Generalized anxiety disorder (GAD) and the partial response

QUESTION

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.

In your office, 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”. Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect 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

Paxil 10mg PO daily was prescribed.

• Client returns to clinic in four weeks
• Client informs you that he has no tightness in chest, or shortness of breath
• 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)

What would you do next and explain in details why.

Increase dose to 20mg PO daily

Increase dose to 40mg PO daily

No changes made at this time.

ANSWER

Given the client’s presentation of generalized anxiety disorder (GAD) and the partial response to Paxil (paroxetine) at a dose of 10mg PO daily, the appropriate next step would be to increase the dose to 20mg PO daily. This adjustment aims to optimize the therapeutic effect of the medication and further alleviate the client’s symptoms.

Firstly, it is important to note that the initial prescription of Paxil at 10mg PO daily was a conservative starting dose. This approach is often employed to minimize the risk of side effects and allow the client’s body to adjust to the medication. However, the client’s HAM-A score of 18 after four weeks indicates a partial response, suggesting that there is still room for improvement in symptom management.

Increasing the dose to 20mg PO daily is a reasonable next step for several reasons. Firstly, it falls within the standard therapeutic dose range for Paxil in the treatment of GAD. Higher doses of Paxil have been shown to have a greater likelihood of producing a significant clinical response. By increasing the dose, there is a higher potential for achieving the desired therapeutic effect.

Additionally, the client’s report of decreased worries about work over the past 4 or 5 days aligns with the expected trajectory of improvement with Paxil. It suggests that the medication is having a positive impact on the client’s anxiety symptoms, but there is still room for further reduction in anxiety levels.

It is important to consider that each individual may respond differently to medication, and dose adjustments should be made based on the individual’s specific needs and tolerability. Regular monitoring of the client’s symptoms and side effects is essential to guide treatment decisions.

In conclusion, based on the client’s partial response to Paxil at a dose of 10mg PO daily and the reported decrease in worries about work, increasing the dose to 20mg PO daily is a reasonable next step. This adjustment aims to further alleviate the client’s symptoms and optimize the therapeutic effect of the medication. Regular monitoring and follow-up will be essential to assess the client’s response and adjust the treatment plan accordingly.