According to McCance & Huether (2019), Generalized anxiety disorder (GAD) is a psychological condition wherein the norepinephrine and serotonin systems are abnormal such as α2-adrenergic receptor binding, decreased serotonin levels in the cerebrospinal fluid, decreased platelet binding of paroxetine, an SSRI. McCance et al. (2019) also noted that there is decease Benzodiazepine binding in the left temporal hemisphere in GAD. According to Rosenthal & Burchum (2021), situational anxiety responds to everyday stressful situations, but symptoms resolve sooner.

McCance et al. (2019) noted that GAD is diagnosed when someone worries excessively for at least six months, exhibiting at least three main symptoms: vigilance, tension, apprehension, poor concentration, difficulty falling, or staying asleep.  According to Rosenthal et al. (2021), some physiological symptoms include restlessness, trembling, muscle tension, palpitation, tachycardia, sweating, cold and clammy hands.

Goal to Manage Patient’s Condition, Decision to Administer Effective Treatment and Supporting Evidence

With this patient’s condition, the goal of treatment will be to manage the condition with the least number of drugs and minimize the side effects of medication while maximizing the patient’s health outcomes. McCance et al. (2019) also noted that 5- HT/norepinephrine reuptake inhibitors like Venlafaxine or SSRIs like paroxetine and escitalopram and more are the first line of medications to manage GAD with which relief of symptoms are felt within one week of starting treatment, but optimal effect requires many weeks. In addition, the SSRIs and Norepinephrine reuptake inhibitors have also been effective in the treatment of comorbidities such as depression. Rosenthal et al. (2021) noted that the U.S Food and Drug Administration (FDA) approved the SSRIs, SNRIs, and buspirone as the first line of medications for treating GAD for long-term treatment and comorbidities depression and Benzodiazepines as second-line choices. However, because of delayed relief of symptoms with these medications, they cannot be used on a PRN basis. SSRIs and NE reuptake inhibitors can also be used in decreasing cognitive and psychic symptoms of anxiety, but they are not the best options to treat somatic symptoms. These classes of medications have no potential for abuse, although sudden discontinuation may cause withdrawal symptoms. Cardiotoxicity or death by overdose from SSRIs are rare. It is also essential to take precautions when using Venlafaxine with monoamine Oxidase inhibitors due to toxicity.

Buspirone has an affinity for serotonin receptors (5-HT1A), but it may take up to two weeks to notice the improvement in condition.  SSRIs side effects include dizziness, headache, nausea, and mild nervousness.

Furthermore, McCance et al. (2019) noted benzodiazepines are used to treat GAD in people who do not respond to 5-HT/NE reuptake inhibitors or buspirone and uncomplicated GAD. Also, benzodiazepines can be used as immediate relief when severe anxiety (Rosenthal et al., 2021). Moreover, behavioral and cognitive therapy for relaxation, supportive therapy, and biofeedback may be used to manage GAD to manage anxiety-provoking situations and improve the patient’s coping skills.

 From my job, working with patients in a correctional facility like a jail, the protocol to manage patients’ anxiety, including anxiety from the withdrawal of substance use, is Benadryl 50mg by mouth at bedtime or Hydroxyzine 25 to 50mg by mouth two times a day for three days. This regimen can be repeated by the nurse once. If it is not effective, the nurse has to notify the provider and or place the patient on the provider’s list to be seen during clinic by the Family practice provider or Mental health provider. However, for patients who come in with a diagnosis of GAD and are actively taking antianxiety medications, the order will be verified and continued if the order is current. Patients on Benzodiazepines such as Ativan who come into the jail with their medications will continue to take and gradually tapered by the provider. Where I work, Librium is used for alcohol withdrawal with a high CIWA score.

According to the Laureate interactive video (2019g), in the case scenario where a 46years old patient presented with a complaint of “anxiety attacks” and a history of chest tightness, shortness of breath, and feeling of impending doom that led him to pass out at work and was taken to the ER where myocardial infarction was ruled out, with normal EKG and other physical assessments that appeared to be within normal limit.

The patient admitted to stressful situations going on in his life, using alcohol to help him, which is non-effective. The Hamilton Anxiety (Ham-A) Rating scale score of 26 led to a diagnosis of a generalized anxiety disorder (Laureate interactive video file, 2019g).

As a practitioner, I will initiate Zoloft 50mg by mouth daily and inform the patient to return in four weeks for reassessment or seek immediate help if he feels like hurting himself. I will use Zoloft because it is an SSRI which are among the FDA’s approved first-line medication for the treatment of GAD. Upon reassessing this patient in the clinic after four weeks, his HAM-A score reduced from 26 to 18, indicating the patient is responding well to the treatment regimen as evidenced by a self-report of no chest tightness nor shortness of breath and decreased worrying over the past four or five days.

Based on the evidence that the patient’s symptoms have partially improved and there is still room to increase the dose of his Zoloft without any risk of abuse, given that patient has not experienced any side effect or interaction from taking this medication. I will up the dose to Zoloft 75mg by mouth daily and reassess the patient after 4weeks. When the patient returned in four weeks for a follow-up, he reported that his symptoms got even better. On assessment, his HAM-A score is 10, indicative of effective treatment. The patient denies any side effects from taking Zoloft at this time.

Conclusion

I will maintain the patient on Zoloft 75mg by mouth daily ongoing and continue to monitor since the patient has experienced significant improvement in symptoms with no side effects. Also, I will encourage the patient to follow up about his weight concern with a dietitian and to seek supportive help for anxiety coping mechanisms, and encourage the patient to have trusted people that he can vent to. Another recommendation I will give to this patient is to provide community resources such as respite care for his elderly parents, and other social services that may be of help with taking care of his parents such as meals on wheels, volunteer organizations that may provide help with his parents’ care and needs.

 

 

References

Laureate Education (Producer). (2019g). Generalized anxiety disorder [interactive media file]. Baltimore, MD: Author.

McCance, K. L. & Huether, S. E. (2019). Pathophysiology: the biologic basis of disease in adults and children (8th ed.). St Louis, MO: Mosby/Elsevier

Rosenthal, L. D. & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St Louis, MO: Elsevier