A Middle-Aged Caucasian Man with Anxiety
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A Middle-Aged Caucasian Man with Anxiety
Introduction
It is normal to be anxious from time to time, especially when life is stressful. However, excessive ongoing anxiety and worry might hurt the individual’s life. Generalized anxiety disorder (GAD) is associated with excessive and exacerbated anxiety and worry about daily life events for no obvious reasons (DeMartini et al., 2019). Patients with generalized anxiety disorder often tend to have the fear of a disaster. Such individuals are ever worried about money, family, health, school, or work. GAD affects how one thinks and may also lead to physical symptoms. Some of the symptoms include persistent worrying or anxiety about certain things, perceiving situations and events as threatening, difficulty handling uncertainties, and trouble sleeping (DeMartini et al., 2019). Patients may also develop reduced concentration, a feeling of restlessness, indecisiveness, and fear of making wrong decisions, and others.
The patient is a 46-year-old white male. He presented at the hospital after being referred by his PCP after a trip to the emergency room. The patient complained of chest tightness, shortness of breath, and a feeling of impending doom. The patient’s history indicates that he has some mild hypertension, which he managed using a low sodium diet (Robichaud et al., 2019). Additionally, the patient is overweight and his tonsils were removed when he was 8 years old. The patient accepts occasional use of ETOH to combat worries about work. The patient is alert and oriented to person, place, time, and event. His speech is clear, coherent, and goal-oriented. The Hamilton Anxiety Rating Scale (HAM-A) had a score of 26 (Hamilton, 1959). The patient was diagnosed with generalized anxiety disorder. This paper used the presented case study to discuss decision points one to three, including possible ethical concerns.
Decision Point One
The selected decision point one is to Begin Paxil 10 mg PO daily. Paxil was chosen because it is widely used to treat generalized anxiety disorders. It is also approved for treating symptoms of other mental illnesses such as obsessive-compulsive disorder (OCD), panic disorder, social phobia, post-traumatic stress disorder, and others (Robichaud et al., 2019). Paxil works by balancing the level of serotonin by preventing them from being absorbed quickly by the brain cells (neurons). Paxil is approved to be effective in treating generalized anxiety disorder and symptoms of anxiety (Hahn, 2019). Therefore, Paxil was one of the best decisions for this patient.
Although the other two options could help to some extent, they were not selected for some reasons. For example, Tofranil (Imipramine) was not selected because it is majorly used to treat depression. Tofranil belongs to a class of drugs called Antidepressants, TCAs (Hahn, 2019). It is associated with detrimental side effects such as suicidal thoughts, blurred vision, eye swelling or pain, hostility, seizures, and others. Additionally, Buspirone was a good alternative since, compared to Buspirone, Paxil is more convenient to take because it can be taken just once a day (Hahn, 2019). These drugs although have a slight difference in how they work, they both affect the neurotransmitter serotonin.
With Paxil 10 mg PO daily, the expected results included improvement in the symptoms of generalized anxiety disorder. For example, tightness of chest tightness and shortness of breath are expected to reduce (DeMartini et al., 2019). Worries and anxiety symptoms are expected to reduce alongside any other related symptoms. HAM-A score was expected to reduce by 50% (Hamilton, 1959). The actual result matched most of the expected results. The patient reported a reduction in chest tightness and shortness of breath. He also reported reduced worries and the HAM-A score reduced to 18. Ethical considerations include patient education, patient autonomy, beneficence, and non-maleficence. The patient must be educated about the illness and possible treatment options and allowed to make his own decisions (Robichaud et al., 2019). The decisions made must be harmless and beneficial to the patient.
Decision Point Two
The selected decision point two is to increase the dose (Paxil 10 mg PO daily) to 20 mg PO daily. This decision was selected because the patient showed slight improvement from the previous dose. It is appropriate to increase the Paxil dose when the patient shows an improvement (Hahn, 2019). Normally, the starting and recommended dosage in patients with GAD is 20 mg daily. In clinical trials, the effectiveness of PAXIL in GAD was demonstrated in patients dosed in a range of 20 mg to 50 mg daily. Therefore, this decision was the best.
Increasing the dose to 40mg was not selected because it would result in serious side effects. Dose increment should happen in bits (Hahn, 2019). Rapid dose increment is not recommended because it might result in bad side effects. Some of the side effects associated with Paxil include hypersensitive adverse reactions, suicidal thoughts, serotonin syndrome, increased risk of bleeding, and others (DeMartini et al., 2019). Additionally, the dose could not be maintained at this point because the drug resulted in just a slight improvement.
The therapist expects that, the shortness of breath and tightness of the chest will resolve completely and that no symptoms will recur. Additionally, all other symptoms associated with a generalized anxiety disorder will resolve by 50% (DeMartini et al., 2019). The patient’s sleep pattern is expected to improve. The HAM-A score is expected to decrease to below 13 (Hamilton, 1959). The expected results matched the actual results. When the client returned to the clinic in four weeks, he reported even further improvement of his symptoms. The HAM-A score was 10, which is a 61% reduction in symptoms. During the treatment, the patient received education about every decision made (Robichaud et al., 2019). He was allowed to decide without external influence, this is the principle of autonomy.
Decision Point Three
The selected decision point three is to maintain the current dose (Paxil 20 mg PO daily). This decision was selected because the current dose showed significant symptoms improvement (DeMartini et al., 2019). The patient is having a full response as shown by more than 50% reduction in symptoms. It is recommended that the dose be maintained when it resulted in significant improvement of the symptoms.
Increasing the current dose (Paxil 20 mg PO daily) to 30 mg was not selected because it was not appropriate. There is no apparent reason for increasing the dose to 30mg. Furthermore, such a decision could result in serious side effects that might put the patient’s health at risk (DeMartini et al., 2019). There was no need for an augmentation agent. Nothing in the patient’s case tells the therapist to consider adding an augmentation agent at this point. It is important to avoid poly-pharmacy.
It is expected that in four weeks, the patient will recover fully from the symptoms. All symptoms related to worry and anxiety will resolve completely. Additionally, the sleep patterns of the patient are expected to improve (Robichaud et al., 2019). The HAM-A score results are expected is expected to record below 2 (Hamilton, 1959). More than 98% of the symptoms are expected to disappear. The results of this decision will be evaluated in four weeks. During the treatment, the therapist must consider certain ethical issues. For example, patient autonomy is important. It involves explaining to the patient everything regarding the illness and possible treatment options (Robichaud et al., 2019). The principle of beneficence requires that all decisions made must be beneficial to the patient.
Conclusion
Generalized anxiety disorder is one of the most common mental disorders. It is associated with excessive and exacerbated anxiety and worry about daily life events for no obvious reason. GAD affects how one thinks and may also lead to physical symptoms. GAD patients may also develop difficulty concentrating, a feeling of restlessness, indecisiveness, and fear of making wrong decisions, and others. The patient in the case study is a 46-year-old white male who presents to the hospital after being referred by his PCP after a trip to the emergency room. The patient’s history indicates that he has some mild hypertension, which he managed using a low sodium diet.
Various decisions were made to help improve the GAD symptoms. The selected decision point one is to Begin Paxil 10 mg PO daily. Paxil was chosen because it is widely used to treat generalized anxiety disorders. The selected decision point two is to increase the dose (Paxil 10 mg PO daily) to 20 mg PO daily. The selected decision point three is to maintain the current dose (Paxil 20 mg PO daily). Various ethical considerations should be considered when treating the patient. They include beneficence, non-maleficence, patient autonomy and consent, and justice. All these considerations must be made.
References
DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine, 170(7), ITC49-ITC64. https://doi.org/10.7326/AITC201904020
Hahn, P. D. (2019). The Mass-Marketing of Mental Illness. In Madness and Genetic Determinism (pp. 57-67). Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-21866-9_6
Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests. doi: 10.1037/t02824-0
Robichaud, M., Koerner, N., & Dugas, M. J. (2019). Cognitive behavioral treatment for generalized anxiety disorder: From science to practice. Routledge.