Case Study: Assessing and Treating Patients with Generalized Anxiety Disorder Assignment Paper

Case Study: Assessing and Treating Patients with Generalized Anxiety Disorder Assignment Paper

Case Study: Assessing and Treating Patients with Generalized Anxiety Disorder Assignment Paper

Generalized anxiety disorder falls under a larger group of Anxiety disorders whose hallmark is anxiety, uncurbed fear, worry, and accompanying behavioral distractions and perturbations (American Psychiatric Association, 2013). These disorders most times present with somatic symptoms. GAD is a major predisposing factor for suicide and cardiovascular diseases (DeMartini et al., 2019). Therefore, he purpose of this paper is to discuss the decision points in the management of GAD focusing on the choice of drug, the projection after initiation of therapy, and the ethical considerations that govern the process.

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Case Summary

This week’s case study focuses on a 46-year-old male Caucasian. He works as a manual laborer in a steel fabrication company in the position of a welder. He is a referral from his primary care physician after an episode where he felt like he was having a heart attack. He reported having had dyspnea, chest tightness, and a premonition of doom. He has mild hypertension being managed through the application of lifestyle modification of cutting down sodium intake. He is overweight. He has a history of tonsillectomy which was done at the age of 8 years. Physical examination in the emergency area was normal with a normal EKG. He has apprehensive expectations which make him feel like fleeing from where he is. He takes 3-4 bottles of beer every night to allay worries about his work. He points out ruthless management at his workplace and has constant fears of losing his job. He is single but lives with his parents at his home and takes care of them. He has a HAM-A score of 26. He has never been on treatment for any mental illness. His Mental State Exam reveals that he is properly oriented to the domains of time, place, and person. His speech is normal. He subjectively describes his mood as not good, disgusted, and irritated. He affirms being anxious. His affect is broad and blunted. He has a coherent and logical thought process and no suicidal thoughts. He has no perception disturbance and his judgment and insight are intact. His diagnosis is Generalized Anxiety Disorder as evidenced by his excessive worry and the presence of somatic symptoms like shortness of breath and chest pain in the absence of an actual physical condition. Preti et al., (2021) report the prevalence of GAD at 2.3% in the adult populace with a stronger female predilection. Psychotherapy and pharmacotherapy are the main treatment modalities employed. Decision-making in the management of GAD is dependent on the presence of an underlying physical or mental illness (Ströhle et al., 2018). The patient’s age, the presence of co-morbidities, and history of previous treatment are crucial in decision-making in the treatment of GAD (Strawn et al., 2018).

Decision 1

Begin Paxil 10mg orally daily

Reason for Selection

According to Strawn et al., (2018) Selective Serotonin and Selective Norepinephrine Uptake Inhibitors (SSRIs and SNRIs) are the first-line drugs in the management of GAD. Initiation of Paxil 10mg per oral daily is the best course. A randomized, double-blind, placebo-controlled study by Usmani et al., (2018) revealed that paroxetine was highly efficacious in abating symptoms of anxiety from week one of therapy, improvement in social relationships by week four, and maximal response or remission occurring by the eighth week.

The use of Tricyclic antidepressants like imipramine is reserved for situations where there are multiple failures of the denoted first-line drugs (Strawn et al., 2018). The use of TCA drugs has continued to constrict due to their undesirable side effects such as anticholinergic effects, weight gain, and fatality in the event of an overdose (Garakani et al., 2020). Buspirone on the other hand has a lower efficacy when compared to SSRIs and SNRIs.

Expectation

There is an expected significant response to the treatment evidenced by the reduction in anxiety symptoms and reduction in the scale of anxiety. By week 8, the HAM-A score should have markedly improved. The inclusion of psychotherapy is a crucial aspect in precipitating improvement (Ströhle et al., 2018). Cognitive behavioral therapy is the mainstay.

Ethical Considerations

The ethical considerations revolve around autonomy, beneficence, and justice. These are ensured by offering the patient the best available options to adequately manage his illness. Autonomy allows the patient to be directly involved in the care process and be able to offer informed consent for treatment. The patient despite having a mental illness is in a state where he can still decide what is best for him in terms of management when offered the options.

Decision 2

Increase the dose of Paxil to 20mg PO daily

Reason for Selection

Li et al., (2022) mention a comparison in the efficacy of two different dosages of Paxil; 20mg and 40mg daily dosages, at 8 weeks, there was a greater response achieved in the higher dose compared to the lower dosage. There was also a greater remission rate with the higher dose of Paxil. Increasing the dose of Paxil would yield a much better response. A gradual increase in the dosage is recommended.

A sudden increase in the dosage of SSRIs such as Paxil is a precipitating factor for the development of Serotonin Syndrome which can be fatal (Scotton et al., 2019). Increasing the dosage to 40mg daily dose is overly ambitious and could lead to a detriment marked with altered mentation, sympathetic and parasympathetic system dysfunction, and neuromuscular dysfunction. No change in drug or dose denotes delayed response to therapy and a possible dropping out of the treatment by the patient as no change is perceived.

Expectations

Due to an increase in the dose of Paxil, there is expected improvement of anxiety symptoms by the first week, improvement in the patient’s social patterns by the fourth week, and remission by week eight of therapy. This would be a result of a consequent increase in the plasma concentration of Paxil. Side effects of Paxil also increase as dosage increases. There is an expected increase in the side effects which would be managed accordingly.

Ethical Considerations.

Patient education is an essential tenet of the management of both mental and physical disorders as it provides relevant clinical information (Fereidouni et al., 2019). It lays a foundation for the involvement of patients in their care and further builds on informed consent to the change of drug or education on the change of dosage. In light of providing quality care, counseling is crucial.  A warm patient-doctor relationship is critical to lay the ground for subsequent follow-up.

Decision 3

Discontinue Paxil and begin Celexa at 20mg orally daily.

Reason for Selection

Paxil is associated with side effects like diarrhea, nausea, sexual dysfunction, hypertension, and vomiting (Ramic et al., 2020). These symptoms can be severe that could interfere with adherence and cause defaulting of medication. To prevent such a scenario, it is to discontinue Paxil and start the patient on another medication. Reducing the dose will be another plausible option but it is likely to be subtherapeutic. Replacement of Paxil with another SSRI such as Celexa is the most plausible option as Celexa has a slightly different side effect profile from Paxil. Aakjær et al., (2022) in a population-based cohort study notes that there is no aspect where Lexapro is superior to Celexa as earlier postulated as they both nearly have the same side effect profile. The efficacy of both of these drugs is fairly even with an almost similar safety profile. The introduction of another drug to treat the side effects of Paxil introduces the subject of polypharmacy which may consequently precipitate non-adherence.

Expectations

With the discontinuation of Paxil and initiation of Celexa, there is an expected reduction in diarrhea and vomiting. Celexa is also fairly efficacious in the management of anxiety. It is expected that the patient will stay in remission and improve significantly in social functioning with a marked reduction in anxiety and apprehensiveness.

Ethical Considerations

Major medico-legal considerations are examined when a patient is to use a drug with undesired side effects. Informed consent and proper patient education are key. The patient still ought to be educated on the expected side effects and a proper layout of a follow-up plan.

Conclusion

GAD is a common mental illness characterized by constant worry and apprehension about the future. This case study presents a classic example of GAD. It involves a 46-years-old male who is nervous. The precipitating factor for his illness is likely being single. SSRIs and SNRIs are the recommended first-line therapy for GAD. This informs the decision on Paxil 10mg PO daily. Paxil, as discussed earlier, is highly efficacious in reducing anxiety symptoms and absolute improvements can be seen in the eighth week. Several studies however agree that there should be a comparison of the efficacies and safety profiles of the drugs within the SSRI class as there is no evidence of such. Imipramine and buspirone can also be used in the management of GAD. They are however not the first line of therapy. Their efficacy profile in GAD is much lower than that of Paxil.

 The prescription of psychotropic drugs aims at administering the lowest effective dose. If there is no adequate pharmacotherapeutic response, the doses can be gradually increased for the desired effect. Higher doses are frequently marred with more pronounced side effects as experienced in this case study. Intolerable side effects often precipitate default in medication. In such instances, it is best to discontinue the drug and initiate an alternative. This prompted the discontinuation of Paxil and its replacement with Celexa. The drug choice and dosage are based on the age of the patient, underlying illnesses, and history of previous treatment for the same condition. Patient education, informed consent, and provision of the best available care are crucial.

References

Aakjær, M., Werther, S. K., De Bruin, M. L., & Andersen, M. (2022). Serious arrhythmia in initiators of citalopram, escitalopram, and other selective serotonin reuptake inhibitors: A population‐based cohort study in older adults. Clinical and Translational Science, 15(9), 2105–2115. https://doi.org/10.1111/cts.13319

Guha, M. (2014). Diagnostic and statistical manual of mental disorders: DSM-5. Reference Reviews. https://doi.org/10.1108/rr-10-2013-0256

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of Internal Medicine, 170(7), ITC49. https://doi.org/10.7326/aitc201904020

Fereidouni, Z., Sabet Sarvestani, R., Hariri, G., Kuhpaye, S. A., Amirkhani, M., & Kalyani, M. N. (2019). Moving into action: The master key to patient education: The master key to patient education. The Journal of Nursing Research: JNR, 27(1), 1–8. https://doi.org/10.1097/jnr.0000000000000280

Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. Frontiers in Psychiatry, 11(595584). https://doi.org/10.3389/fpsyt.2020.595584

Li, Q., Zhang, H., Lin, G., Shi, S., Zhang, Y., Ji, J., Yang, L., Yao, J., & Wu, W. (2022). Relative Safety and Efficacy of Two Doses of Tandospirone Citrate for Generalized Anxiety Disorder: A Multicenter Randomized Controlled Trial. Neuropsychiatric Disease and Treatment, 18, 1653–1664. https://doi.org/10.2147/NDT.S366048

Preti, A., Demontis, R., Cossu, G., Kalcev, G., Cabras, F., Moro, M. F., Romano, F., Balestrieri, M., Caraci, F., Dell’Osso, L., Di Sciascio, G., Drago, F., Hardoy, M. C., Roncone, R., Faravelli, C., Gonzalez, C. I. A., Angermayer, M., & Carta, M. G. (2021). The lifetime prevalence and impact of generalized anxiety disorders in an epidemiologic Italian National Survey carried out by clinicians by means of semi-structured interviews. BMC Psychiatry, 21(1). https://doi.org/10.1186/s12888-021-03042-3

Ramic, E., Prasko, S., Gavran, L., & Spahic, E. (2020). Assessment of the Antidepressant Side Effects Occurrence in Patients Treated in Primary Care. Materia Socio Medica, 32(2), 131. https://doi.org/10.5455/msm.2020.32.131-134

Scotton, W. J., Hill, L. J., Williams, A. C., & Barnes, N. M. (2019). Serotonin Syndrome: Pathophysiology, Clinical Features, Management, and Potential Future Directions. International Journal of Tryptophan Research, 12(12), 117864691987392. https://doi.org/10.1177/1178646919873925

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. https://doi.org/10.1080/14656566.2018.1491966

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The Diagnosis and Treatment of Anxiety Disorders. Deutsches Aerzteblatt Online, 115(37). https://doi.org/10.3238/arztebl.2018.0611

Usmani, Z. A., Carson-Chahhoud, K., Esterman, A., & Smith, B. (2018). A randomized placebo-controlled trial of paroxetine for the management of anxiety in chronic obstructive pulmonary disease (PAC Study). Journal of Multidisciplinary Healthcare, Volume 11, 287–293. https://doi.org/10.2147/jmdh.s166022

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Common symptoms of anxiety disorders include chest pains, shortness of breath, and other physical symptoms that may be mistaken for a heart attack or other physical ailment. These manifestations often prompt patients to seek care from their primary care providers or emergency departments. Once it is determined that there is no organic basis for these symptoms, patients are typically referred to a psychiatric mental health practitioner for anxiolytic therapy. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with anxiety disorders.

The Assignment: 5 pages
Examine Case Study (REFER TO FILE “CASE STUDY”). You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

* At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

OUTLINE
– Introduction to the case (1 page) // REFER TO FILE “CASE STUDY”
–> 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) // REFER TO FILE “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) // REFER TO FILE “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) // REFER TO FILE “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 recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.