Posted: February 17th, 2022

Practice guideline for treating patients with acute stress disorder

Assessment and Treatment of Patients with Anxiety Disorders

According to (), almost 20% of adults grapple with anxiety disorders such as generalized anxiety disorder (GAD) every year. Generalized anxiety disorder produces excessive worry, fear, and constant overwhelming feelings. Typically, the worry is persistent, excessive, and unrealistic concerning daily activities. Also, the worry may be multifocal like health, family, finance, and future and is not easy to manage. () highlight the excessive worry is generally alongside several vague physical and psychological symptoms such as insomnia, irritability, muscle tension, easily fatigued, and restlessness. The precise pathophysiology mechanism of GAD is unknown, but some scholars argue that serotonergic, noradrenergic, and other neurotransmitter systems are instrumental in the body’s reaction towards stress. The serotonin and the noradrenergic systems are often the routes involved in anxiety. According to (), several medical researchers perceive that low activity of the serotonin system and increased activity of noradrenergic systems can trigger the development of GAD. In this manner, the first-line treatment for this condition should be selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI). This paper emphasizes three decision points regarding the psychopharmacological treatment approach for a 46-year old white man reporting generalized anxiety disorder symptoms, including events of shortness of breath, chest tightness, and impending doom feelings. Also, it will discuss the associated ethical and legal considerations while undertaking the treatment. The patient reports mild hypertension currently treated with low sodium and is overweight (15lbs). Additionally, the patient agrees that he usually consumes almost three to four bottles of beer every night. The patient factors that could lead to the decision points include ethnicity, gender, and presence of stressors, poor health, and being unmarried. 

Decision Point One

The first drug recommendation for this patient is Paxil 10mg PO daily, a brand name for paroxetine. It is an antidepressant belonging to the selective serotonin reuptake inhibitor (SSRI) class whose main job is to restore specific natural brain components known as serotonin (Bandelow et al., 2017). Ideally, serotonin is a hormone in the brain charged with stabilizing a person’s mood, beliefs, perceptions, and happiness. The Food and Drug Administration (FDA) recognizes Paxil as one of the first-line medication treatments for depression, panic attacks, generalized anxiety disorder, and posttraumatic stress disorder. According to Braun et al. (2020), paroxetine potently prevents the reuptake of 5-HT and hinders norepinephrine reuptake. Since Paxil is an approved treatment for GAD in adults, its use has been studied broadly; several studies advocate for its efficacy in adults grappling with GAD. For instance, in the first double-blind, placebo-controlled study, adults suffering from GAD were randomized to paroxetine (n=161; 20–50 mg/day) or placebo (n=163) for eight weeks. The result was a relief in both anxiety symptoms and daily functioning in patients treated with paroxetine relative to placebo. In the subsequent double-blind, placebo-controlled study, Braun et al. (2020) assessed paroxetine efficacy in adults having GAD over an 8-week double-blind study. The result was an improved HAM-A score for doses relative to placebo realized that Paxil is entirely well-tolerated. Buspirone was not considered because medical research indicates that it increases blood pressure via activating the sympathetic nervous system and directly activating alpha1-adrenergic receptors following a severe haemorrhage (Strawn et al., 2018). Imipramine was also not considered for this patient because it contains inactive ingredients such as polyethene glycol or talc, which may contribute to allergic reactions (Chen et al., 2019). My aim of administering Paxil 10mg every day was to balance, improve the patient’s mood and enthusiasm levels, and eradicate his job fears, worry, and panic attacks. 

Decision Point Two

The patient’s presentation informs the second decision after four weeks, including no tightness in the chest, shortness of breath, and reduced job-related worries. Also, the HAM-A indicates a reduction in symptoms’ severity from 26 to 18. In this regard, my recommendation would be to increase the dosage of Paxil from 10mg PO daily to 20mg PO per day. The client’s presentations show that Paxil is efficient and effective as the patient demonstrates a significant improvement or reduction in the symptoms. Therefore, it is wise to maintain Paxil but increase the dosage so that the medication does obtain the maximum benefits (Melaragno, 2021). In Braun et al. (2020) study, 278 patients were randomly subjected to double-blind treatment with a 10-week placebo course or paroxetine at doses ranging from 10, 20, to 40 mg every day. The outcomes revealed that at 40 mg/day, Paxil was robust to placebo across several measures of outcome. 86% of the patients taking 40 mg, 65.2% taking 20 mg, and 67.4% taking 10 mg of Paxil, and 50.0% of the placebo-treated individuals were entirely relieved of panic attacks in the first two weeks (Braun et al., 2020). Comparing those who took 10mg of Paxil with those who took either 20mg or 40mg, the latter experienced a more significant improvement and tolerance. Substituting Paxil with either Imipramine or Buspirone was not considered because they remain in the body for an extended period; thus, changing the medication could result in potential drug interactions and side effects (Melaragno, 2021). The aim of increasing Paxil dosage to 40mg was to reach an accurate Paxil balance for this client and do away with any side effects. Additionally, I aimed to allow the patient’s body to adapt to Paxil and find the optimum dose to improve daily functioning. 

Decision Point Three

After the patient reported to the facility with further reduction in symptoms, the third decision entailed maintaining Paxil 20mg daily for additional twelve weeks. Also, the HAM-A score of 10 demonstrates a 61% reduction in symptoms meaning that the patient is experiencing a positive response towards the dosage (Bandelow et al., 2017). Also, he does not report having any side effects or drug interactions. In this manner, Paxil 20mg can be seen as effective such that it has induced an accurate therapeutic effect; thus, there was no need to change the regimen (Chen et al., 2019). The third decision of maintaining the current dose was also informed that the patient would realize a placebo effect.

Additionally, maintaining the current dose was considered due to its associated cost savings as manifested in retrospective claims of pharmacy such that using half a tablet of Paxil costs $1 per day, accumulating to more than $175 in annual cost savings (Bandelow et al., 2017). According to Strawn et al. (2018), cost savings can be linked to better clinical outcomes, reduced severe events, and improved adherence to treatment regimens. Increasing the drug dosage or substituting Paxil with Tofranil would increase the risk of side effects. Schuck et al. (2019) argue that when the drug dosage is drastically increased, it can result in quicker health outcomes but can at the same time increase the concentration of the drug concentration in the blood, which may prove poisonous, contributing to medical complications. Maintaining the dosage at 20mg per day for another twelve weeks achieved the placebo impact. The patient understands and is aware that he is being administered an effective drug at a low dose and a lower price. The objective is also to avoid any avoidable drug interactions or side effects. 

Ethical Considerations

The medical provider considered the maleficence and benevolence principles that ensured that the client was safe with maximized benefits (American Psychiatric Association, 2010a). The provider also allowed the client to propose his choice of delivery, share insights and consider the patient’s right of self-determination to allow him to determine his treatment values and his dignity considered (Chen et al., 2019). I considered values like accountability and responsibility to continue and maintain the Paxil dosage at 20mg. This allowed me to openly elucidate for the patient the impacts of our actions, including non-adherence to medication implications. 


The paper has outlined and discussed in detail the three primary decisions made regarding the assessment and treatment of the 46-year old client with symptoms associated with generalized anxiety disorder. The first decision is to administer Paxil 10mg every day, increase the dosage to 20mg per day, and then maintain the current dose for 12 weeks. The medical provider considered Paxil first because it is effective and efficient in restoring serotonin levels with no side effects. Buspirone was not selected first because of its potential risk of increasing blood pressure. Additionally, Imipramine was avoided because it contains inactive ingredients that could result in allergic reactions or drug interactions. The second approach entailed increasing Paxil dosage to 20mg to balance and prevent drug interaction because of substituting Paxil with Buspirone. The third decision involved maintaining the dosage at 20mg per day to enhance a placebo effect as the patient’s health outcomes would be remarkable due to his knowledge regarding the effectiveness and appropriateness of Paxil, no associated side effects, and is cheap. During treatment, the provider considered various ethical considerations, including the maleficence and benevolence principles, right to self-determination, patient autonomy, and values such as responsibility.























American Psychiatric Association. (2010a). Practice guideline for treating patients with acute stress disorder and posttraumatic stress disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd.pdf

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience19(2), 93. http://doi: 10.31887/DCNS.2017.19.2/bbandelow

Braun, C., Adams, A., Rink, L., Bschor, T., Kuhr, K., & Baethge, C. (2020). In search of a dose-response relationship in SSRIs—a systematic review, meta‐analysis, and network meta‐analysis. Acta Psychiatrica Scandinavica142(6), 430-442.https://doi.org/10.1111/acps.13235

Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e Sá, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital Psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier

Chen, T. R., Huang, H. C., Hsu, J. H., Ouyang, W. C., & Lin, K. C. (2019). Pharmacological and psychological interventions for generalized anxiety disorder in adults: a network meta-analysis. Journal of psychiatric research118, 73-83.https://doi.org/10.1016/j.jpsychires.2019.08.014

Melaragno, A. J. (2021). Pharmacotherapy for Anxiety Disorders: From First-Line Options to Treatment Resistance. Focus19(2), 145-160.https://doi.org/10.1176/appi.focus.20200048

Schuck, R. N., Pacanowski, M., Kim, S., Madabushi, R., & Zineh, I. (2019). Use of titration as a therapeutic individualization strategy: an analysis of food and drug administration–approved drugs. Clinical and translational science12(3), 236-239.https://doi.org/10.1111/cts.12626

Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy19(10), 1057-1070.https://doi.org/10.1080/14656566.2018.1491966

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