Pharmacotherapy for Generalized Anxiety Disorder: A Case Study
This paper presents a three-decision pharmacotherapy case study for a hypothetical 46-year-old male patient (Client X) diagnosed with generalized anxiety disorder (GAD). Beginning with a Hamilton Anxiety Scale score of 26, the case traces the rationale for initiating Paxil (paroxetine) at 10 mg, maintaining the dose after initial symptom improvement, and ultimately increasing the dose when progress plateaued. Each decision is grounded in current evidence on SSRI efficacy and safety, patient-specific factors such as hypertension and occupational demands, and ethical principles including fidelity, nonmaleficence, and autonomy. The paper concludes with a recommendation to augment pharmacotherapy with cognitive behavioral therapy (CBT) for improved outcomes.
- Introduction: Patient profile, GAD symptoms, and assessment context
- Decision #1: Begin Paxil 10 mg PO Daily: Rationale for starting SSRI at low dose
- Decision #2: No Change in Drug or Dose: Maintaining dose after partial symptom improvement
- Decision #3: Increase Drug to 75 mg PO Daily: Dose escalation after plateau in symptom relief
- Conclusion: Treatment summary and CBT augmentation recommendation
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What makes this paper effective
- Each clinical decision is paired with a clear rationale drawn from peer-reviewed sources, making the argument traceable and evidence-based rather than opinion-driven.
- The paper consistently links pharmacological choices to patient-specific factors (hypertension, occupation, HAM-A scores), demonstrating individualized clinical reasoning.
- Ethical principles (fidelity, nonmaleficence, autonomy) are woven into each decision section rather than treated as an afterthought, showing integration of professional ethics with clinical practice.
Key academic technique demonstrated
The paper uses a sequential decision-point structure to simulate clinical reasoning across time, allowing the writer to justify not only what was chosen but also what was explicitly rejected and why. This technique of comparative justification — explaining why alternatives such as buspirone, tricyclic antidepressants, and SNRIs were ruled out — strengthens each decision's credibility and reflects real-world prescribing logic.
Structure breakdown
The paper follows a five-part structure: an introduction establishing the patient profile and assessment context; three body sections each devoted to a distinct clinical decision with rationale, expected outcomes, and an ethical consideration; and a conclusion that synthesizes the treatment arc and recommends adjunctive CBT. This decision-by-decision scaffolding keeps the argument focused and mirrors the format of clinical case documentation.
Introduction
Most people experience anxiety at some point in their lives. However, anxiety may be deemed abnormal or unusual when it is not only frequent but also excessive or intense. Client X (a hypothetical name), a 46-year-old white male, presents with symptoms consistent with generalized anxiety disorder (GAD). He has been referred by his primary care physician following an emergency room visit during which he complained of shortness of breath, chest tightness, and a feeling of "impending doom." At the time of assessment, Client X indicates that he still experiences shortness of breath and chest tightness, and that the "impending doom" feeling occurs on an intermittent basis. He also reports frequent alcohol use as a coping mechanism for these symptoms. Results from the Hamilton Anxiety Scale (HAM-A) return a score of 26, which is interpreted as moderate to severe anxiety.
There are a number of patient factors to consider when determining the most appropriate pharmacological intervention. These factors include the patient's age, occupation, and socioeconomic status. It is also important to establish whether the patient is currently taking any other medications and whether he has previously been diagnosed with any psychiatric disorder or chronic illness. There is further need to determine whether Client X has any comorbid psychiatric conditions at this time. The relevance of these factors cannot be overstated, particularly with respect to minimizing the probability of side effects and enhancing patient convenience — a consideration that past studies have identified as crucial to promoting adherence to the treatment regimen.
Decision #1: Begin Paxil 10 mg PO Daily
The decision to commence treatment with Paxil 10 mg PO daily was selected because Paxil is a selective serotonin reuptake inhibitor (SSRI). Strawn, Geracioti, Rajdev, Clemenza, and Levine (2018) note that SSRIs are an ideal first-line treatment for GAD. As those authors explain, SSRIs "inhibit the reabsorption of serotonin by neurons, so increasing the availability of serotonin as a neurotransmitter" (p. 1059). SSRIs also have fewer side effects than many alternatives, which is particularly important given Client X's occupational demands.
This SSRI was selected over the two other available options because, as Strawn et al. (2018) observe, SSRIs are generally safe and well-tolerated compared to anxiolytics such as buspirone and tricyclic antidepressants such as imipramine. Paxil 10 mg was also chosen with Client X's hypertension in mind. Unlike SNRIs and tricyclic antidepressants, Paxil is less likely to adversely affect blood pressure. As Calvi et al. (2021) note, "tricyclic antidepressants have been associated with increases in blood pressure, as well as orthostatic hypotension, particularly imipramine" (p. 113).
Client X is expected to experience symptom relief within two to six weeks of commencing treatment. He will begin on a low dose to allow his body to adjust to the medication. As Clevenger, Malhotra, Dang, Vanle, and IsHak (2018) note, "if an SSRI is effective, it is recommended to take the medication for another 6 to 12 months, and then gradually reduce the dose" (p. 51).
One relevant ethical consideration at this stage is fidelity — that is, ensuring that patients have access to competent, safe, and quality care. It is therefore the clinician's responsibility to recommend an intervention that will benefit Client X in relation to alleviating his GAD symptoms.
Decision #2: No Change in Drug or Dose
The decision to make no change in drug or dose was selected because Client X reports notable symptom improvement. He no longer experiences shortness of breath or chest tightness, and he reports a marked decrease in work-related worries over the past four to five days. The HAM-A returned a score of 18, interpreted as mild to moderate anxiety. The objectives of Decision #1 were therefore met, consistent with the expectation that statistically significant results at lower dosing would emerge within two to six weeks of initiating treatment with Paxil 10 mg, as Strawn et al. (2018) indicate.
Increasing the dose to 20 or 40 mg PO daily would be premature at this point given Client X's improvement. The dose of an SSRI may be increased if the patient's response is unsatisfactory. There is also a need to minimize the risk of dropout. Research by Furukawa et al. (2019) on optimal SSRI dosing found that "the relationship between the dose and dropouts for any reason indicated optimal acceptability for the SSRIs in the lower licensed range" (p. 603).
The goal going forward is continued reduction in anxiety. During the next visit, Client X is expected to report even further decreased work-related worries. Lower doses of SSRIs are also associated with fewer side effects than higher doses (Furukawa et al., 2019).
The relevant ethical consideration at this stage is nonmaleficence — the obligation to take precautions necessary to protect the client's wellbeing and ensure that instituted interventions do not cause harm (McHenry, 2006). Maintaining the current dose, rather than escalating prematurely, reflects this commitment to minimizing risk to Client X's safety.
Conclusion
Upon factoring in the specific circumstances of this particular client, a decision was made that the best medication to initiate treatment with would be Paxil 10 mg PO daily (an SSRI). A lower dosage was selected to minimize the side effects associated with SSRI therapy. Available evidence indicates that SSRIs are generally safe and well-tolerated (Strawn et al., 2018). Minimizing side effects is particularly important given that Client X works in a sector requiring maximum concentration and focus. Common SSRI side effects — including blurred vision, dizziness, and agitation — can be amplified at higher doses.
Going forward, there will be a need to ensure that Client X is well-informed about how to maximize the benefits of the proposed interventions. This includes guidance on what to avoid while taking the medications and when to take them (e.g., before or after meals). Client X will also be advised that noticeable symptom changes may take several weeks to manifest — even following a dose revision — and that any serious adverse effects should be reported promptly.
Finally, it would be prudent to note that incorporating cognitive behavioral therapy (CBT) alongside the pharmacological interventions described above may enhance overall treatment effectiveness. Studies indicate that combining CBT with pharmacological treatment yields better outcomes. As Strawn et al. (2018) note, there is evidence that the effects of SSRIs can be amplified by CBT, making this a valuable adjunct in the management of GAD.
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