Assessing and Treating Patients with Anxiety Disorders

Assessing and Treating Patients with Anxiety Disorders

The patient in the case is a middle-aged Caucasian male referred to the clinic after experiencing a feeling of a heart attack. He stated that he experienced dyspnea, chest tightness, and a feeling of impending doom. The client still experiences episodic shortness of breath and chest tightness. Medical history reveals that he is mild hypertensive and is currently on a sodium-restrictive diet to manage his disease. He also had his tonsils successfully removed when he was eight. The patient admits to taking alcohol occasionally to lessen his worries at work. He currently takes three to four beers every night. The patient is single. However, he reports that he maintains some responsibility as he is attempting to care for his parents. He works at a steel fabrication company and reports that the management at his workplace is harsh and that he fears losing his job. His medication history is negative for psychotropic medication use.

A mental status exam revealed that the client is alert, and oriented to place, event, and time of day. He was also appropriately dressed for the occasion and demonstrated goal-directed, coherency, and clarity in speech. His effect was somehow blunted. He denied suicidal ideation or tendencies, hallucinations, or paranoid thoughts. His judgment was intact. A physical examination of the patient revealed that he is overweight by about 15 lbs. Other physical exam parameters were within normal limits. ER and the EKG readings were normal, ruling out myocardial infarction. The client’s HAM-A score was 26.

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The patient presented with shortness of breath, chest tightness, and the feeling of impending doom. These manifestations are suggestive of an anxiety attack. Laboratory and diagnostic findings in this client’s case ruled out myocardial infarction, which is a differential in this case. The client, in the case, had mild hypertension. Elevated blood pressure may trigger anxiety (Abdisa et al., 2022). Hypertensive symptoms may also cause panic or anxiety. This may be the case for this client. The client’s work environment is also tense. As evident in the case, the client noted that the management at his workplace was harsh and that he feared losing his job. Notably, work-related stress is a risk factor for anxiety attacks. The client’s work environment may have contributed to his current presentations (Pfaffinger et al., 2020). The general anxiety disorder diagnosis was confirmed by a HAM-A score of 26, indicating moderate to severe anxiety.

Decision Point One: Begin Paxil 10 mg PO daily

Upon confirmation of the diagnosis, the first decision point is to begin Paxil at 10 mg every 24 hours. Paxil, paroxetine, is a selective serotonin reuptake inhibitor (SSRI). Along with other medications in this pharmacological class, this medication maintains use as the first line in the management of generalized anxiety disorder. Its tolerability and effectiveness in lessening anxiety symptoms informed its selection for this condition. Additionally, its once-daily dosing promotes compliance and is acceptable to many clients (Li et al., 2020). It is, thus, a medication of choice for this patient.

Imipramine, a tricyclic antidepressant (TCA), is also effective in the management of generalized anxiety. Its antihistaminic effects may, however, lead to dizziness and sedation, which may be unfavourable to the client due to his nature of work (Melaragno, 2021). Buspirone is another FDA-approved medication for the management of anxiety. However, it is reserved as a second-line agent for this indication. Dizziness is also common with Buspirones’s use (Melaragno, 2021). This makes its selection unfavourable to the client.

The selection of Paxil was aimed at lessening the severity of anxiety symptoms. This medication maintains effectiveness in addressing anxiety symptoms. Its tolerability and effectiveness warrant its use in this scenario (Li et al., 2020). The expected outcome was the resolution of anxiety symptoms due to the effectiveness of Paxil in managing anxiety (Li et al., 2020). When treating this client, his work history has to be taken into consideration. Working in a steel fabrication plan where the risk for injury is high, medications considered should be those that maintain his mental functioning per the ethical consideration of non-maleficence that requires caregivers to do no harm to their clients. Buspirone and Imipramine use may predispose the client to injuries due to their potential to cause sedation and dizziness among their users. Thus, it may be unethical to give the client these medications.

Decision Point Two: No Change in Drug/Dose at This Time

The second decision point is to maintain the dose of Paxil. The client is thus continued on Paxil at 10 mg every 24 hours. Paxil use in this client proved efficacious in lessening the severity of anxiety symptoms. As evident in the case, the client reported decreased worries about work and that his chest tightness and shortness of breath were gone. Additionally, HAM-A scores decreased to 18, revealing a partial response to therapy.

The other options were to increase the dose to 20 mg and 40 mg. Upwards titration of paroxetine in the management of general anxiety disorders corresponded to better clinical response (Li et al., 2020). Doubling the dose or increasing the dose to 40 mg every 24 hours would have thus realized a superior clinical response than the 10 mg initiated for this client. However, these options were not considered due to the possibility of adverse events. Many adverse events of paroxetine are dose-dependent. At higher doses, side effects such as drowsiness may occur (Li et al., 2020). Additionally, Paxil may induce suicidal ideation in some patients, especially those with substance use disorders. Therefore, it was necessary to take a wait-and-see precaution on this client before titrating the dose upwards.

Maintaining the dose of Paxil, in this client’s case, was aimed at assessing the client’s response to paroxetine at the stated dose. At 10 mg, partial response was seen in the client. He also noted decreases in the severity of his anxiety symptoms. However, precaution had to be taken when increasing the dose due to the possibility of adverse events that may be debilitating to the client. Ethical considerations, in this case, are non-maleficence and veracity. Maintaining the dose was geared at ensuring no harm accustomed to side effects of paxil befalls the client. When communicating with the client, it is important that the caregiver maintains veracity and gives accurate information to the client. In this case, the client will be educated on the available options and why the caregiver chose to maintain the dose of Paxil.

Decision Point Three: Increase Drug to 75 mg PO Daily

The next decision point is to increase the dose of Paxil to 75 mg every 24 hours. Upward titration of paroxetine has been associated with increased clinical response and consequent effectiveness in eliminating anxiety symptoms. The client only had a partial response to the stated dose. Increasing the dose to 75 mg is thus warranted in this case. Augmenting paxil with buspirone would also have been an effective alternative in managing anxiety disorder. However, this option was not selected due to the possible toxicity profile of this regime. Concomitant use of buspirone and paroxetine can cause serious heart problems. In a client with mild hypertension, this option is not recommended. Switching to venlafaxine is another option. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor, is also effective in the management of general anxiety disorders. However, its use is not warranted in this client’s case. This is because venlafaxine has near similar efficacy in lessening the severity of anxiety manifestations and switching from paxil to venlafaxine does not confer any pharmacological advantage (Carboni et al., 2019). For these reasons, these options were not selected.

Optimizing the dose to 75 mg was aimed at eliminating anxiety manifestations in the client. As evident in the case, the client returned to the clinic after four weeks and questioned the effectiveness of the medication. Optimizing the dose ensured superior clinical response. Thus, the client is expected to respond to the dose optimization and have a better quality of life. An ethical consideration during this decision point is beneficence. Beneficence requires caregivers to do good and protect the welfare of their clients. Addressing the client’s queries on the effectiveness of the medication he was given is thus necessary. Optimizing the dose was the best available option for the client. This ensures that his complaints are addressed and that he can get back to his normal life.

Conclusion

The client in the case presented with generalized anxiety disorder. General anxiety disorder is a common mental health illness among adults. Individuals with anxiety often present with constant feelings of fear, worry and being overwhelmed. Other symptoms characteristic of this disorder include chest tightness, dyspnea, irritability, and insomnia (Szuhany & Simon, 2022). Pharmacotherapeutic management of general anxiety disorders utilizes SSRIs such as Paroxetine, SNRIs such as venlafaxine, TCAs such as imipramine, antipsychotic medications, benzodiazepines, and buspirone. These medications maintain effectiveness in lessening the severity of anxiety symptoms and may thus be indicated for the client in the case.

SSRIs are the first line in the management of generalized anxiety disorders. These medications are highly efficacious and are well tolerated. Paxil, an SSRI, was selected for the client above. Paxil is usually started at a low dose and then titrated upwards. Upwards titration depends on dose response, as many side effects become apparent as the dose increases. The choice of whether to discontinue Paxil, substitute, or augment is dependent on the clinical response, as demonstrated by the reduction in symptom severity and the side effects profile. Paxil can be discontinued in case life-threatening and debilitating side effects arise. Augmentation is warranted where the clinical response is inadequate.

The choice of medication to use is also dependent on the client’s history. Medications with a lower potential for drowsiness and sedation are recommended for clients who work in areas that require optimum mental functioning. Such include plant operators and drivers. Recommending medications such as imipramine, benzodiazepines, and buspirone that have a high potential for sedation is not warranted for such clients.

References

Abdisa, L., Letta, S., & Nigussie, K. (2022). Depression and anxiety among people with hypertension on follow-up in eastern Ethiopia: A multi-center cross-sectional study. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.853551

Carboni, L., McCarthy, D. J., Delafont, B., Filosi, M., Ivanchenko, E., Ratti, E., Learned, S. M., Alexander, R., & Domenici, E. (2019). Biomarkers for response in major depression: Comparing Paroxetine and Venlafaxine from two randomized placebo-controlled clinical studies. Translational Psychiatry, 9(1). https://doi.org/10.1038/s41398-019-0521-7

Li, X., Hou, Y., Su, Y., Liu, H., Zhang, B., & Fang, S. (2020). Efficacy and tolerability of paroxetine in adults with social anxiety disorder. Medicine, 99(14). https://doi.org/10.1097/md.0000000000019573

Melaragno, A. J. (2021). Pharmacotherapy for anxiety disorders: From First-line options to treatment resistance. FOCUS, 19(2), 145–160. https://doi.org/10.1176/appi.focus.20200048

Pfaffinger, K. F., Reif, J. A., Spieß, E., & Berger, R. (2020). Anxiety in a digitalized work environment. Gruppe. Interaktion. Organization. Zeitschrift Für Angewandte Organisationspsychologie (GIO), 51(1), 25–35. https://doi.org/10.1007/s11612-020-00502-4

Szuhany, K. L., & Simon, N. M. (2022). Anxiety disorders. JAMA, 328(24), 2431. https://doi.org/10.1001/a:link {text-decoration: none;}a:visited {text-decoration: none;
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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 a feeling of impending doom. He does have some mild hypertension (which is treated with a 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. The remainder of the physical exam was WNL.

Assessing and Treating Patients with Anxiety Disorders

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.

The 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