A 26 Year Old Woman Presenting With Fatigue, Insomnia ,Irritability And Difficulty In Concentrating.

A 26-year-old African-American woman presents to her primary care physician because of fatigue and insomnia for the past 8 months. She also complains of difficulty concentrating and irritability as well as feeling continually worried. She states that nothing seems to make her feel better or worse; she is still able to perform all of her work duties as a public relations officer and was recently promoted. She denies palpitations and any weight change in this time period and her past medical history is unremarkable. Her vitals signs are within normal range, and physical examination shows no focal findings, but the woman appears markedly agitated. Which of the following is this patient’s
most likely diagnosis?

(A) Adjustment disorder
(B) Attention deficit/hyperactivity disorder
(C) Generalized anxiety disorder
(D) Hyperthyroidism
(E) Social phobia disorder

Answer And Discussion:


The correct answer is C. Patients with generalized anxiety disorder (GAD) have uncontrollable anxiety unrelated to a specific person, situation, or event. In order for the diagnosis to be made, the patient must have experienced uncontrollable anxiety or worry out of proportion to his or her life events for at least 6 months. They also need three or more of the following symptoms: fatigability, irritability, inability to concentrate, insomnia, muscle tension, or restlessness. This patient complains of fatigue, insomnia, difficulty concentrating, and irritability in addition to generalized anxiety.
Affected patients respond well to behavioral therapy and treatment with antidepressants and buspirone. Benzodiazepines can be used for short-term management but are not recommended
for long-term management because of their addictive potential. GAD is often a chronic disease, but it can be controlled. Comorbid depression is common in GAD.

Answer A is incorrect. Adjustment disorder presents with depression and anxiety in the setting of a psychosocial stressor (e.g., divorce or job loss) in the past 6 months. This patient has been feeling anxiety and worry for 8 months.

Answer B is incorrect. Adult attention deficit/ hyperactivity disorder (ADHD) is becoming recognized as an under-diagnosed condition however, this patient has not developed the degree of impairment that would be expected with ADHD. Symptoms of ADHD include difficulty concentrating and irritability. A hallmark of adult ADHD can be difficulty at work, which this patient is not experiencing.

Answer D is incorrect. Signs and symptoms of hyperthyroidism include tachycardia, palpitations, isolated systolic hypertension (diastolic pressure is normal), anxiety, tremor, atrial fibrillation, diaphoresis, weight loss despite increased appetite, insomnia, fatigue, heat intolerance, exophthalmos, and diarrhea. The fact that this patient denies recent weight change and palpitations, that her vital signs are normal, and her physical exam is normal suggest that she is not suffering from hyperthyroidism.

Answer E is incorrect. Patients with social phobia disorder are anxious and nervous in social situations. This patient has a job with a significant social component in which she has
been very successful.