How should I evaluate and manage a 27-year-old woman with anxiety and brief electric‑shock paresthesias, who is not pregnant, takes no regular medications, and has no history of head injury?

Evaluation and Management of Anxiety with "Brain Shocks" in a 27-Year-Old Woman

This presentation of anxiety with brief electric-shock sensations ("brain shocks") in a young woman not on medications strongly suggests an anxiety disorder, but you must first rule out medical causes before initiating psychiatric treatment. 1

Initial Medical Workup

Before confirming an anxiety disorder diagnosis, exclude these medical conditions that can mimic or cause anxiety symptoms:

• Thyroid function tests to rule out hyperthyroidism, which can cause anxiety, palpitations, tremor, and sweating 1, 2
• Fasting glucose to exclude hypoglycemia/diabetes, which can trigger panic-like symptoms with autonomic activation 1, 2
• ECG if palpitations are prominent, to distinguish cardiac arrhythmias from panic attacks 2
• Caffeine intake assessment, as excessive caffeine can cause anxiety symptoms and should be reduced 1

The "brain shocks" (brief electric-shock paresthesias) are particularly important. While these sensations can occur with anxiety and panic attacks 3, they are also characteristic of SSRI/SNRI discontinuation syndrome. Since she reports no regular medications, this makes discontinuation syndrome unlikely, but specifically ask about:

• Recent cessation of any antidepressants (even if stopped weeks ago)
• Over-the-counter supplements containing St. John's Wort
• Any medications borrowed from others 4

Psychiatric Assessment

Once medical causes are excluded, assess for specific anxiety disorder subtypes:

Generalized Anxiety Disorder (GAD) is characterized by chronic, pervasive worry about multiple topics with physical symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances) persisting for at least 6 months 1, 5, 6

Panic Disorder presents with recurrent unexpected panic attacks—abrupt surges of intense fear with physical manifestations (palpitations, shortness of breath, dizziness, paresthesias) and anticipatory anxiety about future attacks 2, 5

Social Anxiety Disorder involves persistent fear across multiple social situations lasting 6 months or more 7, 4

Use the GAD-7 screening tool (validated for patients ≥8 years) to quantify severity and guide treatment decisions 2, 5

Critical Red Flags Requiring Immediate Attention

• Suicidal ideation or self-harm behaviors require immediate intervention 2
• Comorbid depression, especially GAD with depression, significantly increases suicide risk 2
• Assess for trauma history, including sexual harassment or assault, which are common underlying triggers for panic attacks, particularly in women 2

First-Line Treatment Approach

For this patient, initiate treatment with both an SSRI and cognitive behavioral therapy (CBT) concurrently, as combination therapy provides superior outcomes compared to either modality alone. 4, 1, 5, 8

Pharmacotherapy

Start with an SSRI as first-line medication:

• Escitalopram 5-10 mg daily or sertraline 25-50 mg daily are preferred first-line agents due to lowest potential for drug-drug interactions and smallest discontinuation-symptom burden 4, 1
• Begin with lower doses to minimize initial anxiety/agitation that can occur with SSRIs 4
• Titrate sertraline by 25-50 mg increments every 1-2 weeks as tolerated, targeting 50-200 mg/day 4
• Titrate escitalopram by 5-10 mg increments, targeting 10-20 mg/day 4

Expected timeline for response:

• Statistically significant improvement may begin by week 2 4
• Clinically significant improvement expected by week 6 4
• Maximal therapeutic benefit achieved by week 12 or later 4

Common side effects to counsel about:

• Nausea, headache, insomnia, sexual dysfunction, dizziness (most emerge within first few weeks and typically resolve) 4
• Critical warning: All SSRIs carry a boxed warning for suicidal thinking and behavior (pooled absolute rates 1% vs 0.2% for placebo); close monitoring is essential, especially in the first months 4

Psychotherapy

Individual CBT is the psychotherapy with the highest level of evidence for anxiety disorders (large effect size for GAD: Hedges g = 1.01) 4, 5, 8

CBT should include:

• Education on anxiety physiology and the fight-or-flight response 7
• Cognitive restructuring to challenge distorted thoughts 4
• Relaxation techniques (breathing exercises, progressive muscle relaxation, grounding strategies) 7, 4
• Gradual exposure to feared situations when appropriate 4
• 12-20 sessions are recommended for significant symptomatic and functional improvement 4, 1

The combination of CBT and SSRI provides durable skills that may prevent relapse after medication discontinuation. 1, 5

Adjunctive Non-Pharmacological Strategies

• Structured physical activity/exercise provides moderate to large reduction in anxiety symptoms 4
• Sleep hygiene education to address insomnia, which commonly co-occurs with anxiety 4
• Avoid excessive caffeine and alcohol, as both can exacerbate anxiety symptoms 4
• Sensory grounding techniques (noticing environmental details, cognitive distractions) can help prevent dissociation if panic attacks occur 7, 4

What NOT to Do: Critical Pitfalls

Do not prescribe benzodiazepines as first-line or long-term therapy. Benzodiazepines should be limited to short-term (days to a few weeks) adjunctive use only due to high risk of dependence, tolerance, cognitive impairment, and withdrawal syndromes 4, 9, 8. The FDA label for lorazepam explicitly warns of abuse, misuse, addiction, physical dependence, and life-threatening withdrawal reactions 9.

Do not use bupropion for anxiety—it is contraindicated because it is activating and can exacerbate anxiety symptoms, agitation, and nervousness 4

Do not abandon treatment prematurely. Full response may take 12+ weeks; allow 1-2 weeks between dose increases to assess tolerability 4

Monitoring and Follow-Up

• Schedule follow-up at 2 weeks, then monthly for the first 3 months to monitor for worsening anxiety, suicidal ideation, and medication adherence 1
• Assess response using standardized anxiety rating scales (GAD-7 or HAM-A) 4
• If no improvement after 8-12 weeks at therapeutic doses despite good adherence, switch to a different SSRI (e.g., sertraline to escitalopram) or consider venlafaxine extended-release 75-225 mg/day as a second-line SNRI 4, 5, 8
• Continue effective medication for a minimum of 9-12 months after achieving remission to prevent relapse 4

If SSRI Fails or Is Not Tolerated

Venlafaxine extended-release (75-225 mg/day) is an effective alternative for patients whose anxiety symptoms do not improve after an adequate SSRI trial, with demonstrated efficacy for GAD, panic disorder, and social anxiety disorder 4, 5, 8. However, venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 4.

Pregabalin/gabapentin can be considered when first-line treatments are ineffective or not tolerated, particularly for patients with comorbid pain conditions 4