History of Present Illness (HPI): Alexander describes her anxiety as a constant presence, often leading to difficulty concentrating, irritability, and muscle tension. She also reports trouble sleeping, frequently waking up in the middle of the night with a racing mind. These symptoms have been present for the past six months and have gradually worsened, affecting her ability to enjoy activities she once found pleasurable.
Social History: Alexander is a retired school teacher who lives alone. She has two adult children who live in different states. Although she is in regular contact with them, she worries excessively about their safety and well-being. She spends most of her days at home, occasionally engaging in community activities but often feels too anxious to participate.
Family Medical History: There is a history of anxiety disorders in Alexander’s family. Her mother was diagnosed with generalized anxiety disorder (GAD) and was treated with medication for many years. Her father had a history of depression.
Past Medical History (PMHx): Alexander has a history of hypertension, which is well-controlled with medication. She has no history of major psychiatric disorders prior to the onset of her current symptoms.
Current Medications:
- Lisinopril 10 mg daily for hypertension.
- Multivitamin daily.
Discussion and Diagnosis
Generalized Anxiety Disorder (GAD): Alexander’s symptoms are consistent with Generalized Anxiety Disorder (GAD), characterized by persistent and excessive worry about various aspects of life. GAD often manifests with physical symptoms such as muscle tension, restlessness, and sleep disturbances, all of which Alexander has reported. The chronic nature of her worry, along with the significant impact it has on her daily functioning, supports this diagnosis.
DSM-5 Criteria for GAD:
- Excessive anxiety and worry occurring more days than not for at least six months, about a number of events or activities.
- Difficulty controlling the worry.
- The anxiety and worry are associated with three (or more) of the following symptoms:
- Restlessness or feeling keyed up or on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Irritability.
- Muscle tension.
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
- The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder (American Psychiatric Association, 2013).
Alexander meets the criteria for GAD, given the duration, nature, and impact of her symptoms.
Treatment Plan
1. Pharmacotherapy:
- First-Line Medication:
- Selective Serotonin Reuptake Inhibitor (SSRI): Sertraline (Zoloft) 25 mg daily, titrating up to 50 mg after one week if tolerated, with further increases based on response and tolerability. SSRIs are the first-line treatment for GAD and are effective in reducing anxiety symptoms (Bandelow et al., 2017).
- Adjunct Medication:
- Benzodiazepine (Short-term use): Lorazepam 0.5 mg as needed for acute anxiety episodes, with careful monitoring to avoid dependence. This should be used sparingly and only in situations where immediate relief is necessary.
2. Psychotherapy:
- Cognitive Behavioral Therapy (CBT): CBT is the most evidence-based psychotherapeutic approach for GAD. It helps patients challenge and modify maladaptive thoughts and behaviors associated with anxiety. Regular sessions with a licensed therapist are recommended (Hofmann et al., 2012).
3. Lifestyle Modifications:
- Exercise: Encouraging regular physical activity, such as walking or yoga, to help reduce anxiety symptoms. Exercise has been shown to improve mood and reduce stress (Jayakody et al., 2014).
- Sleep Hygiene: Advising Alexander on good sleep practices, such as maintaining a regular sleep schedule, avoiding caffeine in the evening, and creating a relaxing bedtime routine.
- Mindfulness and Relaxation Techniques: Introducing mindfulness practices, such as deep breathing exercises or meditation, to help manage anxiety and promote relaxation.
4. Follow-Up and Monitoring:
- Regular Follow-Up Appointments: Scheduling follow-up visits every 2-4 weeks initially to monitor the effectiveness of treatment, side effects of medications, and Alexander’s overall well-being.
- Referral: If Alexander’s symptoms do not improve with initial treatment, consider referral to a psychiatrist for further evaluation and management.
Conclusion
Managing Generalized Anxiety Disorder in primary care involves a comprehensive approach that includes pharmacotherapy, psychotherapy, and lifestyle modifications. For Alexander Quinoir, initiating treatment with an SSRI, such as Sertraline, combined with Cognitive Behavioral Therapy and lifestyle changes, offers a balanced approach to managing her anxiety symptoms and improving her quality of life. Regular monitoring and adjustments to the treatment plan will be crucial in ensuring effective management of her condition.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596
Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in Clinical Neuroscience, 19(2), 93-107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow