NMS Q&A Family Medicine

298 NMS Q&A Family MedicineOf such patients, 70% will complain of paroxysmal hotflashes, making the diagnosis more readily apparent. Theacute menopause syndrome is a great imitator of otherorganic diseases. Only after the acute symptoms of estrogenwithdrawal have been addressed and treated shouldthe elements of depression and anxiety be addressed, ifsymptoms have not dissipated during the empiric therapeutictrial.9. The answer is D. Generalized anxiety disorder isdefined as the situation in which a person has symptomsof irritability, apprehension, anxiety, difficulty concentrating,somatic complaints, and insomnia on more daysthan he or she does not have them, over a period lasting atleast 6 months. Panic attacks do not last all day, not tomention several days running. This patient has notchanged her pattern of living to avoid symptoms; therefore,she does not have a phobic disorder. Her sleep patternsare not those usually encountered in depression (i.e.,early and frequent awakening). Adjustment disorder doesnot fit the situation because nothing has changed materiallyin her life.10. The answer is E. Diazepam (Valium), an intermediatelylong-acting benzodiazepine, is appropriate for generalizedanxiety disorder. Not mentioned but quite acceptableand perhaps safer is buspirone for generalized anxiety. Paroxetineis an antidepressant (and in some cases, psychiatristsare not beyond mixing an anxiolytic and an antidepressant).Chloral hydrate, zolpidem, and temazepam are all sedativesfor facilitation of sleep. On occasion, one of the latter groupcan be used adjunctively in generalized anxiety but is notthe main aspect of therapy.11. The answer is C. SSRIs have shown a 54% to 62%improvement in patients in 12-week trials, as opposed to37% improvement in those who received placebo forPTSD. The diagnostic criteria for this entity are as follows:(a) the traumatizing event; (b) the recurrent reexperiencingof the event; (c) persistent avoidance of stimuli thatremind the patient of the precipitating event; (d) persistentsymptoms of increased arousal (e.g., the insomnia,irritability, and temper flare-ups); (e) duration of thesymptoms for more than 1 month; and (f) significantresultant stress in social life.12. The answer is C. A period of 64 months. With treatment,the average duration of symptoms is reduced to32 months. These data come from research and call for askeptical eye in dealing with patients who promotePTSD as a way of life.13. The answer is E. Triazolam has no active metabolitesto prolong its pharmacologic effects and partly as a resultof this has a half-life of 1 to 3 hours. For this reason, it ispromoted as a sleep-facilitating drug without significantmorning “hangover.” Its popular trade name is Halcion.All of the other drugs mentioned are employed as anxiolyticdrugs, of which alprazolam has the shortest half-life(i.e., 24 hours); the remaining three benzodiazepines(chlordiazepoxide, diazepam, and clonazepam) each havea half-life of 24 hours. Clonazepam is used as an anticonvulsant.Drugs with short half-lives, when used asanxiolytics, may give rise to rebound anxiety within a dosagecycle. Those with half-lives of 24 hours should beused with caution in the aged population.ReferencesEisendracht SJ , Lichtbacher JE . Psychiatric disorders . In: TierneyLM , McPhee SJ , Papadakis MA , eds. Current Medical Diagnosisand Treatment . 45th ed . New York : McGraw-Hill/Appleton& Lange ; 2006 :1038–1099.Ronning GF . Anxiety, phobias, and the undifferentiated primarycare syndrome . In: Rudy DR , Kurowski K , eds. FamilyMedicine: House Officer Series . Baltimore : Williams & Wilkins ;1997 : 811 – 828 .