels of warfarin.

b. Buspirone must be taken at least ...

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