ASSESSING AND TREATING PATIENTS WITH ANXIETY DISORDERS

Assessing and Treating Patients with Anxiety Disorders

NURS - 6630N

Psychopharmacologic Approaches to Treatment of Psychopathology

04/08/2022

Assessing and Treating Patients with Anxiety Disorders

Introduction

This week’s case study involves a 46-year-old white male working as a welder at a local steel fabrication factory. The patient presented to the clinic after being referred by his PCP following a visit to the ER in which he felt he had a heart attack. The patient reported that he felt chest tightness, shortness of breath, and a feeling of impending doom. The patient admits to having some mild hypertension (well-managed with a low sodium diet). The patient has added about 15 lbs. and is overweight. The has his tonsils removed at 8 years old. His medical history has been unremarkable. Myocardial infarction was ruled out in the ER, and his EKG was normal. The patient also admits that his chest is tight and experiences episodes of shortness of breath that he terms “anxiety attacks.” He also reports occasional feelings of impending doom and the need to “run” or “escape” from wherever he is. In your office, he confesses to the occasional use of ETOH to combat worries about work. The patient also admits to consuming approximately 3-4 beers per night. 

The patient is single and is attempting to care for aging parents in his home. He states that the management at his place of employment is harsh, and he fears for his job. This client has never been on any kind of psychotropic medication. He is alert and oriented X4. Speech is clear, coherent, and goal-directed. The client’s self-reported mood is “bleh,” and he does endorse feeling “nervous.” His affect is broad and somehow blunted but does brighten several times throughout the interview with the clinician. He denies visual or auditory hallucinations. Reports no overt delusional or paranoid thought processes. His judgment is grossly intact. The patient denies suicidal or homicidal ideations. The PMHNP administered the Hamilton Anxiety Rating Scale (HAM-A), which yielded a score of 26, indicating that the client suffers generalized anxiety disorder.

Decision #1

Which decision did you select? I chose to start the patient with Paxil (paroxetine) 10 mg po daily. 

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Why did you select this decision? As the PMHNP attending to this patient, I chose to start him on Paxil 10 mg PO daily because Paxil (Paroxetine) is a selective serotonin reuptake inhibitor (SSRIs), which are generally used as first-line agents for anxiety and panic disorder (Melaragno et al., 2020). The patient is diagnosed with generalized anxiety disorder, a condition wherein the major mediators of the symptoms appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA) in the central nervous system (CNS). This medication targets the serotonin transporter (SERT) to catalyze the thermodynamically unwanted movement of synaptic serotonin into the presynaptic neuron. This mechanism would increase the availability of serotonin in the synapse, making it available for binding to its receptor. Receptor binding would then activate serotonin activities, leading to effects such as euphoria and the feeling of a good mood (Melaragno et al., 2020). Therefore, the client will more likely benefit from this medication to treat his condition. 

Why did you not select the other two options provided in the exercise? As the PMHNP treating this patient, I did not choose to begin the patient on Imipramine 25 mg PO BID because it is not recommended as the first treatment for anxiety and panic disorders. It is a tricyclic antidepressant (TCA) indicated for the treatment of depression and to reduce childhood enuresis (Strawn et al., 2018). As a TCA, it potently inhibits serotonin and norepinephrine reuptake, with direct anticholinergic effects. This diminished anxiolytic effect may lead to therapeutic failure. Further, I did not choose to begin the patient on Buspirone 10 mg PO BID because it is not recommended for initial therapy to treat anxiety and panic disorders (Strawn et al., 2018). It is an anxiolytic drug used when the patient does not respond to first-line agents. 

What were you hoping to achieve by making this decision? By starting the patient on Paxil 20 mg PO daily, the hope was to relieve the patient’s physical anxiety symptoms if he is compliant with his therapy. His serotonin imbalances should be corrected at least within 24 hours onwards. His HAM-A score is expected to improve during follow-up, including other physical exams.

 Ethical Considerations- When prescribing Paxil, patient safety is an important ethical consideration because anxiolytic drugs are toxic and must be used in controlled and monitored conditions. Secondly, consider the potential adverse effects of Paxil in White patients. The practitioner should check if there are any genetic-induced effects of this drug, such as CYP-450 2D6 activity (Kellmeyer, 2018). Other ethical concerns may include fear of symptom exacerbation (which sometimes occurs for anxiolytics) and dropout or non-compliance (due to intolerable side effects).

Decision #2

Why did you select this decision? At this point, I chose to increase the Paxil dose to 20 mg PO daily because clinical trials indicate that Paxil is effective when dosed in a range of 20 mg to 60 mg daily. Again, the 20 mg dose is still within the recommended dosage range of 10 mg to 60 mg per day (Melaragno et al., 2020). Moreover, anxiety symptoms often resolve earlier than depressive symptoms and often require a lower dose. The safety of Paxil has been evaluated in patients with SAD at doses up to 60 mg daily (Melaragno et al., 2020). This decision was based on the fact that the client returned to the clinic in four weeks and reported no tightness in the chest, or shortness of breath, implying that increasing the dosage from 10 mg to 20 mg would lead to a further decrease in symptoms.

    Why did you not select the other two options provided in the exercise? I did not choose to increase the dose to 40 mg because the Paxil dosage should be increased in increments of 10 mg per day at intervals of at least one week, depending on tolerability. Increasing the dose from 10 mg to 40 abruptly in elderly patients is associated with an increased risk for suicidal behavior and hostility (Ostacher & Cifu, 2019). Therefore, the dosage should be restricted to the lower end of the dosage range. I did not choose "no change in drug/dose" at this time because when taking Paxil, the treatment should be continued until all symptoms are eliminated or significantly reduced (Ostacher & Cifu, 2019). The result of decision two after four weeks is that the client's HAM-A score decreased to 18 (partial response). The client had no complaints of adverse effects or side effects from taking Paxil after decision two. 

What were you hoping to achieve by making this decision? By increasing the dose to 20 mg, the hope was to reach a therapeutic dose that is safe to maintain the patient on and for the patient to have a decrease in depressive symptoms and improvement in his quality of life.

Ethical Considerations- When choosing drug treatment for clients suffering from anxiety, an anxiety rating scale must be used to determine the severity of anxiety. According to Kellmeyer (2018), drug prescribing should be based on the level of anxiety. For instance, drug treatment is not recommended if a patient exhibits mild anxiety. However, if the patient suffers from moderate to severe anxiety, prescribing an antidepressant is appropriate (Kellmeyer, 2018). Therefore, ethical considerations that promote patient safety and autonomy need to be considered to help guide the decision-making process to better care for the patient.

Decision #3

Why did you select this decision? – At this point, I chose to maintain the current dose. I chose to maintain the patient on the current dosage since the patient has had a 61% reduction in symptoms after being on Paxil 20 mg for four weeks, with an increase in medication dosage after four weeks. According to Strawn et al. (2018), the patient has had a good response to the drug, as evidenced by an improvement in symptoms by more than 50%. Increasing the medication at this point may result in further reduction of symptoms; however, it also will increase the chances of the patient experiencing side effects. At this time, the safest action would be to monitor the patient on the current dose for 12 weeks to evaluate the drug's full effect. 

Why did you not select the other two options provided in the exercise? I did not choose to increase the dosage to 30 mg because the patient responds well to the current (20 mg), evidenced by a 61% reduction in symptoms. Even though increasing the dosage at this point may yield a further decrease in symptoms, this may also elevate the risk of side effects (Strawn et al., 2018). Again, I did not choose to add an augmentation agent such as BuSpar (buspirone) because nothing in the client’s case tells that adding an augmentation agent at this point should be considered because the client is showing a positive response to the medication. Avoid polypharmacy unless a single drug cannot manage symptoms.

What were you hoping to achieve by making this decision? The hope was to realize at least 60% relief in symptoms since research shows an average of 60 % relief in patients treated with SSRIs for anxiety disorders.

Ethical Considerations- When deciding to maintain the current dose, the client's safety should be maintained during therapy (Kellmeyer, 2018). The client has never been on any type of psychotropic medication; therefore, the psych nurse practitioner must first establish a rapport with the client and communicate effectively concerning the medication prescribed, including the dosage schedule, possible side effects or adverse effects, and expected results. The federal and state laws must be observed, including the seven principles of biomedical ethics. The seven principles of biomedical ethics include autonomy, veracity, beneficence, nonmaleficence, confidentiality, justice, and role fidelity (Kellmeyer, 2018).

Conclusion

Overall, generalized anxiety disorder is among the most common mental disorders affecting millions of Americans. The disorder is characterized by persistent, excessive, and unrealistic worry about everyday life events. The worry could be multifocal and include things such as finance, family, health, and the future (Munir & Takov, 2019). In most cases, a generalized anxiety disorder can be excessive, difficult to control, and is often accompanied by other non-specific psychological and physical symptoms. In the decision, one Paxil 10 mg was used to treat the patient. The first line of therapy used to treat Generalized Anxiety Disorder is SSRIs such as Paxil. Paxil 10 mg was well tolerated and caused an improvement in symptoms reflected in HAM-A score improvement from 26 to 18. 

In decision two, the decision was made to increase the dose of Paxil from 10 mg to 20 mg. The decision was within the range of recommended dose and based on the fact that the client’s response to Paxil is often delayed (Bui et al., 2016). The result of decision two yielded a further reduction in the HAM-A score from 18 to 10. The HAM-A score of 10 represented mild anxiety (Hamilton, 1959). The choice made in decision three was to continue to the current dose of Paxil of 20 mg. Decision three was made because the patient had no side effects or adverse effects to Paxil and was having a response to therapy with Paxil. 

References

Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e Sá, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier.

Hamilton, M. (1959). Hamilton Anxiety Rating Scale (HAM-A). PsycTESTS. https://doi.org/10.1037/t02824-0

Kellmeyer, P. (2018). Neurophilosophical and ethical aspects of virtual reality therapy in neurology and psychiatry. Cambridge Quarterly of Healthcare Ethics, 27(4), 610-627.

Melaragno, A., Spera, V., & Bui, E. (2020). Psychopharmacology of Anxiety Disorders. Clinical Handbook of Anxiety Disorders, 251-267.

Munir, S., & Takov, V. (2019). Anxiety, Generalized Anxiety Disorder (GAD). Nih.Gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/

Ostacher, M. J., & Cifu, A. S. (2019). Management of posttraumatic stress disorder. JAMA, 321(2), 200–201. https://doi.org/10.1001/jama.2018.19290

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.