GAD: Generalized Anxiety Disorder
Courtney Robertson
Chamberlain College of Nursing
NR 603: Advanced Clinical Diagnosis and Practice Across the Lifespan
July 2019
Running head: GAD 1
GAD 3
GAD: Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is characterized by excessive anxiety, uncontrolled worry, feeling on edge, poor concentration, restlessness, irritability, impaired social or occupational functioning physical symptoms, fatigue, muscle tension, and difficulty sleeping (Kehoe, 2017). Patients who have confirmed diagnosis of GAD experience decrease in quality of life and have difficulty finding enjoyment in their normal daily activities. Treatment should be aimed toward improving symptoms and maintaining a prevention of relapses (Kehoe, 2017).
Summary of Case Study
H.W. is a 27-year-old Caucasian female who presents to the family practice clinic with reports of constant worry and feeling like something bad could happen since a serious illness/hospitalization 4 months ago. Also, she reports stress from a poor relationship with her mother and being the sole provider to her boyfriend and 3-year-old daughter. Symptoms include not wanting to get out of bed in the mornings and unable to fall asleep at night due to not being able to shut her mind off. She has been coming home from work to re-do all housework already completed by her boyfriend and is not able to sit still and relax. She also reports finding herself crying over issue that would not have bothered her before. Symptoms have been at their worse for the last month. A known history of migraines, cholecystectomy, sepsis/pyelonephritis, kidney stone and obesity with current medication being Propranolol 80mg BID. She lives with her boyfriend and 3-year-old daughter, boyfriend does not work due to diagnosis of PTSD. She recently lost her 2 year job as a secretary for a chiropractor and began her new position as an admitting director at a nursing home 5 months ago. She does not smoke or partake in any illicit drugs or alcohol consumption and reports only getting 3-4 hours of sleep at night. No significant family history that pertains to today’s complaints. During her assessment the patient was pleasant and cooperative but tearful at times during conversation. Her PHQ-9 results were 8, the GAD-7 score added up to 18 and the patient denied any suicidal ideations.
Treatment Plan
Diagnostics:
CBC, CMP, TSH, T4, and a B-12 to rule out any medical conditions that could cause her symptoms and also to obtain baseline results. GAD-7, PHQ-9 tests.
Medications:
Zoloft 25mg tablet
Sig: Take 1 tablet daily for three days and then increase to two tablets daily for 50mg daily
Dispense: 60 tablets
Refill: 0
Ativan 0.5mg tablet
Sig: Take 1 tablet three times a day as needed for anxiety
Dispense: 12 tablets
Refill: 0
Education:
Patient education is key in the management of their GAD and patients should know that self-directed approaches should be used such as relaxation techniques, stress reduction, and exercise (Kehoe, 2017). Keeping a good rapport with your patient will help in managing a successful treatment plan. Patients should also be informed that Zoloft is an SSRI drug and this medication can take up to 4 weeks to see desired results, then the dose can be titrated every two weeks until a therapeutic effect is achieved reassessing then in 4-6 weeks (Kehoe, 2017). The use of Ativan should be well educated because the use of benzodiazepines are concerning due to the adverse effects of the drug (Kehoe, 2017). This medication should only be used in times of severe anxiety or in situations that can not be avoided that may cause an increase in anxiety. The patient should also be made aware of the potential in dependence of medication and should avoid using on a daily basis, this will not improve symptoms only temporarily mask them. Treatment with SSRI medications could have a potential serious side effect of suicidal ideations. The patient should be made aware of this and if experiences any thoughts of suicide know that it is a side effect of the drug and to call office immediately or go to the emergency room for professional help.
Referrals:
Spero Counseling & Wellness Center for psychotherapy.
Follow-Up
2 weeks in office for re-evaluation of symptoms, medication adherence/adjustment, and emotional support.
Analysis
Pathophysiology
Generalized anxiety disorder may be mediated by abnormalities of neurotransmitter systems such as serotonin, norepinephrine, and y-aminobutyric acid. It is also is linked to altered regional brain function with a disruption in the function of the connectivity of the amygdala and how it processes the feeling of fear and anxiety (Kehoe, 2017).
Pharmacology
SSRI and SRNI antidepressants have demonstrated efficacy, are well tolerated, do not cause abuse/dependence, and treat comorbid depression (Kehoe, 2017). Comparison between the two agents is very limited as to one class being more favorable over the other (Kehoe, 2017). Doses should be started at the lowest available then titrated up every 2-4 weeks and use the highest FDA-approved dose for at least 2 weeks before deeming as ineffective (Kehoe, 2017). If medication is found to not hold favorable results patient should be switched to a different SSRI/SNRI (Kehoe, 2017). Do not switch with out adequate dosing or duration because this could lead to ineffective treatment for the patient. Most common side effects are nausea, agitation, sedation, and sexual side effects of SSRIs (Kehoe, 2017). SNRIs may also cause elevated blood pressure. Second line treatment is benzodiazepines for short term use in the control of symptoms, will not have a long term effect but may cause dependence and abuse (Kehoe, 2017).
National Guidelines:
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. 5th edition offers a guideline in the diagnosis, treatment, and management of Generalized Anxiety Disorder.
Follow-Up:
Two week follow for this patient. Time frame has not yet been met to know of treatment effect.
Coding / billing:
CPT: 99213
ICD 10 Generalized Anxiety Disorder (F41.1)
Conclusion
Generalized anxiety disorder is a commonly seen diagnosis in primary care, this condition can cause a decrease in the quality of life for many patients. Proper diagnosis and treatment is important in the management of these patients. This case study has an ongoing treatment plan that requires further monitoring of the patient. Adjustment to medication, care, and follow up will unfold in future encounters.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders:
Dsm-5 (Fifth ed.). Retrieved from https://chamberlain-on-worldcat- org.chamberlainuniversity.idm.oclc.org/search?bquery=&queryString=DSM5&database=all&stickyFacetsChecked=on&scope=wz%3A67344&content=fullText&format=Book&database=all&author=all&language=all
Kehoe, W. (2017). Generalized Anxiety Disorder. Neurologic/Psychiatric Care, 2, 7-27.
Retrieved from https://www.accp.com/docs/bookstore/acsap/a17b2_sample.pdf
