Case Study – Generalized Anxiety Disorder

Case Study – Generalized Anxiety Disorder

A Brief Explanation of Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) is characterized by a worry that is excessive and persistent over several different things. A person with GAD may be anticipative of disaster and can also be overly concerned about work, family, health, and money, among other issues. A person with GAD has a problem controlling the way they experience. Such a person will tend to worry more than the situation warrants or may be expectant of the worst, even when they have no reason to have such elevated concern (Stein & Sareen, 2015). A person is diagnosed with GAD when they find it challenging to control worry for several days within a period of 6 months and exhibits 3 or more symptoms. This is what differentiates GAD from specific worry over a stressor occurring over a short period.

The patient is a 46-year-old white male. He is a welder at a local steel fabrication factory. He had visited the ED after complaining of chest pain, similar to what he said was like a heart attack. He said that he experienced a feeling of impending doom, shortness of breath, and chest tightness. He takes a low-sodium diet to treat his mild hypertension. He is overweight but has had an unremarkable medical history besides the tonsillectomy he had at 8 years old. His EKG is within the normal range, and Myocardial Infarction was ruled out. He states that he is still experiencing shortness of breath and chest pains and calls these anxiety attacks. He also says that he frequently wants to run away from what he fears to be impending doom. The patient says he takes 3-4 beers every night to counter his worries about work. He has trouble coping with the management at his workplace, and caring for his aged parents is also a challenge. He has never taken any psychotropic medication, and his HAM-A score is 26.

The Decision Steps for Diagnosing Generalized Anxiety Disorder

Decision Point 1 was to begin the patient on Zoloft (Sertraline) 50mg orally daily. Sertraline is used in the treatment of social phobia, social anxiety disorder, PTSD, OCD, panic attacks, and depression. The medication improves one’s mood, energy levels, and appetite and could help restore a person’s interest in daily activities. Additionally, the drug may decrease the number of panic attacks, unwanted thoughts, anxiety, and fear. Because it is an SSRI, the drug helps in restoring serotonin balance in the brain (Singh & Saadabadi, 2019).

I did not choose imipramine because it is a TCA and is only prescribed when other anti-depressants do not work. It was the first TCA to be marketed. In the last decades, the use of imipramine and other TCAs has continued to decline because of the introduction of SSRIs. SSRIs are preferred because of the fewer side effects and also because they are a safer option in case of overdose (Brown & Rosdolsky, 2015). I did not choose Buspirone as it belongs to the group of anti-anxiety drugs, Anxiolytics, and Nonbenzodiazepines. Buspar may cause serious side effects such as lightheadedness, shortness of breath, and chest pain. The patient complains of shortness of breath and chest pains, and prescribing Buspirone may exacerbate the symptoms (Howland, 2015). I was hoping to reduce the symptoms that the patient was experiencing, as described above. I was also hoping to completely eliminate anxious thoughts and panic attacks. After administering the drug, the patient reported he had no chest tightness, and the shortness of breath had ceased. He worries less about his work, and the HAM-A score is 18. The difference in the expected and achieved results may be due to the low dosage of the drug; therefore, I decided to increase the dosage.

Decision 2 was to increase the dose to 75mg daily. I was hoping to have better results by increasing the dosage. The patient showed signs of symptom improvement, so increasing the dose would be more effective. It is also safe to increase the dosage as Zoloft is not known to be addictive. The dosage may be increased by 25 mg at 1-week intervals, not to exceed 200 mg per day (Singh & Saadabadi, 2019). When the patient returned to the clinic after 4 weeks, he reported a reduction in the symptoms, and his HMA-A score had declined to 10. The current dose is continued following a 61 percent reduction in symptoms.

Decision 3 was to continue the patient on the current dose. The patient will be better able to cope with the stressors he had earlier experienced. Although increasing the drug dosage to 100mg may prove to be more effective, it predisposes the patient to major side effects (Singh & Saadabadi, 2019). At this point, augmentation will be introduced for better results. The patient will be introduced to psychotherapy and, more specifically, Cognitive Behavior Therapy. Evidence shows that psychotherapy is effective when used in combination with anti-depressants. Cognitive Behaviour Therapy is the most widely used anxiety disorders therapy (El Alaoui et al., 2015). CBT has been shown to be effective in the treatment of generalized anxiety disorders, social anxiety disorders, phobias, and panic disorders, among other conditions. CBT will help the patient change his negative thought patterns, improve his feelings, and better manage his problems.

How Administration of the Associated Pharmacotherapeutics May Impact the Patient’s Pathophysiology

According to the FDA (2008), the sertraline mechanism action is linked to the CNS inhibition of neuronal serotonin uptake (5HT). Sertraline blocks serotonin uptake in human platelets. After an oral dose taken once a day over 50mg-200mg over 14 days, the plasma peak concentrations occur 4.5-8.4 hours after dosing. The terminal half-life average for plasma sertraline is approximately 26 hours. Based on this parameter of pharmacokinetics, it should be possible to achieve the steady state of plasma level sertraline after approximately 7 days of daily (once) dosing. Consistent with the half-life terminal elimination, there is close to a two-times accumulation in comparison to a sertraline single dose with a repeated dosing over a dose range of 50mg-200mg. The bioavailability of a single dose of sertraline is approximately equal to a dose solution of equal measure FDA (2008).

How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples.

Based on the pharmacokinetics of the drug, it will prove to be effective when doses are increased at least 7 days after the initial dose. Doing so will increase the accumulation of the drug in the CNS two-fold, which means that the effects it has will last longer and be more impactful in the patient’s behavior. According to an FDA study (2008), patients were put on flexible use of Zoloft for 10 weeks. Based on patient responses, the initial dose was 25mg, which was increased to 50mg-100g. The results showed that symptoms reduced significantly as the weeks progressed. Hence, in this case, the patient will be put on Zoloft, and the dosage increased from 50mg to 75 mg to get the best outcomes with minimal to no side effects FDA (2008).

References

Brown, W. A., & Rosdolsky, M. (2015). The clinical discovery of imipramine. American Journal of Psychiatry, 172(5), 426-429.

FDA 2008). ZOLOFT® (sertraline hydrochloride) Tablets and Oral Concentrate. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019839s070,020990s032lbl.pdf

Howland, R. H. (2015). Buspirone: back to the future. Journal of psychosocial nursing and mental health services, 53(11), 21-24.

Singh, H. K., & Saadabadi, A. (2019). Sertraline. In StatPearls [Internet]. StatPearls Publishing.

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Generalized Anxiety Disorder

Post a brief explanation of the psychological disorder presented and the decision steps you applied in completing the interactive media piece for the psychological disorder you selected. Then, explain how the administration of the associated pharmacotherapeutics you recommended may impact the patient’s pathophysiology. How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples.

Generalized Anxiety Disorder

Generalized Anxiety Disorder

Middle-Aged White Male With Anxiety

BACKGROUND INFORMATION

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.

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 the 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

Generalized Anxiety Disorder

The client is alert, and oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. The 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 are readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.

You administers the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.

Diagnosis: Generalized anxiety disorder

RESOURCES

§ Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0