Generalized Anxiety Disorder

Generalized Anxiety Disorder Chief Complaint “I am so worried all the time that I can’t do anything else. I need some serious help.” HPI Ned Johnson is a 61-year-old man who presents to his PMHNP with complaints of severe irritability, feelings of “being on edge,” and inability to fall asleep at night. He states that he always feels tense and exhausted with constant muscle tension and body aches. He was laid off from his job as a manager at a building supply store 9 months ago. Over the past year, he has had difficulty concentrating when filling out job application forms, and his mind often “goes blank” when talking with people. His irritability has impacted his relationship with his wife, and he is worried that she will leave him. He has developed frequent abdominal pain and daily episodes of diarrhea. He constantly worries about the lack of financial resources, his wife losing her job, and his relationship with his wife. He is afraid that he and his wife will lose their house and cars. He states that he cannot control his constant worry and that his anxiety has increased in intensity over the past 6 months. He denies having obsessive–compulsive thoughts or behaviors or symptoms of panic disorder. He recently went to the emergency department because he was so worried about multiple issues in his life that he could not eat or sleep for 2 days. He was given an IM injection of hydroxyzine and sent home with a prescription for hydroxyzine 25-mg capsules orally four times daily as needed for anxiety. He stopped this medication last week secondary to constipation and decreased urinary flow. He tried kava kava from a herbal store a few months ago. It was not effective, and he discontinued it after 2 weeks because of severe abdominal pain. PMH Records from the family physician indicate frequent visits over the past 9 months for insomnia, headaches, abdominal pain, and diarrhea. He has been treated with buspirone for anxiety for the past 6 months. After a recent visit to the ED, he was prescribed hydroxyzine to be taken up four times daily as needed for anxiety. Past psychiatric history is significant for episode of depression and alcohol abuse when he was 33 years old, that was treated with fluoxetine. He took the fluoxetine for 2 weeks and discontinued it secondary to insomnia. FH Father, 85 years old, on “nerve medication” for several years. Mother deceased at age 73 from breast cancer with history of major depression and alcohol abuse. Patient has one sister who has been treated with multiple medications in the past for anxiety and depression and was treated for benzodiazepine abuse 5 years ago. SH Married for 30 years; no children; high school graduate; past tobacco user (quit 5 years ago with 40 pack-year history); past alcohol abuse (has been sober for 10 years and attends Alcoholics Anonymous on a weekly basis); little exercise because of time constraints; drinks four to five cups of coffee per day, and three to four Mountain Dew soft drinks throughout the day. He admits to occasional marijuana use when his anxiety is “out of control.” (Note: marijuana is not legal for medical or recreational use in his state.) He does not have any prescription drug coverage at this time. Meds Buspirone 30 mg PO BID for anxiety Phenylephrine 10 mg PO QID PRN nasal congestion Loperamide 2 mg PO Q 6 H PRN diarrhea All Sulfa (hives); codeine (nausea) ROS Positive only for paresthesias and mild diaphoresis; negative for dizziness, palpitations, SOB, chest pain Physical Examination