Generalised anxiety disorder — structured clinical viva

This is chronic GAD with iatrogenic long-term benzodiazepine use and inadequate prior antidepressant trials (stopped within 10 days — not therapeutic dose/duration). Positive metacognitive belief that worry is protective is a core CBT target, not a reason to abandon therapy. Do not escalate benzos as the primary plan.[1][4]

Formulation. Vulnerability (trait anxiety), maintaining factors (cognitive avoidance, positive beliefs about worry, safety behaviours, benzo negative reinforcement), precipitants (life stress), and iatrogenic maintenance via continuous diazepam without skills acquisition.[1]

SSRI re-challenge strategy. Explain early activation; start low (e.g. sertraline 25 mg), frequent early review, short-term non-escalating support, parallel CBT engagement work. Prior "failure" at 10 days is not pharmacological non-response.[4][5]

Benzodiazepine stewardship. Agree collaborative slow taper; convert to long half-life agent if needed; avoid abrupt cessation; educate on tolerance/rebound. Evidence pathways exist for patients discontinuing long-term benzos with alternative anxiolysis.[3][4]

Pregabalin / buspirone. Pregabalin has RCT efficacy and may be considered as alternative/adjunct with misuse counselling. Buspirone has delayed onset and historically poorer outcomes in recent chronic benzo users — set expectations.[2][3][5]

CBT sales pitch without collusion. Validate that worry feels protective; introduce experiments testing whether worry truly prevents catastrophe versus costing sleep, relationships and health; worry postponement and intolerance-of-uncertainty work.[1][4]