NURS 6630 – Evaluating and Treating Anxiety Disorders in Patients
This case discusses a 46-year-old Caucasian man who came in with symptoms of chest tightness, shortness of breath, and a feeling of impending doom. He has a history of mild hypertension and a tonsillectomy but no significant medical issues. The patient experiences occasional shortness of breath, chest tightness, and a constant sense of impending doom. He often feels the need to escape or run away from situations. He admits to using alcohol (ETOH) to cope with work-related stress, as he is concerned about the strict management at his workplace and fears losing his job. These symptoms are indicative of generalized anxiety disorder.
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Anxiety is a common part of life, where worries about health, family, financial issues, and more can temporarily dominate a person’s thoughts. Post-Traumatic Stress Disorder (PTSD) is another type of anxiety disorder characterized by nightmares, flashbacks, and intrusive thoughts related to traumatic events in a person’s life. Exposure to such traumatic and frightening events can trigger PTSD, which can be debilitating. It affects not only those who directly experience the trauma but also witnesses to events like accidents, natural disasters, loss of loved ones, violent assaults such as rape, war, and other life-threatening incidents. These events can lead to recurrent and distressing behaviors, increasing feelings of fear, worry, helplessness, and hopelessness. Nightmares, intrusive memories, and flashbacks are common in individuals with past traumatic experiences, which can also increase the risk of panic disorders.
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Generalized anxiety disorders are frequently observed in adults who have experienced PTSD, with symptoms appearing several months after exposure to traumatic events. These anxiety symptoms can be quite disruptive, affecting daily functioning and self-care. Anxiety disorders, according to Holmes (2022), are mental conditions that impact the quality of life by influencing neurotransmitter activity. Individuals with anxiety disorders often experience heightened levels of worry and fear.
Treatment for anxiety disorders primarily focuses on symptom relief rather than complete cure. Recommended medications for managing anxiety disorders include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), antipsychotics, beta and adrenergic medications, antihistamines, and GABAergic medications (Garakani et al., 2020). The choice of treatment takes into account the pharmacokinetics, pharmacodynamics, and ethical considerations surrounding the use of pharmacotherapy. This paper discusses three decisions regarding Generalized Anxiety Disorders.
Decision One
Which decision did you make?
I chose the first-line treatment for the patient, which is the first-line SSRI, oral paroxetine at 10 mg daily.
Why did you choose this decision?
Anxiety disorders are managed using various pharmacological approaches that aim to alleviate symptoms and restore mental, physical, and social well-being. In the case of PTSD, SSRIs and SNRIs are recommended for treatment, with sertraline and paroxetine being FDA-approved as the first-line medications for managing PTSD. According to Ostacher and Cifu (2019), benzodiazepines are not suitable for PTSD. Paxil, or paroxetine, is FDA-approved for the treatment of anxiety disorders and PTSD and is considered the first-line pharmacotherapeutic choice for anxiety disorders. Paxil is an SSRI that enhances serotonin activity, affecting serotonergic neurotransmission (Davidson, 2016). This medication helps balance serotonin levels, regulate mood swings, and reduce anxiety, fear, and panic attacks. Paxil has minimal sedative and anticholinergic effects and has a low impact on the cardiovascular system. Its therapeutic effects become noticeable after 4-6 weeks, making it effective in managing generalized anxiety disorder. It also has fewer anticholinergic, adrenergic, and antihistamine properties compared to tricyclic antidepressants.
Why didn’t you choose the other two options provided in the exercise?
Paxil is a safer and more tolerable option for a wide range of patients compared to other medications like Buspirone and Imipramine, which can lead to adverse reactions such as increased drowsiness, blurry vision, and dizziness. Additionally, these alternatives are not approved as first-line treatments for anxiety and PTSD, making Paxil my preferred choice for anxiety treatment.
What were you hoping to achieve with this decision?
Paxil is slowly absorbed by the body, with a half-life ranging from 11 to 20 hours, and it reaches peak concentration within 4 to 10 hours. Its mechanism of action involves elevating serotonin levels, which helps establish a mental balance. As explained by Strawn (2018), Paxil can elicit minimal adverse effects and alleviate symptoms such as fear, worry, helplessness, chest tightness, and shortness of breath. My goal was to alleviate the symptoms of anxiety by increasing serotonin levels.
Explain how ethical considerations may impact your treatment plan and communication with patients.
Paxil has minimal adverse effects that respect individual ethical values and treatment models. Patient safety is a central concern in pharmacological therapeutic approaches, making it a key consideration in medical ethics. However, since the patient is capable of making decisions, the healthcare provider should inform the patient about the available psychotherapeutic and pharmacotherapeutic models and educate them appropriately before treatment consent is obtained.
Decision Two
The most likely option for managing the patient is the first-line medication for treating anxiety and PTSD. However, I chose to stick with Paxil as my second decision, rather than switching to a different medication. However, I will increase the dosage from 10mg to 20mg daily to enhance its therapeutic effect.
Why did you choose this decision?
Paxil may take a while to show a response. To improve the Hamilton Anxiety Rating Scale (HAM-A) score, I decided to opt for a higher dosage. Paxil is well-tolerated and has minimal side effects (Strawn, 2018). Although it may have a slower response, increasing the dosage can have a more immediate impact on mood and anxiety symptoms. According to Slee (2022), using a higher dose of SSRIs can elevate serotonin levels in the brain and improve treatment outcomes. Patient compliance with treatment can also positively affect HAM-A scores and achieve better results.
Why didn’t you select other options in this exercise?
There are various medications for treating anxiety, each with its set of potential side effects. However, Paxil is known for being well-tolerated and having minimal side effects. Rather than switching to another first-line SSRI with similar pharmacokinetics and therapeutic effects, I opted to increase the dose. Paxil is recommended as the best first-line treatment for anxiety disorders and PTSD. According to Javed and Fountoulakis (2018), Paxil significantly reduces symptoms more effectively than other medications like imipramine. Therefore, I believed that maintaining the patient on a higher dose of Paxil was the best course of action.
What were you hoping to achieve by making this decision?
While the medication might take time for the client to experience a significant reduction in clinical symptoms, the primary goal of the decision was to further lower the HAM-A score and stabilize mood and anxiety symptoms.
Explain how ethical considerations may impact your treatment plan and communication with patients.
Ethical concerns in medication include patient consent and safety. Medication should align with major ethical principles that advocate for the patient’s autonomy, beneficence, and nonmaleficence. Since Paxil is well-tolerated, increasing the dose implies that the medication is likely to continue being well-tolerated. Additionally, patient education should be emphasized to enable the patient to make informed consent.
Decision Three
The third decision will involve transitioning to an SSRI alternative. However, the drug withdrawal process might be lengthy, so I would opt for 10 mg of oral buspirone. Buspirone will also require close monitoring to assess the need to adjust the treatment plan.
Why did you choose this decision?
Buspirone is well-tolerated in the body, although it is typically used for short-term management of anxiety symptoms. It is also FDA-approved for treating Generalized Anxiety Disorder. Changing from an SSRI to an Azapirone like buspirone can potentially achieve a better therapeutic effect than non-responsive paroxetine. The drug is well-tolerated, although it may exhibit some adverse effects.
Why didn’t you select the other two options provided in this exercise?
The rationale behind choosing these medications was primarily based on their effectiveness and tolerability. Buspirone is known for being well-tolerated, with minimal adverse effects, and it is FDA-approved for the treatment of anxiety disorders. Therefore, I opted for drug safety and the FDA’s recognition in the decision for combination therapy.
What are you hoping to achieve by making this decision?
Adopting a combination therapy is aimed at improving the patient’s condition by reducing anxiety symptoms. Buspirone regulates the actions of neurotransmitters, which can help reduce anxiety symptoms (Javed & Fountoulakis, 2018). Changing medications from non-responsive or slow-responding SSRIs to Azapirones can significantly reduce the HAM-A score and alleviate the clinical manifestations of anxiety disorder.
Explain how ethical considerations may impact your treatment plan and communication with patients.
Ethical considerations in the medical field are crucial, especially in the management of mental health disorders. Patient autonomy may be compromised due to family involvement in the treatment process. However, the psychiatrist can assess the patient’s competence and compliance to determine the best intervention. As noted by Javed and Fountoulakis (2018), buspirone may have side effects such as chest pain, drowsiness, nausea, and increased sweating. However, some severe side effects, such as blurred vision, uncontrollable shaking, agitation, hallucinations, confusion, irregular heartbeat, and seizures, can occur. Clear communication should be established to allow the patient to provide informed consent for the medication.
Conclusion
The management plan involved a transition from Paxil 10 mg to 20 mg once a day and further to Azapirone therapy with 10 mg of buspirone twice a day. The choice of Paxil and buspirone was based on their recommendation and FDA approval for treating anxiety disorders and PTSD. However, due to the slow response and limited impact on the HAM-A score, increasing the Paxil dose aimed to elevate serotonin levels, reduce anxiety, and regulate mood. The third decision focused on shifting from SSRIs to Azapirones, with buspirone having partial agonist properties on serotonin, potentially improving serotonin levels and reducing the HAM-A score.
References
Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: going beyond the guidelines. BJPsych Open, 2(6), e16-e18. http://bjpo.rcpsych.org/content/2/6/e16
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, 1412. https://doi.org/10.3389/fpsyt.2020.595584
Holmes, L. (2022). The 4 Major Classes of Anxiety Medications. Verywell Mind. Retrieved 2 July 2022, from https://www.verywellmind.com/mental-health-medications-for-anxiety-2337705.
Javed, A., & Fountoulakis, K. N. (Eds.). (2018). Advances in psychiatry. Springer.
Ostacher, M. J., & Cifu, A. S. (2019). Management of post-traumatic stress disorder. JAMA, 321(2), 200-201. https://doi.org/10.1001/jama.2018.19290
Slee, A. (2022). Generalized Anxiety Disorder: Incidence and Drug Treatment (Doctoral dissertation, UCL (University College London)). https://discovery.ucl.ac.uk/id/eprint/10146430
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%2F14656566.2018.1491966
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