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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify target symptoms associated with generalized anxiety disorder (GAD).

  • Construct pharmacotherapeutic goals for GAD.

  • Recommend appropriate pharmacotherapy and duration of treatment for the acute, continuation, and maintenance phases of GAD.

  • Develop a plan to educate patients and consult with providers about the pharmacotherapy used in the treatment of GAD.

  • Develop a monitoring plan for a patient treated for GAD based on the treatment regimen.

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PATIENT PRESENTATION

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Chief Complaint

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“I am so worried all the time that I can’t do anything else. I need some serious help.”

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HPI

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Ned Johnson is a 55-year-old man who presents to his family physician with complaints of severe irritability, feelings of “being on edge,” and inability to fall asleep at night. He states that he always feels tense and exhausted with constant muscle tension and body aches. He was laid off from his job as a manager at a building supply store 9 months ago. Over the past year, he has had difficulty concentrating when filling out job application forms, and his mind often “goes blank” when talking with people. His irritability has impacted his relationship with his wife, and he is worried that she will leave him. He has developed frequent abdominal pain and daily episodes of diarrhea. He constantly worries about the lack of financial resources, his wife losing her job, and his relationship with his wife. He is afraid that he and his wife will lose their house and cars. He states that he cannot control his constant worry and that his anxiety has increased in intensity over the past 6 months. He denies having obsessive–compulsive thoughts or behaviors or symptoms of panic disorder. He recently went to the emergency department because he was so worried about multiple issues in his life that he could not eat or sleep for 2 days. He was given an IM injection of hydroxyzine and sent home with a prescription for hydroxyzine 25-mg capsules orally four times daily as needed for anxiety. He stopped this medication last week secondary to constipation and decreased urinary flow. He tried kava kava from a herbal store a few months ago. It was not effective, and he discontinued it after 2 weeks because of severe abdominal pain.

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PMH

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Records from the family physician indicate frequent visits over the past 9 months for insomnia, headaches, abdominal pain, and diarrhea. He has been treated with buspirone for anxiety for the past 6 months.

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After a recent visit to the ED, he was prescribed hydroxyzine to be taken up four times daily as needed for anxiety.

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Past psychiatric history is significant for episode of depression and alcohol abuse when he was 33 years old, that was treated with fluoxetine. He took the ...

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