Mr. Lewinsky is a 29 year-old man suffering from excessive sweating for as long as he can remember. The patient’s general practitioner diagnosed the condition as chronic hyperhidrosis when he was 15. Ever since, he has been treated with several topical drying agents without any benefits. He reports experiencing daily episodes of sweat dripping uncontrollably down his face, palms, and soles. During psychiatric evaluation, he revealed a history of untreated anxiety attacks, which have a temporal relationship with the sweating episodes. The patient disclosed that he had been held at gunpoint in an armed mugging 1 year before the anxiety episodes and uncontrollable sweating began. Any sign of potential danger can trigger the same fear and panic that he experienced during the armed mugging incident.

The decision to start the patient on a benzodiazepine called alprazolam was made. Following a trial of this medication, Mr. Lewinsky’s anxiety attacks occurred less frequently and were milder in nature, as were the severity of his concurrent hyperhidrosis episodes. As the residual anxiety attacks and hyperhidrosis episodes persisted, you added another medication, a TCA called doxepin, to the treatment regimen. After 6 months of the combination therapy, the patient was symptom-free. He also began working with a psychotherapist on developing awareness of upcoming anxiety attacks and anxiety-relieving techniques. Another 6 months later, he felt confident enough to make a joint decision with you to begin tapering off alprazolam first and then doxepin in a very gradual, cautious fashion. According to the latest follow-up report, his anxiety disorder and hyperhidrosis are still under control.