Introduction
In the case study, a 46-year-old man sought medical attention due to anxiety symptoms. The patient’s primary complaints include “chest tightness, shortness of breath, and feeling of impending doom” (Generalized Anxiety Disorder, n.d., para. 1). Because of these symptoms, the man was taken to the emergency room with a suspected heart attack. However, physical examination showed no significant abnormalities, and an electrocardiogram (ECG) performed in the ER was within normal limits. The patient’s medical history has no significant medical conditions other than hypertension and a slight excess weight.
The patient reports that symptoms recur, and the frequency of their occurrence increases. In addition, the man stated that he had “anxiety attacks” (Generalized Anxiety Disorder, n.d., para. 2). The patient’s symptoms may be influenced by his lifestyle since, according to the man, he drinks 3-4 bottles of beer daily.
Moreover, based on available information, the patient may be subject to additional stress associated with caring for elderly parents. The patient also noted that his working conditions are strict, so he constantly worries about his employment. The patient’s diagnosis is generalized anxiety disorder (GAD), which may be complicated by panic disorder and post-traumatic stress disorder (PTSD).
The Hamilton Anxiety Rating Scale (HAM-A) was used to assess the severity of the patient’s anxiety. The patient’s condition is assessed according to HAM-A using 14 parameters, which allow one to analyze the patient’s physical and mental state, focusing on specific manifestations of anxiety (Hamilton, 1959). In this case, the man scored 26 on the Hamilton scale. It demonstrates a moderate to severe form of anxiety requiring treatment.
Treatment Decisions
Decision #1
To begin with, Paxil 10mg orally daily was chosen as a drug intervention. It is an example of selective serotonin reuptake inhibitors (SSRIs), effectively used to treat various mental disorders (Stahl, 2021). The choice of the minimum dose of Paxil is due to the patient’s mild hypertension and regular alcohol consumption. Moreover, Paxil may effectively eliminate symptoms of panic attacks and reduce stress levels (Stein et al., 2009; Ursano et al., 2010). Therefore, this choice of medication and dosage is driven by the need to reduce the severity and frequency of symptoms while still ensuring the patient’s safety.
Other drug treatment options were excluded after careful consideration of all factors. Imipramine is a powerful antidepressant that may be effective in treating anxiety and panic attacks. Drugs of this type have a substantial calming effect on humans (Stein et al., 2009). It may negatively impact the patient’s work productivity, increasing the anxiety and stress associated with their employment. Another option was Buspirone 10 mg orally BID (Generalized Anxiety Disorder, n.d.). The patient’s condition and the results of assessing the severity of anxiety require urgent intervention, which Buspirone at this dosage cannot provide. Consequently, alternative treatment options were considered and rejected due to contraindications or ineffectiveness. By choosing Paxil 10 mg, I plan to reduce the patient’s symptoms, including tightness in the chest and shortness of breath, the frequency of panic attacks, and the severity of anxiety.
The choice of treatment must be based on ethical considerations. Therefore, it is necessary to inform the patient about all possible treatment options, potential results, and side effects. It will ensure informed consent is obtained, which is necessary to practice medicine ethically (Ursano et al., 2010). Additionally, it is crucial to maintain regular monitoring and control of treatment outcomes. It will help ensure patient safety and positive outcomes.
Decision #2
Four weeks later, at a follow-up appointment with the patient, I decided to increase the Paxil dose to 20 mg. This decision is based on the patient’s positive response to treatment and the absence of significant side effects. In four weeks, it was possible to eliminate physiological symptoms and reduce the number of worries about work (Generalized Anxiety Disorder, n.d.). The HAM-A score dropped to 18, a good indicator but insufficient to ensure the patient’s comfortable living conditions. Gradually increasing the dose of Paxil under specialist supervision may help minimize the manifestations of GAD and optimize treatment effectiveness.
At the same time, a sharp increase in dose to 40 mg could increase the risk of side effects. Considering the patient’s age and the effectiveness of previous treatment, exposing him to additional risk through unnecessarily high doses does not have sufficient justification (Stein et al., 2009). However, maintaining the dose of SSRIs at 10 mg may slow down the treatment process, keeping the patient’s anxiety scores at the current level. Therefore, to ensure the continuation of treatment and its effectiveness while minimizing risks to the patient.
By increasing the dose of Paxil to 20 mg, I hope to eliminate the physiological manifestations of anxiety, reduce stress levels in the long term, and eliminate anxiety and panic associated with work. In addition, the previous four weeks demonstrated partial changes in HAM-A anxiety severity. Therefore, by increasing the drug dose, I aim to achieve a more significant response to treatment regarding the HAM-A score over the next four weeks.
Continuation of treatment must be performed in accordance with established ethical standards. The patient should be informed of the current results and advised of further intervention options (Stein et al., 2009). Moreover, it is essential to inform the patient about the potential consequences of increasing the dose, as well as potential side effects, and the plan of action in case they occur. Finally, it is essential to continue monitoring the patient’s treatment process and outcomes to intervene promptly if necessary.
Decision #3
After another four weeks, the decision was made to continue to maintain the current dosage of Paxil. During treatment, a 61% reduction in the patient’s GAD severity was achieved, a satisfactory indicator (Generalized Anxiety Disorder, n.d.). Furthermore, increasing the Paxil dose to 30 mg potentially increases the risk of side effects but does not guarantee effectiveness in further reducing GAD symptoms. The current dosage is optimal if treatment success exceeds 50% (Stahl, 2021). For the same reason, another alternative option, which was to add an augmentation agent to the treatment plan, was rejected. The use of drugs like BuSpar is justified only if the primary treatment is ineffective. At the same time, current indicators demonstrate significant progress in treatment.
Maintaining the current dose of Paxil may help keep the patient stable at this level, with the potential for gradual reduction of GAD symptoms. Moreover, the effectiveness of treatment for acute stress disorder is only visible in the long term (Ursano et al., 2010). Therefore, to maintain the achieved results, it is necessary to continue taking the medications at the exact dosage. In addition, continued use of SSRIs is necessary to prevent abrupt drug withdrawal (Lochmann & Richardson, 2019). It carries the potential risk of reverting the patient to their pre-treatment condition and exacerbating symptoms.
Ethical considerations for continuing treatment include obtaining informed consent, patient education, and ongoing monitoring and follow-up. The patient should be informed of all available options for further intervention and actively participate in decision-making. Additionally, it is crucial to educate the patient about potential drug interventions and other available therapies to facilitate effective collaboration with the healthcare provider. Finally, it is crucial to understand that the treatment process is ongoing, so patients must undergo regular follow-ups, and their response to the medications taken must be closely monitored.
Conclusion
This paper analyzed a case study of a 46-year-old man diagnosed with GAD. Assessment of the patient’s condition on the Hamilton scale showed a level of anxiety above average. Moreover, the man’s GAD was accompanied by other disorders, including panic attacks, PTSD, and constant stress due to work. These conditions led to physical symptoms that manifested through tight chest tightness and shortness of breath. After assessing the patient’s condition and personal factors, it was decided to select SSRIs as the optimal option for drug intervention.
At the first stage of treatment, the patient was prescribed Paxil 10 mg PO daily. This choice of drug and dosage made it possible to ensure the effectiveness of the intervention and simultaneously minimize risks for the patient (Stahl, 2021). After four weeks, given the positive trends in the results, the drug dosage was increased to 20 mg. It has contributed to the positive impact of Paxil use on the treatment of GAD symptoms (Lochmann & Richardson, 2019). Within eight weeks, drug intervention managed to eliminate physical symptoms, minimize worries about work, and achieve a 61% reduction in anxiety severity on the HMA-A scale. Further intervention includes maintaining Paxil 20 mg and monitoring the patient’s condition.
References
Generalized Anxiety Disorder: Middle-aged white male with anxiety. (n.d.). Generalized anxiety disorder.
Hamilton, M. (1959). Hamilton Anxiety Rating Scale[Database record]. Retrieved from PsycTESTS.
Lochmann, D., & Richardson, T. (2019). Selective serotonin reuptake inhibitors. Handbook Of Experimental Pharmacology, 250, 135–144.
Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.
Stein, M. B., Goin, M. K., pollack, M. H., Roy-Byrne, P., Sareen, J., Simon, N. M., & Campbell-Sills, L. (2009). Practice guideline for the treatment of patients with panic disorder (2nd ed.) [PDF document].
Ursano, R. J., Bell, C., Eth, S., Friedman, M., Norwood, A., Pfefferbaum, B., Pynoos, R. S., Zatzick, D. F., & Benedek, D. M. (2010). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder [PDF document].