Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

Case Study: A Middle-Aged Caucasian Man with Anxiety

            Generalized anxiety disorder (GAD) is one of the most common mental health disorders, starting in teenage or early adulthood and progressing throughout life. GAD is diagnosed in approximately 20% of the adult population annually (de Vries et al., 2018). This mental disorder is accompanied by excessive worry, fear, a constant feeling of being overwhelmed, restlessness, lack of concentration, and irritability. People diagnosed with GAD report persistent and unrealistic worry about various things (de Vries et al., 2018). For this reason, GAD compromises one’s functioning capacity, productivity, quality of life, and overall well-being. The case study is about a 46yo Caucasian male who presented to the clinic with anxiety symptoms and other clinical manifestations. His primary care provider (PCP) referred him to a psychiatrist after reporting a heart attack incident. The client reported heart attack symptoms, including chest tightness and shortness of breath. Additionally, he revealed experiencing a feeling of impending doom. The client also reported a history of chronic illnesses, including mild hypertension and overweight. He further added that his tonsils were removed at eight years of age. However, his medical history has been unremarkable since that time. His PCP performed ER and EKG, and the results of both procedures ruled out myocardial infarction. The client describes shortness of breath and chest tightness as “anxiety attacks.” He further reveals occasional impending doom, which makes him feel like “running” or “escaping” from his condition. While at the psychiatrist’s office, the client reports occasional use of ETOH to curb his worries about work. He also reports taking about 3 to 4 beers every night but denies using any psychotropic medication. He reports that he fears losing his employment since the management is harsh. Upon administering the HAM-A, the client scored 26, indicating generalized anxiety disorder. This paper covers the three most appropriate pharmacological interventions for treating GAD in this client. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

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Decision One

The client’s first treatment option involves beginning Paxil 10mg PO daily. This decision is preferred since Paxil is an antidepressant, effective and safe in treating anxiety symptoms in adults. According to de Vries et al. (2018), antidepressants are an effective treatment for adults’ anxiety disorders. Therefore, beginning Paxil 10mg PO daily is the best first treatment option.

The PMHNP dismissed other potential interventions for treating GAD in adults, including beginning Imipramine 25 mg PO BID and beginning Buspirone 10 mg PO BID. First, Imipramine is a tricyclic antidepressant associated with adverse drug effects involving the cardiovascular system, including myocardial depression and cardiac conduction disturbances. Therefore, Imipramine is not recommendable for treating anxiety symptoms in this client due to the reported heart attack symptoms, including chest tightness and shortness of breath. Administering Imipramine to this client would result in cardiovascular disease and increase heart failure risk. Additionally, Buspirone was rejected since it is a benzodiazepine anxiolytic, which increases abuse and dependence risks following long-term use (Tjiong et al., 2018). Thus, beginning Imipramine 25 mg PO BID and starting Buspirone 10 mg PO BID are inappropriate for treating GAD symptoms in this client. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

Beginning Paxil 10mg PO daily was expected to improve anxiety symptoms. According to de Vries et al. (2018), Paxil is an antidepressant which is an effective and safe treatment for anxiety symptoms in adults. The client returned to the clinic after four weeks and reported that he was no longer experiencing shortness of breath or tightness in the chest. He further reported decreased work-related worries over 4 or 5 days ago. Additionally, the HAM-A score had reduced to 18, indicating a partial response.

The treatment plan was impacted by the ethical principles of beneficence and nonmaleficence. The psychiatrists aimed to benefit the client through recommended treatment intervention. Additionally, he prevented the client from potential harm associated with dismissed options.

Decision Two

The second decision was to increase the current dosage to Paxil 20mg. This option was selected following the outcomes of the first decision, Paxil 10mg. After taking this dosage for four weeks, the client denied experiencing shortness of breath or tightness in the chest. He further reported decreased work-related worries over 4 or 5 days ago. Additionally, the HAM-A score had reduced to 18. These results indicated partial response, implying that Paxil is effective and safe for treating anxiety symptoms in this client. Hence, increasing the dosage to Paxil 20mg would further improve anxiety symptoms and decrease the HAM-A score. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

The PMHNP rejected other potential decisions, including increasing Paxil dose to 40 mg orally daily and making no change in drug/dose at this time. Increasing the Paxil dose to 40 mg orally daily was rejected due to potential side effects. According to Coupland et al. (2018), the risk of drug-related side effects in tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) increases with dosage. Thus, increasing the dosage to Paxil 40mg would expose the client to drug-related side effects. Additionally, maintaining the current dosage would not significantly improve anxiety symptoms since the client only reported partial improvement after taking Paxil 10mg for four weeks.

Increasing the current dosage to Paxil 20mg was expected to improve anxiety symptoms further. According to Strawn et al. (2020), the efficacy of antidepressants in managing anxiety symptoms increases with dosage since they are dose-dependent. The client reported a further decrease in the HAM-A score to 10, representing a 61% decline in the reported symptoms.

The psychiatrist considered the ethical principle of beneficence in developing this treatment plan. This ethical guideline requires PMHNPs to focus on benefiting their patients (Bipeta, 2019). The psychiatrist helped the client through the provided treatment. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

Decision Three

This treatment decision involves maintaining the current dose. This option was selected following its efficacy in improving the client’s symptoms. During the eight-week clinic visit, the client’s HAM-A score had decreased to 10, representing a 61% decline in the reported symptoms. Additionally, the client did not report any drug-related side effects, indicating that the current drug and dosage were highly tolerated. Therefore, continuing with Paxil 20mg for the next four weeks would further improve the client’s symptoms.

The PMHNP rejected other potential options, including increasing to 30mg and adding an augmentation agent such as Buspar. The client’s HAM-A score had decreased to 10 (61% decline in the reported symptoms) after using the current dosage of Paxil 20mg daily for four weeks. Therefore, no increase in the current dosage or adding an augmentation was needed. Additionally, increasing Paxil to 30mg would expose the client to potential drug-related adverse effects. According to Coupland et al. (2018), the risk of drug-related side effects in tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) increases with dosage. Similarly, adding an augmentation would raise the risk of side effects. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

Upon returning to the clinic after four weeks, the client was expected to report further improvement if anxiety symptoms. According to Strawn et al. (2020), higher dosages of antidepressants are more effective in improving anxiety symptoms in adults diagnosed with GAD. Thus, the client’s HAM-A score would have been reduced to zero, indicating total remittance in anxiety symptoms.

The PMHNP adhered to the ethical principle of confidentiality and non-disclosure, which prohibits disclosing one’s health-related information to unauthorized individuals. Therefore, the PMHNP should not disclose the client’s medical details to third parties without obtaining his consent. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

Conclusion

Three pharmacological decisions are recommended in treating anxiety symptoms in this client. The client’s first treatment option involves beginning Paxil 10mg PO daily. This decision is preferred since Paxil is an antidepressant, effective and safe in treating anxiety symptoms in adults. The PMHNP dismissed other potential interventions for treating GAD in adults, including beginning Imipramine 25 mg PO BID and beginning Buspirone 10 mg PO BID. First, Imipramine is a tricyclic antidepressant associated with adverse drug effects. Buspirone was rejected since it is a benzodiazepine anxiolytic, which increases abuse and dependence risks following long-term use. Beginning Paxil 10mg PO daily was expected to improve anxiety symptoms. The second decision was to increase the current dosage to Paxil 20mg. This option was selected following the outcomes of the first decision, Paxil 10mg. The PMHNP rejected other potential choices, including increasing the Paxil dose to 40 mg orally daily and making no change in drug/dose at this time. Increasing the Paxil dose to 40 mg orally daily was rejected due to potential side effects. Additionally, maintaining the current dosage would not result in significant improvement in anxiety symptoms since the client only reported partial improvement after taking Paxil 10mg for four weeks. This treatment decision involves maintaining the current dose. This option was selected following its efficacy in improving the client’s symptoms. The PMHNP rejected other potential options, including increasing to 30mg and adding an augmentation agent such as Buspar. The client’s HAM-A score had decreased to 10 (61% decline in the reported symptoms) after using the current dosage of Paxil 20mg daily for four weeks. Therefore, no increase in the current dosage or adding an augmentation were needed. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

References

Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian journal of psychological medicine, 41(2), 108-112. Doi: 10.4103/IJPSYM.IJPSYM_59_19.

Coupland, C., Hill, T., Morriss, R., Moore, M., Arthur, A., & Hippisley-Cox, J. (2018). Antidepressant use and risk of adverse outcomes in people aged 20–64 years: cohort study using a primary care database. BMC medicine, 16(1), 1-24. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1022-x

de Vries, Y. A., Roest, A. M., Burgerhof, J. G., & de Jonge, P. (2018). Initial severity and antidepressant efficacy for anxiety disorders, obsessive‐compulsive disorder, and posttraumatic stress disorder: An individual patient data meta‐analysis. Depression and anxiety, 35(6), 515-522. Doi: 10.1002/da.22737

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 pharmacotherapy, 19(10), 1057-1070. Doi: 10.1080/14656566.2018.1491966.

Tjiong, E. B., Buwalda, V. J., & De Weert-van Oene, G. H. (2020). Patients with benzodiazepine dependence in substance dependence treatment: baseline characteristics and comorbidities. Addiction Research & Theory, 28(2), 124-131. https://doi.org/10.1080/16066359.2019.1596260

Ungvari, Z., Tarantini, S., Yabluchanskiy, A., & Csiszar, A. (2019). Potential adverse cardiovascular effects of treatment with fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) in patients with geriatric depression: implications for atherogenesis and cerebromicrovascular dysregulation. Frontiers in Genetics, 10, 898. https://doi.org/10.3389/fgene.2019.00898. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

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 feeling of impending doom. He does have some mild hypertension (which is treated with 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. Remainder of physical exam was WNL. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

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.

Client has never been on any type of psychotropic medication. Generalized Anxiety Disorder in Adult And Paediatric Patients Essay

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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 Generalized Anxiety Disorder in Adult And Paediatric Patients Essay