A Middle-Aged Caucasian Man with Anxiety
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A Middle-Aged Caucasian Man with Anxiety
Introduction
People who have generalized anxiety disorder (GAD) tend to worry uncontrollably about common situations or occurrences. Generalized anxiety disorder is different from normal feelings of anxiousness (Gerlach & Gloster, 2021). People who have GAD tend to worry a lot about their finances, work, relationships, and other things, several times a day. Generalized anxiety disorder is a relatively common disorder that affects approximately 3% of the U.S population. About 6.8 million Americans are affected by the disease. Women are twice as likely as men to be affected by the mental disorder. Although its exact cause is not known, evidence shows that biological factors, life experiences, and family background play an important role (Gerlach & Gloster, 2021). Symptoms of GAD include difficulty sleeping, reduced concentration, persistent worries, impeding feelings of threat, and others.
The case study is about a 46-year-old White male who was diagnosed with generalized anxiety disorder. The patient is a welder at a local steel fabrication factory. He was referred to the clinic by his PCP after he felt like having a heart attack (Hamilton, 1959). The patient stated that he experienced chest tightness, shortness of breath, and a feeling of impending doom. Although he has mild hypertension, he managed to control it by eating a low sodium diet. During the examination, the patient admits occasional use of ETOH to combat worries about work (Hamilton, 1959). Mental status examination revealed that the patient is alert and oriented to person, place, time, and event. In that regard, this paper discusses three decisions points (options) and some of the ethical issues that need to be considered during the treatment.
Decision Point One
Regarding decision point one, the therapist began Paxil 10 mg PO daily for four weeks. The therapist selected Paxil 10 mg because the drug is approved to be effective for the treatment of generalized anxiety disorder. Paxil is commonly used in GAD and other mental problems such as panic disorder, obsessive-compulsive disorder, post-traumatic disorder, and others (Shrestha et al., 2018). Paxil was the most appropriate option because of its effectiveness in the treatment of generalized anxiety disorder.
The other two options were Tofranil (Imipramine) and Buspirone. Tofranil (Imipramine) was not selected because Paxil seemed more effective than it. Additionally, it is mostly used in the treatment of major depressive disorders. Based on the therapist’s judgment, Paxil was the best. Paxil belongs to a group of medicines called Selective Serotonin Reuptake Inhibitors (SSRIs). It works by preventing the reuptake of serotonin by brain nerves (Shrestha et al., 2018). Paxil was also chosen over Buspirone because it was deemed the best. One advantage is that Paxil can be taken just once a day, unlike Buspirone.
The expectation is that the symptoms would resolve and the patient’s condition would improve. Symptoms associated with generalized anxiety disorder are expected to reduce on the HAM-A score to below 20. The patient’s worry and anxiety are expected to reduce significantly. Additionally, his sleep is expected to improve (Gerlach & Gloster, 2021). Tightness of the chest and shortness of breath should be resolved. The results after four weeks were positive since most of his symptoms were reduced. The patient noticed a reduction in chest tightness and shortness of breath. He also experienced a reduction in anxiety and worries (Hamilton, 1959). Some of the ethical considerations include the principles of beneficence and non-maleficence. The principle of beneficence requires that all decisions bring benefits to the patient (Montreuil et al., 2019). Additionally, the principle of non-maleficence requires that all decisions made do not harm the patient.
Decision Point Two
Increasing Paxil 10 mg PO daily to 20mg PO daily was deemed the best option at this stage. Paxil 10 mg PO daily resulted in a slight improvement of the symptoms, making the therapist increase the dose. Paxil seems to have a positive response, therefore, increasing the dose would lead to significant symptom improvement (Gerlach & Gloster, 2021). It is medically correct to increase the dose gradually until at least 50% of symptoms have been resolved. Additionally, Paxil doses range between 20 mg and 50 mg PO daily. Therefore, the dose is within acceptable limits.
Doses should be increased gradually to realize a positive result. Furthermore, Paxil should be increased by 10mg (from 10mg to 20mg). Increasing Paxil doses rapidly might lead to serious medication side effects, hence, putting the patient at risk (Shrestha et al., 2018). Paxil can have bad side effects including seizures, hypertension, and increased risk of bleeding, among others. Also, maintaining the dose at this point is not recommended because there was no significant symptoms improvement.
Shortness of breath and chest tightness is expected to resolve on increasing Paxil to 20mg. Other symptoms of generalized anxiety disorder such as excessive worry and anxiety should reduce. In four weeks, the patient should report improved sleep, concertation, and improved daily activities. The HAM-A score should read below 13, depicting 50% reduced symptoms. In four weeks, the patient returned to the clinic and the results matched the expectations. The patient reported further improvement of the symptoms (Hamilton, 1959). Additionally, there was a 61% reduction in symptoms. The HAM-A score was 10, indicating significant improvement. Important ethical considerations are patent education, autonomy, and consent (Montreuil et al., 2019). The patient was educated about the illness, impact on health, treatment options, and alternatives. The patient made his own decisions based on education.
Decision Point Three
Here, the therapist decided to maintain Paxil 20 mg PO daily (current dose). The patient reported significant improvement with the current dose, therefore, there was no need to change it. Maintaining the dose is more appropriate when significant symptom improvement is noticeable. In this particular case, the patient experienced a full response to the symptoms. Normally, 50% reduction in symptoms is considered full response, though not full recovery.
The other two decisions include increasing Paxil to 30 mg PO daily and adding augmentation agents such as buspirone. Increasing the dose to 30 mg would lead to serious side effects. Therefore, it was not selected as one of the most preferred options (Shrestha et al., 2018). Since the patient reported significant symptom improvement, there was no need to either change the medication or the dose. Also, there was no need to consider adding an augmentation agent at this point. Therefore, the best decision is to maintain the current dose.
The patient is expected to recover fully from the symptoms of generalized anxiety disorder. The worries and the anxiety are expected to resolve completely (Gerlach & Gloster, 2021). Additionally, the HAM-A score is expected to indicate full recovery, which is a 100% reduction of the symptoms. In four weeks, the patient’s sleep patterns are expected to improve significantly. The patient’s sleep pattern should return to normal. Some of the important ethical considerations include beneficence, autonomy, non-maleficence, justice, and patient education (Montreuil et al., 2019). Furthermore, a proper follow-up plan should be devised to ensure a full recovery.
Conclusion
Generalized anxiety disorder is associated with uncontrollably worrying and being anxious about common issues and situations. People who have GAD tend to worry a lot about their finances, work, relationships, and other things, several times a day. Although its exact cause is not known, evidence shows that biological factors, life experiences, and family background play an important role. The patient in the case study is a 46-year-old white male who was diagnosed with generalized anxiety disorder. The patient is a welder at a local steel fabrication factory. He was referred to the clinic by his PCP after he felt like having a heart attack. Various decisions were made in an attempt to help the patient recover.
The therapist began Paxil 10 mg PO daily for four weeks. The therapist selected Paxil 10 mg because the drug is approved to be effective for the treatment of generalized anxiety disorder. Increasing Paxil 10 mg PO daily to 20mg PO daily was deemed the best option at the second stage. At stage three, the therapist decided to maintain Paxil 20 mg PO daily (current dose). The patient reported significant improvement with the current dose, therefore, there was no need to change it. Some of the important ethical considerations include beneficence, autonomy, non-maleficence, justice, and patient education.
References
Gerlach, A., & Gloster, A. T. (2021). Generalized anxiety disorder and worrying: A comprehensive handbook for clinicians and researchers. Hoboken, NJ Chichester Wiley Blackwell.
Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0
Montreuil, M., Martineau, J. T., & Racine, E. (2019). Exploring ethical issues related to patient engagement in healthcare: Patient, clinician and researcher’s perspectives. Journal of bioethical inquiry, 16(2), 237-248. https://doi.org/10.1007/s11673-019-09904-6
Shrestha, P., Fariba, K., & Abdijadid, S. (2018). Paroxetine. https://europepmc.org/article/NBK/nbk526022