Patient evaluation on intake

31-year-old man with a chief complaint of anxiety of “different types”

Patient states that he “has been successful in graduate school, has financial worries, but states that he worries and is tense most of the time”

Psychiatric history

Has been anxious for many years, mostly since college and now graduate school

Working part-time and going to school part-time and feels “torn in many directions”

Generally is tense, restless, irritable, and worries about things even outside school and work

• – When legitimate stressors diminish, the anxiety lowers, but is still present and discouraging

This causes him to be argumentative and temperamental most of the time

He says he is active and likes to stay busy all of the time, but he wonders if “he is doing too much, as he has no time for all of the things” he wants to do

Social and personal history

Graduated high school, college, and is enrolled in a graduate-level training program for family counseling

Gainfully employed now in a clinical setting

Married and without children

Does not use drugs or alcohol

Medical history

There are no medical issues but is allergic to penicillin

Family history

Father has AUD

Distant family members have probable bipolar disorder

Medication history

There was serendipitous anxiety relief when his PCP placed him on hydroxyzine (Vistaril) 50 mg/d for an allergic skin reaction

• – This helped to “calm him down” but was only temporary

Has taken the SSRI paroxetine (Paxil) 40 mg/d but had a difficult time balancing its anxiolytic effects and its sexual side effects

• – Felt that he was less anxious at these higher doses of this SSRI, but this was too problematic from a tolerability point of view

• – Next changed to the slow-release preparation at a lower dose (paroxetine-CR 25 mg/d), which better balanced efficacy and tolerability

Next, he responded to a radio advertisement for an anxiety research study and he was placed on an SGRI antiepileptic, tiagabine (Gabitril), as an augmentation strategy, which he found moderately beneficial at a dose of 12 mg/d

Psychotherapy history

Patient has seen a few psychotherapists for both supportive psychotherapy and PDP

He reports having psychological issues regarding his father, who was abusive and an alcoholic

• – Psychotherapy has been very helpful

• – There is no DSM-5 evidence of PTSD despite this history

Patient evaluation on initial visit

Patient suffers from chronic GAD symptoms that fluctuate over time

Clear stress-based, adjustment disorder-driven causes of anxiety are superimposed over a baseline of persistent GAD symptoms

Despite these symptoms, he is coping fairly well at work and in relationships

Has been compliant with medication management, but has somewhat fragmented care in that he was seeing different providers who were monitoring his individual medications separately

Does not appear to be at risk for any suicidal attempts

Experiences minor sexual side effects and fatigue from his current medications

Current medications

Hydroxyzine (Vistaril) 50 mg/d (antihistamine anxiolytic)

Paroxetine (Paxil-CR) 25 mg/d (SSRI)

Tiagabine (Gabitril) 12 mg/d (SGRI)