Colette is a 47-year-old woman with early-stage breast cancer in remission, currently maintained on tamoxifen by her oncologist. She presents to psychiatry with a 6-month history of persistent worry, muscle tension, and difficulty sleeping that escalated during cancer treatment and has not resolved since achieving remission. Her oncologist supports initiating an antidepressant for generalized anxiety disorder and asks for a medication recommendation. Colette has no prior psychiatric medication trials.

Esme is a 15-year-old girl referred to child psychiatry by her pediatrician for generalized anxiety disorder and social anxiety disorder. She avoids answering questions in class, eats lunch alone, and has difficulty falling asleep most nights due to worry. Her Screen for Child Anxiety Related Disorders (SCARED) score is 35 (clinical threshold: 25). The pediatrician has been managing the case for 6 months with weekly school counselor check-ins and relaxation strategies, without meaningful improvement.

Bernard is a 68-year-old retired engineer referred by his primary care physician for management of chronic benzodiazepine use. He has been taking alprazolam 1 mg three times daily for 6 years, originally prescribed by a previous provider for panic disorder. He reports that the medication "takes the edge off" but still has occasional panic attacks and notices his thinking has become "foggy" over the past two years. He has never been prescribed an SSRI. He drinks one glass of wine most evenings.

Pilar is a 36-year-old paralegal presenting with a new diagnosis of generalized anxiety disorder. Her primary concerns are persistent worry, difficulty concentrating, and daily tension headaches. She also reports that a high-stakes custody hearing is scheduled in three weeks. Her anxiety has become acutely impairing in anticipation of the hearing. Her clinician plans to start sertraline today.

Fern is a 55-year-old woman with generalized anxiety disorder who achieved a partial response on escitalopram 20 mg over 12 weeks but continues to experience significant somatic anxiety symptoms including muscle tension, tremor, and autonomic hyperarousal. She also has a 15-year history of alcohol use disorder, currently in sustained remission (sober for 8 years). Her prescriber is considering augmentation or switching strategies.

Malcolm is a 40-year-old man with generalized anxiety disorder who has been treated for the past 3 years. He completed 12 weeks of sertraline at 200 mg (adequate trial) with a 30% reduction in Hamilton Anxiety Rating Scale (HAM-A) scores. He was then switched to escitalopram 20 mg for 10 weeks (adequate trial) with similar partial improvement. He completed 16 sessions of manualized CBT with a certified therapist specializing in exposure-based protocols. His HAM-A remains 18, indicating moderate anxiety. He continues to experience daily worry, muscle tension, and avoidance of professional situations.

Stefan is a 34-year-old software engineer with generalized social anxiety disorder that has been functionally disabling for 12 years. He has completed adequate trials of sertraline 200 mg (12 weeks), escitalopram 20 mg (10 weeks), and venlafaxine XR 225 mg (14 weeks), with no more than modest improvement. He completed two courses of CBT with exposure therapy, including the full hierarchy of feared social situations. He avoids meetings, has declined two promotions, and eats lunch alone in his car daily. His psychiatrist is considering escalation to either a tricyclic antidepressant or a monoamine oxidase inhibitor.

Leah is a 30-year-old woman with generalized anxiety disorder who has been well-controlled on sertraline 100 mg for 2 years. She presents for a routine appointment and reports two new developments: she has been having significant difficulty sleeping due to anxiety-driven hyperarousal over the past 6 weeks, and she has just learned she is 6 weeks pregnant. She asks about both a sleep intervention and whether to continue her sertraline.