ANXIETY DISORDERS

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Generalized Anxiety Disorder Middle-Aged White Male With Anxiety

Decision Point One

Begin Paxil 10 mg po daily

RESULTS OF DECISION POINT ONE � Client returns to clinic in four weeks

� Client informs you that he has no tightness in chest, or shortness of breath

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� Client states that he noticed decreased worries about work over the past 4 or 5 days

� HAM-A score has decreased to 18 (partial response)

Decision Point Two

Increase dose to 20 mg po daily

RESULTS OF DECISION POINT TWO � Client returns to clinic in four weeks

� Client reports an even further reduction in his symptoms

� HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms)

Decision Point Three

Maintain current dose

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Guidance to Student

At this point, it may be appropriate to continue client at the current

dose. It is clear that the client is having a good response (as

evidenced by greater than a 50% reduction in symptoms) and the

client is currently not experiencing any side e�ects, the current

dose can be maintained for 12 weeks to evaluate full e�ect of drug.

Increasing drug at this point may yield a further decrease in

symptoms, but may also increase the risk of side e�ects. This is a

decision that you should discuss with the client. Nothing in the

client’s case tells us that we should consider adding an

augmentation agent at this point as the client is demonstrating

response to the drug. Avoid polypharmacy unless symptoms

cannot be managed by a single drug.

Start Over (index.html)

12/31/23, 8:16 AM Psychopharmacologic Approaches to Treatment of Psychopathology

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Generalized Anxiety Disorder Middle-Aged White Male With Anxiety

BACKGROUND INFORMATION The client is a 46-year-old white male who works as a welder at a local steel fabrication

factory. He presents today after being referred by his PCP after a trip to the emergency

room in which he felt he was having a heart attack. He stated that he felt chest tightness,

shortness of breath, and feeling of impending doom. He does have some mild

hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He

had his tonsils removed when he was 8 years old, but his medical history since that time

has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was

normal. Remainder of physical exam was WNL.

He admits that he still has problems with tightness in the chest and episodes of

shortness of breath- he now terms these “anxiety attacks.” He will also report occasional

feelings of impending doom, and the need to “run” or “escape” from wherever he is at.

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In your o�ce, he confesses to occasional use of ETOH to combat worries about work. He

admits to consuming about 3-4 beers/night. Although he is single, he is attempting to

care for aging parents in his home. He reports that the management at his place of

employment is harsh, and he fears for his job. You administer the HAM-A, which yields a

score of 26.

Client has never been on any type of psychotropic medication.

MENTAL STATUS EXAM The client is alert, oriented to person, place, time, and event. He is appropriately dressed.

Speech is clear, coherent, and goal-directed. Client’s self-reported mood is “bleh” and he

does endorse feeling “nervous”. A�ect is somewhat blunted, but does brighten several

times throughout the clinical interview. A�ect broad. Client denies visual or auditory

hallucinations, no overt delusional or paranoid thought processes readily apparent.

Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.

You administer the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.

Diagnosis: Generalized anxiety disorder

RESOURCES § Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0

Decision Point One Select what you should do:

Begin Paxil 10 mg po daily

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Begin Imipramine 25 mg po BID

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Begin Buspirone 10 mg po BID

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