Assessing and Treating Patients with Anxiety Disorders

Assessing and Treating Patients with Anxiety Disorders

A 46-year-old white male presented to the office after a referral from his primary care provider (PCP). He had visited the PCP’s emergency room with fears of a heart attack, as per the PCP’s report. In the ER, presented symptoms included chest tightness, shortness of breath, and feelings of impending doom. The client has some mild hypertension, which was treated with a low-sodium diet. He was also found to be a bit overweight. Although his medical history is unremarkable, it shows that the client’s tonsils were removed when he was eight years old. Myocardial infarction was ruled out, his EKG was expected, and the rest of his physical exam was WNL.

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In the office, the client has noted that he still experiences tightness in the chest and incidents of shortness of breath, self-diagnosed as anxiety attacks. He also feels like he needs to run or escape from wherever he is and occasionally experiences feelings of impending doom. He sometimes uses EtOH to manage work-related worries and consumes about three to four beers a night. However, he has never used any psychotropic medication. On his social status, the client is single and takes care of his aging parents in his house. The client noted that his workplace is harsh and has fears for his job.

Examining the client’s mental status indicated that the client was alert and well-oriented to person, time, place, and occasion. He is well-dressed and has clear, coherent, and goal-oriented speech. He is monotonous and feels nervous. He is mainly blunted but brightens sometimes and has no visual or auditory hallucinations or delusions. He has no suicidal or homicidal ideation. He scores 26 on the Hamilton Anxiety Rating Scale (HAM-A) and is therefore diagnosed with generalized anxiety disorder.

Decision #1

The first decision is to prescribe Paxil 10 mg to be taken orally daily. Unlike the other two options, Imipramine 25 mg and Buspirone 10 mg, Paxil is a selective serotonin reuptake inhibitor (SSRI). SSRIs and antidepressants have been shown to have better tolerability and higher efficacy in the treatment of anxiety and comorbid disorders such as depression (Melaragno et al., 2020). Therefore, SSRIs are selected as first-line pharmacological agents for generalized anxiety disorders. SSRIs’ mechanism of action includes inhibiting the presynaptic reuptake of serotonin, increasing serotonin levels in the brain, and impacting neurotransmission (Edinoff et al., 2021). This enables the patient to have improved moods, reduced feelings of fear, and a better sense of well-being.

The other options, Imipramine 25 mg and Buspirone 10 mg were not selected based on efficacy and safety. For instance, Buspirone 10 mg as an anxiolytic, though effective in improving anxiety symptoms, has been shown to have short-term relief of the symptoms (Wilson & Tripp, 2022). Imipramine is a tricyclic antidepressant (TCA). Drug tests comparing TCAs to SSRIs and other SNRIs have shown TCAs to have reduced efficacy, while SNRIs and SSRIs had superior efficacy (Williams, 2022). Therefore, Imipramine 25 mg and Buspirone 10 mg can only be considered second-line treatments. The decision to use Paxil was based on the need to improve the anxiety symptoms effectively and efficiently with fewer safety concerns.

Ethical considerations such as safety and confidentiality impact the treatment plan and communication with the patient. For example, as the client has concerns and stress at their workplace, anxiety is confused with depression, leading to the wrong diagnosis and medication plan. This will require a careful diagnosis to avoid therapeutic misconceptions, therefore developing safe treatment plans. Confidentiality will enable the patient to be more open and provide precise details to improve the diagnosis of presented symptoms.

Decision #2

The second decision point includes increasing the Paxil dose to 20mg to be taken orally daily. After four weeks of using Paxil 10 mg po daily, the client has observed a reduction in symptoms, such as reduced worries related to their work, in about the last five days. The client scored 18 on the HAM-A score. A HAM-A score of 18 still presents mild anxiety and a partial response to Paxil 10 mg daily. An increase of Paxil dose by 10 mg is recommended for adults to improve the symptoms associated with generalized anxiety disorder in adults (Petty & Maul, 2018).

Increasing the Paxil dose to 40 mg po daily and not changing the drug or dosage was not selected. Although the Paxil dosage can be increased to 40 mg per day, there is an increased risk of the patient experiencing adverse effects (Edinoff et al., 2021). The current dose was not maintained as it did not achieve the treatment goals. There was no change in the drug as alternatives to Paxil are only recommended for use in the short term due to safety concerns. For instance, benzodiazepines are effective in managing acute anxiety symptoms; however, prolonged use can lead to addiction, dependency, and reduced efficacy (Edinoff et al., 2021).

The increase in the Paxil dosage to 20 mg was intended to increase the efficacy of Paxil and improve the anxiety syndromes to achieve the treatment goals. The proper dosage regimen can increase the drug’s therapeutic effectiveness and help manage adverse effects related to prolonged use (Maheshwari et al., 2018). The ethical considerations affecting my decision to increase dosage are the client’s preferences and the patient’s right to safe care. Considering the client’s preference can compromise the centeredness of patient care and the patient’s engagement in the plan. Research has shown that patients are willing to get involved in their care, significantly impacting health outcomes (van Hoof et al., 2022).

Decision #3

The third decision point after the current visit by the client is to maintain the current dose. This means that the Paxil 20 mg po daily will be continued for the rest of the treatment plan. The client returned to the clinic after another four weeks. Notably, there has been a further significant reduction in anxiety syndromes. The patient also scored ten on the HAM-A score. A 60 percent reduction in symptoms indicates a suitable and sufficient response to the 20 mg po daily dose of Paxil. There are no side effects during their use of the current dose. Therefore, there is no need to increase the dose. Although increasing the dosage based on the recent observation will improve the symptoms, it risks the patient experiencing adverse side effects. Higher doses of SSRIs such as Paxil have been linked to adverse effects such as extrapyramidal symptoms (EPS), serotonin syndrome, poor sex drive, congenital disabilities, hyponatremia, and cataracts (Edinoff et al., 2021).

The other two options, including increasing the dose to 30 mg po daily and using Add augmentation agent such as BuSpar (Buspirone), were not selected as the client had shown significant improvements. The increase of Paxil from 20 mg to 30 mg po daily will present unintended side effects and adverse outcomes. The client does not need any augmentation. Polypharmacy risks cases of drug interactions, undesired side effects, health impairment, and an increased risk of unnecessary hospitalizations (Kratz & Diefenbacher, 2019). The decision to maintain the current dose is to ensure the patient recovers smoothly without adverse effects. The ethical considerations that may impact the treatment plan include maintaining the client’s autonomy and ensuring that the care provided benefits them. The client may decide they do not want to continue with the dosage. As a health professional, I must educate them on adhering to the dosage for maximum benefits and avoid relapses.

Conclusion

The diagnosis of generalized anxiety disorder is majorly based on the symptoms expressed by the patient. However, the symptoms may be misinterpreted for other disorders, leading to a wrong diagnosis and the risk of gross medical errors. The client presented at the clinic was diagnosed with generalized anxiety disorder and required the proper treatment to be administered to manage the related symptoms. However, several iterations must be made during the diagnosis and the selection of the self-treatment regimen. Of the factors to consider during diagnosis and choice of the treatment plan are the medical history of the patient, presence of comorbid conditions, current medication under use, the patient’s lifestyle, thorough assessment of the presented symptoms based on the existing guideline, and the efficacy and safety of the treatment options. Failure to consider these factors risks wrong diagnosis, errors in the treatment plan, and treatment resistance. Anxiety might fail to respond to effective treatments due to clinician errors in selecting and delivering effective treatment and non-involvement and non-adherence to medications (Kratz & Diefenbacher, 2019).

The client presented in the case has no clear medical history; however, their lifestyle includes the use of EtOH and alcohol to manage their worries. The client also presents symptoms that apply to heart attacks and experiences at work that can be considered to trigger depression. However, after feeling these symptoms and carrying out tests to rule out a heart attack and depression, the patient was effectively diagnosed with generalized anxiety disorder. This requires the use of first-line medications to manage and improve anxiety symptoms effectively. Due to their mechanism of action, SSRIs provide a more productive method of treating generalized anxiety disorder. In conclusion, a health professional should follow through with all decision points to ensure the patient receives the best care, medication, and dosage to support safe and long-lasting recovery.

 References

Edinoff, A. N., Akuly, H. A., Hanna, T. A., Ochoa, C. O., Patti, S. J., Ghaffar, Y. A., Kaye, A. D., Viswanath, O., Urits, I., Boyer, A. G., Cornett, E. M., & Kaye, A. M. (2021). Selective Serotonin Reuptake Inhibitors and Adverse Effects: A Narrative Review. Neurology International 2021, Vol. 13, Pages 387-401, 13(3), 387–401. https://doi.org/10.3390/NEUROLINT13030038

Kratz, T., & Diefenbacher, A. (2019). Psychopharmacological Treatment in Older People: Avoiding Drug Interactions and Polypharmacy. Deutsches Ärzteblatt International, 116(29–30), 508. https://doi.org/10.3238/ARZTEBL.2019.0508

Maheshwari, R., Sharma, P., Seth, A., Taneja, N., Tekade, M., & Tekade, R. K. (2018). Drug Disposition Considerations in Pharmaceutical Products. Dosage Form Design Considerations: Volume I, 337–369. https://doi.org/10.1016/B978-0-12-814423-7.00010-1

Melaragno, A., Spera, V., & Bui, E. (2020). Psychopharmacology of Anxiety Disorders. 251–267. https://doi.org/10.1007/978-3-030-30687-8_13

Petty, F., & Maul, A. (2018). Paroxetine. XPharm: The Comprehensive Pharmacology Reference, 1–5. https://doi.org/10.1016/B978-008055232-3.62366-9

van Hoof, M., Chinchilla, K., Härmark, L., Matos, C., Inácio, P., & van Hunsel, F. (2022). Factors Contributing to Best Practices for Patient Involvement in Pharmacovigilance in Europe: A Stakeholder Analysis. Drug Safety, 45(10), 1083–1098. https://doi.org/10.1007/S40264-022-01222-Y/TABLES/4

Williams, C. (2022). Tricyclic Antidepressants versus Selective Norepinephrine Reuptake Inhibitors in the Management of Fibromyalgia. Lynchburg Journal of Medical Science, 4(3). https://digitalshowcase.lynchburg.edu/dmscjournal/vol4/iss3/126

Wilson, T. K., & Tripp, J. (2022). Buspirone. XPharm: The Comprehensive Pharmacology Reference, 1–5. https://doi.org/10.1016/B978-008055232-3.61355-8

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Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. You will be asked to make three decisions concerning the medication to prescribe to this patient. Consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

You should evaluate all options at each decision point before deciding and moving throughout the exercise. Before deciding, ensure that you have researched each option and considered the conclusion you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision-making when prescribing medication for this patient.
Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your suggestions and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your reasoning, it will not count toward the resource requirement. It would be best if you were utilizing the primary and secondary literature.