Drug-induced Manic Episode

C.D. is a 29-year-old female established patient who initially presented ~1.5 years ago for sleep-onset insomnia and mild bedtime-focused anxiety related to stress as a new attorney. She was started on hydroxyzine 25–50 mg PRN with good control using it only occasionally. About a year later, she returned seeking more aggressive treatment due to daily pervasive worry, continued difficulty falling asleep, and reduced concentration at work. She denies panic attacks but reports feeling overwhelmed with episodic anxiety and racing heart 2–3 times weekly lasting ~15 minutes until she can calm herself. She reports no new triggers and recognizes her anxiety may be longstanding.