Case of the month:

When it’s okay to prescribe benzodiazepines 


A 29-year-old woman presents with a diagnosis of panic disorder and generalized anxiety disorder (GAD), for which she is treated with paroxetine for 6 months.  She seeks consultation because she reports “not feeling myself” in recent months.  She saw her primary care doctor a year ago for panic attacks, which occurred about once monthly.  The primary care doctor was reluctant to give her benzodiazepines, and prescribed paroxetine 20 mg/d.  This dose produced tremor, which improved at 15 mg/d.  Her panic symptoms completely resolved for 6 months, and her function at work improved. However, about 3 months ago, she began to feel less interested in social activities and less interested in her work.  She denied low energy or other depressive symptoms.  She had one depressive episode 4 years ago, after a break-up, which improved a year later without medication treatment.  She has no other mood episodes in the past, and denies any manic or hypomanic episodes.  Manic symptom denial was confirmed in a phone call by the consultant to the patient’s mother.  She denies any other past psychiatric symptoms, has no medical illnesses, no drug allergies, and no past trauma. She is single and in a long-standing relationship, and has been productive and functioning well at her work in a publishing company for 5 years.  She has no current or past history of alcohol or drug abuse of any kind. 

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The past does not repeat itself; but it rhymes. 

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