Assignment: Assessing and Treating Patients with Anxiety Disorders
Assignment: Assessing and Treating Patients with Anxiety Disorders
Generalized Anxiety Disorder (GAD) is a type of anxiety disorder that presents with chronic anxiety, excessive worry, and tension. The constant worry and tension are often accompanied by physical symptoms, like feeling on edge, restlessness, easy fatigue, difficulty concentrating, muscle tension, and sleeping difficulties (Bandelow et al., 2022). The purpose of this assignment is to discuss the treatment for a patient with an Anxiety disorder.
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Summary of the Case
The case study portrays a 46-year-old white man who previously presented to the ER because he felt like he had a heart attack. He had experienced dyspnea, chest tightness, and a feeling of impending doom. The client has a history of mild hypertension, usually managed with a low-sodium diet, and is overweight. During the ER visit, his EKG was normal, ruling out myocardial infarction and his physical exam was normal. The patient reports still experiencing chest tightness and dyspnea, which he calls anxiety attacks. He also experiences intermittent feelings of impending doom and a need to escape. The client says he occasionally takes alcohol to ease worries about work and currently takes 3-4 beers every night. He has never been on any psychotropic drugs.
The PMHNP administers the HAM-A, of which the client scores 26. On MSE, the patient reports feeling nervous, and his affect is fairly blunted. He is diagnosed with Generalized anxiety disorder. Factors that should be taken into account when prescribing treatment for patients with anxiety disorders include age, co-morbidities, the severity of GAD, drug cost effectiveness, tolerability, safety, and prior treatment (Strawn et al., 2018). Therefore the PMHNP must consider the patient’s age, drug safety and tolerability, and co-morbidities like hypertension and overweight when selecting drug therapy.
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Decision #1
Begin Paxil 10 mg orally daily
Why I Selected This Decision
Paxil was selected because it is an FDA-approved drug for treating GAD in adults. Strawn et al. (2018) explain that Paxil potently hinders serotonin reuptake and norepinephrine reuptake. According to Koen & Stein (2022), there is concrete evidence supporting the efficacy and tolerability of Paxil in the short and long-term management of GAD.
Why I Did Not Select the Other Options
Imipramine was not selected because of its associated anticholinergic effects, like dry mouth, sedation, and constipation, which can affect medication adherence and is usually more effective in alleviating psychic symptoms (Strawn et al., 2018). Bandelow et al. (2022) found that Buspirone has neither shown superiority to placebo nor equivalence to standard anxiolytics drugs. It is less efficacious than other drugs like SSRIs and benzodiazepines, making Buspirone a less ideal drug for this client.
What I Was Hoping To Achieve
I hoped prescribing Paxil would alleviate the patient’s anxiety symptoms by about 50% within four weeks of starting therapy. This is because paroxetine is efficacious and well-tolerated in the treatment of GAD. According to Kowalska et al. (2021), paroxetine’s clinical efficacy can be compared with TCAs, but it is safer and more tolerated by patients.
Ethical Considerations Impact on the Treatment Plan and Communication
Ethical considerations of beneficence may impact the treatment plan since, in this case, the PMHNP had to select the drug associated with the best outcomes and least side effects. Besides, autonomy may impact communication since the clinician must seek informed consent before initiating treatment.
Decision #2
Increase the Paxil dose to 20 mg orally daily.
Why I Selected This Decision
The client had achieved a partial response with the initial dose, and it was essential to increase the dose to 20 mg to improve his response. SSRIs like Paxil have a delayed onset of action and must be increased continuously to achieve the desired treatment results (Kowalska et al., 2021).
Why I Did Not Select the Other Options
Increasing Paxil to 40 mg was not ideal because a high dose increase is associated with dose-dependent adverse events like nausea, dizziness, dry mouth, insomnia, somnolence, constipation, headache, sweating, yawning, tremor, anorexia, reduced appetite, and sexual problems (Li et al., 2020). Maintaining the dose at this time was also not appropriate since the patient had not attained a complete remission of GAD symptoms. Although SSRIs are initiated at lower doses, higher doses are usually needed to attain a considerable clinical response (Koen & Stein, 2022).
What I Was Hoping To Achieve
By increasing the Paxil dose from 10 to 20 mg, the PMHNP hoped that the patient would attain a complete response after four weeks. Li et al. (2020) found that Paxil effectively alleviated anxiety symptoms of fear and improved social participation. Regarding tolerability and acceptance, Paxil was found to be generally well-tolerated.
Ethical Considerations Impact on the Treatment Plan and Communication
Nonmaleficence may influence the treatment plan since the clinician must assess the drug’s associated side effects and change medication or lower doses if adverse effects are reported. Confidentiality may influence communication since the clinician is expected to assure the client that the confidentiality of his medical information will be upheld and information will not be shared without his consent.
Decision #3
Maintain the current dose.
Why I Selected This Decision
The client had attained a 61% reduction in GAD symptoms, and the HAM-A score had decreased to 10. Therefore, it was ideal to maintain the current dose since the client had achieved an adequate clinical response with a 20 mg dose (Koen & Stein, 2022). The dose is adequate to facilitate the patient’s full remission of GAD symptoms.
Why I Did Not Select the Other Options
Increasing the dose to 30 mg was not selected because the client had achieved an adequate clinical response with a 20 mg dose. Li et al. (2020) explain that higher SSRI doses increase the chances of dose-dependent side effects, which may lower the patient’s medication adherence. Augmenting with Buspirone was not ideal since augmentation is recommended in persons who fail to achieve an adequate clinical response with the initial medication (Strawn et al., 2018).
What I Was Hoping To Achieve
I hoped that maintaining the dose would continue improving GAD symptoms up to full remission after 4-6 weeks. Strawn et al. (2018) explain that SSRIs like Paxil have flexibility in dosing, which promotes considerable improvement in GAD symptoms.
Ethical Considerations Impact on the Treatment Plan and Communication
Autonomy may influence the treatment plan since the clinician has to involve the patient in making treatment decisions and respect the patient’s decisions when making the treatment plan. Besides, the PMHNP has to uphold the confidentiality of the patient’s medical information, which may impact communication with the patient.
Conclusion
The patient in the case study was diagnosed with GAD due to positive anxiety symptoms accompanied by dyspnea, chest tightness, and a feeling of impending doom. The patient’s factors that should be considered in developing the treatment plan include his age and current co-morbidities. The first treatment decision was initiating the client on Paxil 10 mg, which potently hinders serotonin reuptake and norepinephrine (Strawn et al., 2018). Imipramine was not ideal because of its associated anticholinergic effects, which often affect medication adherence and are preferred for alleviating psychic symptoms (Strawn et al., 2018). Buspirone was not also selected because it is less efficacious than other drugs like SSRIs and benzodiazepines (Bandelow et al., 2022).
The Paxil 10 mg led to a partial response, leading to the PMHNP increasing the dose to 20 mg to achieve a better clinical response. The increased dose led to a remission of 61% of the patient’s GAD symptoms. Consequently, the dose was maintained since increasing the dose further would have increased the risk of dose-dependent side effects. Furthermore, since the client had attained a satisfactory clinical response with Paxil 20 mg, it was inappropriate to augment with Buspirone.
References
Bandelow, B., Michaelis, S., & Wedekind, D. (2022). Treatment of anxiety disorders. Dialogues in clinical neuroscience. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow
Kowalska, M., Nowaczyk, J., Fijałkowski, Ł., & Nowaczyk, A. (2021). Paroxetine-Overview of the Molecular Mechanisms of Action. International journal of molecular sciences, 22(4), 1662. https://doi.org/10.3390/ijms22041662
Koen, N., & Stein, D. J. (2022). Pharmacotherapy of anxiety disorders: a critical review. Dialogues in clinical neuroscience. https://doi.org/10.31887/DCNS.2011.13.4/nkoen
Li, X., Hou, Y., Su, Y., Liu, H., Zhang, B., & Fang, S. (2020). Efficacy and tolerability of paroxetine in adults with social anxiety disorder: A meta-analysis of randomized controlled trials. Medicine, 99(14), e19573. https://doi.org/10.1097/MD.0000000000019573
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