Generalized anxiety disorder
The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. Remainder of physical exam was WNL.
He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at.
In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26.
Client has never been on any type of psychotropic medication.
MENTAL STATUS EXAM
The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. Client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.
You administers the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.
Diagnosis: Generalized anxiety disorder
Decision Point One
Select what you should do:
Begin Zoloft 50 mg po daily
Begin Imipramine 25 mg po BID
Begin Buspirone 10 mg po BID
Decision Point One
Begin Zoloft 50 mg orally daily
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client informs you that he has no tightness in chest, or shortness of breath
- Client states that he noticed decreased worries about work over the past 4 or 5 days
- HAM-A score has decreased to 18 (partial response)
Decision Point Two
Select what you should do next:
Increase dose to 75 mg orally daily
Increase dose to 100 mg orally daily
No change in drug/dose at this time
Decision Point Two
Increase dose to 75 mg orally daily
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client reports an even further reduction in his symptoms
- HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms)
Decision Point Three
Select what you should do next:
Increase current dose of medication to 100 mg orally daily
Add augmentation agent such as BuSpar (buspirone)
Decision Point Three
Guidance to Student
At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that you should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.
For discussion, you will review this week’s interactive media pieces and select one to focus on for this discussion.
You will reflect on the decision steps in the interactive media pieces and consider the potential impacts from the administration of the associated pharmacotherapeutics based on the patient’s pathophysiology.
Post a discussion of pharmacokinetics and pharmacodynamics related to anxiolytic medications used to treat GAD. In your discussion, utilizing the discussion highlights, compare and contrast different treatment options that can be used.
Supported by at least three current, peer reviewed scholarly work credible sources. DO NOT USE PATIENT -ORIENTED PUBLICATIONS AS YOUR CITATIONS.
