Case outcome: interim follow-up visits through six years (continued)

The patient agrees to taper off paroxetine-CR (Paxil-CR) and is started on an SNRI, duloxetine (Cymbalta), and is titrated to 60 mg/d

• – Its escalation further is limited by side effects of frequent headaches and lightheadedness that do not dissipate with time

During this time, he is allowed 0.5 mg as needed and uses the BZ GABA-A receptor PAM, alprazolam (Xanax), with close monitoring for misuse

• – Misuse does not occur and the anxiolytic is clinically effective while awaiting the SNRI to become more effective

At the 60 mg/d monotherapy SNRI dose, the patient states that his GAD symptoms are well controlled but not in remission

• – Still has fluctuating bouts of tenseness, irritability, and worry, regardless of situational stress

• – No longer requires the as-needed alprazolam and it is discontinued

In addition, states that one of the main residual complaints is inattention, inability to focus on longer tasks. This leads to actual and perceived performance problems at work, raising his anxiety and dysphoria further

• – Interestingly, while physically injured recently and unable to exercise for a few weeks, he realized he is routinely hyperactive

• – Reflects that he has been this way “since he was a kid”

Question

Does this patient have ADHD that was missed in the initial evaluation?

No, GAD has indecisiveness, inattention, poor concentration, and psychomotor agitation are key symptoms that can look identical to ADHD

No, the ADHD was not diagnosed in his elementary school years and is not valid as an adult diagnosis as such

Yes, his GAD has likely been treated to remission, his adjustment disorders have resolved, and these residual symptoms are likely comorbid ADHD that went undiagnosed for years

Maybe, but it does not matter as inattention as a residual symptom of GAD or from comorbid ADHD may be treated by similar medications

Attending physician’s mental notes: interim visits through year six (continued)

The patient’s history, in retrospect, makes a good case for long-standing inattention, which likely predates the GAD onset

Despite adequate GAD treatment and resolution of social stressors, he is inattentive and not at his peak of possible wellness

It would be a win–win situation if an augmentation agent could be utilized that might lower his remaining anxiety and also treat his inattentive symptoms

As his SNRI, duolextine (Cymbalta), has full ability as an NRI, using an ADHD-approved NRI such as atomoxetine (Strattera) would be redundant and likely not be helpful

Owing to intolerability, his current SNRI cannot be increased to gain better NRI effects

Adding bupropion-XL (Wellbutrin-XL) might act in a novel manner as a DRI and redundantly as an NRI, would not risk addiction, but again is partially redundant given his SNRI use

Adding a stimulant or wakefulness-promoting agent may work well for inattention, but escalate his anxiety as a side effect and further risk addiction

Adding an alpha-2 receptor agonist, such as guanfacine-ER (Intuniv) (approved for child and adolescent ADHD) might allow for an improvement in ADHD-driven inattention or dampen anxiety further, secondarily improving inattention

• – There would be little risk of addiction or escalating his anxiety

• – This drug is also an antihypertensive, hence low blood pressure may be a risk