The role of his moderate alcohol intake came under more scrutiny, and his psychiatrist advised Mr. A to stop drinking altogether. Transient episodes of severe anxiety were treated with low doses of lorazepam over several weeks. Mr. A began to obsess about the timing of any further work-up regarding his hepatitis C, including the question of a liver biopsy. He wanted to make sure that he did not get any LFTs prior to travel, knowing that he would obsess about the results and ruin the vacation for his wife and himself.
Several months later, after more than 3 years on nortriptyline, it became clear that Mr. A’s anxiety about his hepatitis—combined with his ongoing concern about memory side effects—indicated a need to change his medication. A taper of nortriptyline resulted in significantly increased anxiety symptoms, but also in an obvious improvement in his memory.
In your view, what would be your next choice of therapy? Another antidepressant? Back to an anxiolytic? Why?
Dr. Carter’s observations
The general goal is to maintain long-term compliance with treatment of a chronic condition. Therefore, judicious use of benzodiazepines as adjunctive treatment might play a crucial role during flare-ups of the illness, as when Mr. A learns that he actually has a serious medical condition other than his anxiety disorder. We have already established that anxiolytics are not a sensible choice as the foundation of treatment, but they can help patients who experience temporary increases in anxiety with initiation of antidepressant treatment.
We have already reviewed the critical nature of education in treatment, as anxiety limits one’s ability to process new information. Mr. A’s idea of bringing his wife to appointments is a simple and elegant means of his later testing any possible distortions of the conversation. I have patients who audiotape sessions for their subsequent use, and anxious patients frequently attribute significant value to the chance to review certain points “on their own turf” and when their anxiety level is optimally reduced for learning.
In the case of Mr. A, there was a sound working relationship between the internist and the psychiatrist, which is an asset in managing somatic presentations of anxiety disorders, particularly with the risk of depression and even suicide associated with potential interferon treatment of hepatitis.
Final chapter: Confronting anxiety, side effects
Fluoxetine was the next form of treatment, subsequently titrated up to 60 mg/d. Mr. A’s worries about the state of his liver improved, but he was still troubled by infrequent, brief episodes when his anxiety would soar. The overlap between nonspecific symptoms of progressive liver disease—nausea, fatigue, and abdominal pains—and Mr. A’s baseline anxiety symptoms presented new fodder for his anxiety.
His response to fluoxetine illustrated a clear dose-response relationship: His anxiety improved after each dosage increase, and symptoms escalated whenever the dosage was decreased to address a given side effect. Mr. A reported tolerable sexual side effects but ultimately nightmares were too distressing, limiting the quality of his nighttime sleep and resulting in daytime fatigue.
To address this sleep disruption and sexual side effects, fluoxetine was discontinued and Mr. A began taking nefazodone. He took up to 375 mg/d for approximately 20 months with moderate benefit, offset only somewhat by a recurrence of vivid dreams. Then case reports appeared possibly linking liver failure to nefazodone. Mr. A agreed to stop this agent and to evaluate gabapentin as an anxiolytic.
With limited dosages of gabapentin, up to a total of 1,200 mg/d, Mr. A noted significantly improved anxiety symptoms overall, but nightmares and other vivid dreams still interfered with his recovery.
No clear correlation between medication or anxiety level and severity of sleep disturbance emerged. The nature of Mr. A’s work rendered the “sleep hygiene” intervention of a regular sleep cycle impossible, and he understandably did not consider a career shift feasible. A sleep disorders consultation to address this one remaining symptom is under way.
Overall, Mr. A is delighted with his progress. He is now able to participate in informed decision making about treatment of his hepatitis, rather than merely obsess about obtaining LFTs.
Related resources
- Anxiety Disorders Association of America. www.adaa.org. Information for psychiatrists, researchers, residents, patients, caregivers, and the media
- About.com: Generalized Anxiety Disorder: A Real Illness. http://www.MentalHealth.About.com/library/mh/anx/blgadri1.htm
- National Institute of Mental Health: Anxiety Disorders http://www.nimh.nih.gov/anxiety/anxietymenu.cfm
Drug brand names
- Buspirone • Buspar
- Diazepam • Valium
- Fluoxetine • Prozac
- Gabapentin • Neurontin
- Lorazepam • Ativan
- Nefazodone • Serzone
- Nortriptyline • Pamelor
- Sertraline • Zoloft
- Trazodone • Desyrel
- Venlafaxine • Effexor
Disclosure
The author reports that he received research support from Eli Lilly and Co. and Pfizer Inc., and serves as a consultant for Eli Lilly and Co. and Ortho-McNeil Pharmaceutical.