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Introduction to the Case
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 primary care physician after a trip to the emergency room, where he felt he had a heart attack. He stated that he felt chest tightness, shortness of breath, and a feeling of impending doom. He does have some mild hypertension which is treated with a low sodium diet, and is about 15 lbs. overweight. He had his tonsils removed when he was eight years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the emergency room, and his electrocardiogram was normal. The remainder of the physical exam was within normal limits. 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. The client occasionally uses ethanol alcohol to combat worries about work and to consume about 3-4 beers at night.
He is single and cares for his elderly parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. During the mental status exam, the client was alert and oriented to person, place, time, and event. He was appropriately dressed, and his speech was clear and coherent. The clients self-reported mood is bleh , and he does endorse feeling nervous . The affect is blunted and broad but brightens several times throughout the clinical interview. The client denies visual or auditory hallucinations, and no overt delusional or paranoid thought processes are readily apparent. Judgment is grossly intact, as is insight. He has never been on psychotropic medication and denies suicidal or homicidal ideation. Considering all the factors and symptoms, the final diagnosis is a generalized anxiety disorder, and the Hamilton anxiety rating scale indicated 26 scores.
Decision #1
The first decision is to prescribe the man to begin buspirone 10 mg PO BID. This medication was supposed to reduce the anxiety and stabilize the patients mental health for a little bit. This course should last four weeks and aims to study the condition further to understand what treatment should follow next. This decision was selected to identify the seriousness of the problem and improve the mans current condition so that he could be relatively stable during further procedures. This medication was supposed to reduce the symptoms and increase the amount of serotonin in the organism (Potter, 2019). Other options were incompatible with the purpose of the first treatment stage; therefore, in comparison, the current one seemed more appropriate for the situation. Buspirone treatment, for example, was necessary to include since it could reverse the anxious pattern of behavior (Thom et al., 2020). The primary goal of this decision was to decrease the intensity of the generalized anxiety disorder symptoms in the patient. This approach would prepare him for the next steps in the treatment and would allow him to assess the reaction to the certain medication and its amount (Strawn et al., 2019). Eventually, the patient felt slight changes in his state, although the disorder still affected him significantly. Some ethical considerations served as guidance for the prescribed treatment. The main one was that the symptoms would become more disturbing and complicate the healing process. Thus, to avoid it, specific treatment and medications were prescribed to decrease the symptoms or at least prevent them from worsening.
Decision #2
After four weeks, the client returned to the clinic for the evaluation and discussion of the further direction of the course. He reported a slight decrease in symptoms but still experienced anxiety. The Hamilton anxiety rating scale indicated that the initial 26 scores decreased to 23, which is already evidence of progress. The following step was to discontinue buspirone and begin Lexapro 10 mg orally daily. The reason for choosing the specific drug is to achieve better outcomes in the patients mental health so that he could feel less anxious during the course. Other options would not serve the purpose of the treatment; therefore, the choice was Lexapro. It boosts neurotransmitter serotonin blocks serotonin reuptake pump, desensitizes serotonin receptors, and presumably increase serotonergic neurotransmission (Potter, 2019, p. 1938). Moreover, although buspirone might be effective for treating generalized anxiety disorder, it does not demonstrate the best possible outcome (Thom et al., 2020). The primary goal of the decision was to achieve a significant increase in the clients psychological wellbeing, considering the choice of medication for his age group (Strawn et al., 2019). In addition, the symptoms should have been notably decreased, and the anxiety would not concern the client that much eventually. However, the most expected outcome was the decrease in scores by the Hamilton anxiety rating, which would indicate the effectiveness of the implemented methods. Regarding the ethical considerations, there was a need to recognize the clients fears and eliminate them by talking about all the possible outcomes of the treatment and explaining the necessity of following all the recommendations.
Decision #3
After another four-week course, the client returned for the appointment to assess the progress in the treatment. He reported that his mental state noticeably got better, and the anxiety was as troubling as it was before the medications. However, he noticed that he started to feel sleepy for several hours after taking the medication, but then the feeling disappeared over time. In addition, the Hamilton anxiety rating scale demonstrated that the score decreased from 23 to 13 points which means that the course was successful.
The next decision is to continue the same dose of Lexapro but change the administration time to bedtime. Since the medication demonstrated great results, seemed to suit the patient, and contributed to the successful treatment of the mental disorder. The selection of the decision has several important reasons for it. This way, the client will not be troubled by the medications sedating effects, and sleep may be enhanced, improving overall anxiety.
Other options would not be the best for the current situation and could even cause negative drawbacks. An adequate trial can be as long as 12 weeks, and there is no need to increase the drug at this point as it is unknown how much the current dose will improve the clients symptoms (Generoso et al., 2017). It is possible to increase the dose, but this could increase the risk of side effects- especially the sleepiness the client complains about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation. At this point, nothing in the clients presentation suggests the need to augment his Lexapro with any other agents; therefore, buspirone augmentation would not be an appropriate response (Thom et al., 2020). That decision aims to provide the patient with the possibility of being in a stable condition with a normal sleeping schedule and the lowest possible level of anxiety (Thom et al., 2020). Although, the main ethical concern the client might have is worries about the safety of the treatment and how it would affect his everyday life. Thus, it is necessary again to have a conversation about his conditions and supposed outcomes so that there are no misunderstandings between both sides.
Conclusion
In conclusion, the patient with a generalized anxiety disorder was provided certain treatment that demonstrated positive results. The first decision is to prescribe the man to begin buspirone ten mg PO BID. This medication was supposed to reduce the anxiety and stabilize the patients mental health for a little bit. Buspirone treatment, for example, was necessary to include since it could reverse the anxious pattern of behavior (Thom et al., 2020). The primary goal of this decision was to decrease the intensity of the generalized anxiety disorder symptoms in the patient. The following step was to discontinue buspirone and begin Lexapro 10 mg orally daily. The reason for choosing the specific drug is to achieve better outcomes in the patients mental health so that he could feel less anxious during the course. Other options would not serve the purpose of the treatment; therefore, the choice was Lexapro. Finally, the most prudent course of action would be to continue the same dose of medication but change the administration time to bedtime. This way, the client will not be troubled by the medications sedating effects, and sleep may be enhanced, improving overall anxiety. Therefore, all the recommendations aim to ensure that the mans well-been illness improves over time, and he will be able to deal with the anxiety and reach a critical state. Prescribing certain medications in specific amounts is a primary source for successful recovery.
References
Generoso, M. B., Trevizol, A. P., Kasper, S., Cho, H. J., Cordeiro, Q., & Shiozawa, P. (2017). Pregabalin fora generalized anxiety disorder: an updated systematic review and meta-analysis.International clinical psychopharmacology, 32(1), 49-55.
Potter, D. R. (2019). Major depression disorder in adults: a review of antidepressants. Int. J. Caring Sci, 12(3) 1936.
Thom, R. P., Keary, C. J., Waxler, J. L., Pober, B. R., & McDougle, C. J. (2020). Buspirone for treating generalized anxiety disorder in Williams syndrome: a case series. Journal of Autism and Developmental Disorders, 50(2), 676-682.
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.
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