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Assessing And Treating Clients With Anxiety Disorders

Assessing And Treating Clients With Anxiety Disorders

Assessing And Treating Clients With Anxiety Disorders

Generalized Anxiety Disorder Middle-Aged White Male With Anxiety Case Study

BACKGROUND INFORMATION

The client is a 46-year-old white male who works as a welder at a local steel fabrication factory. He presents today after being referred by his PCP after a trip to the emergency room in which he felt he was having a heart attack. He stated that he felt chest tightness, shortness of breath, and feeling of impending doom. He does have some mild hypertension (which is treated with low sodium diet) and is about 15 lbs. overweight. He had his tonsils removed when he was 8 years old, but his medical history since that time has been unremarkable. Myocardial infarction was ruled out in the ER and his EKG was normal. Remainder of physical exam was WNL.

He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these “anxiety attacks.” He will also report occasional feelings of impending doom, and the need to “run” or “escape” from wherever he is at.

In your office, he confesses to occasional use of ETOH to combat worries about work. He admits to consuming about 3-4 beers/night. Although he is single, he is attempting to care for aging parents in his home. He reports that the management at his place of employment is harsh, and he fears for his job. You administer the HAM-A, which yields a score of 26.

Client has never been on any type of psychotropic medication.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is appropriately dressed. Speech is clear, coherent, and goal-directed. Client’s self-reported mood is “bleh” and he does endorse feeling “nervous”. Affect is somewhat blunted, but does brighten several times throughout the clinical interview. Affect broad. Client denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, as is insight. He denies suicidal or homicidal ideation.

The PMHNP administers the Hamilton Anxiety Rating Scale (HAM-A) which yields a score of 26.

Diagnosis: Generalized anxiety disorder

RESOURCES

Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0

Decision Point One

Select what the PMHNP should do:
  • Begin Zoloft 50 mg po daily
  • Begin Imipramine 25 mg po BID
  • Begin Buspirone 10 mg po BID

Decision Point One

Begin Zoloft 50 mg orally daily

RESULTS OF DECISION POINT ONE

  • Client returns to clinic in four weeks
  • Client informs you that he has no tightness in chest, or shortness of breath
  • Client states that he noticed decreased worries about work over the past 4 or 5 days
  • HAM-A score has decreased to 18 (partial response) Assessing And Treating Clients With Anxiety Disorders

Decision Point Two

Increase dose to 75 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client reports an even further reduction in his symptoms
  • HAM-A score has now decreased to 10. At this point- continue current dose (61% reduction in symptoms)

Decision Point Three

Guidance to Student

At this point, it may be appropriate to continue client at the current dose. It is clear that the client is having a good response (as evidenced by greater than a 50% reduction in symptoms) and the client is currently not experiencing any side effects, the current dose can be maintained for 12 weeks to evaluate full effect of drug. Increasing drug at this point may yield a further decrease in symptoms, but may also increase the risk of side effects. This is a decision that the PMHNP should discuss with the client. Nothing in the client’s case tells us that we should consider adding an augmentation agent at this point as the client is demonstrating response to the drug. Avoid polypharmacy unless symptoms cannot be managed by a single drug.

The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.

At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.

The Assignment:

Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

· Decision #1:

o Which decision did you select?

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

· Decision #2:

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

· Decision #3:

o Why did you select this decision? Support your response with evidence and references to the Learning Resources.

o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

o Explain any difference between what you expected to achieve with Decision

#3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

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Optional Resources

Lupi, M., Martinotti, G., Acciavatti, T., Pettorruso, M., Brunetti, M., Santacroce, R., & … Di Giannantonio, M. (2014). Pharmacological treatments in gambling disorder: A qualitative review. Biomed Research International, 2014. doi:10.1155/2014/537306

To access:

  1. Week 5 Discussion
  2. Week 5 Assigment
  3. NURS 6630 Psychopharmacologic Approaches to Treatment of Psychopathology
  4. Week 5 Assignment Rubric
Required Readings
  1. Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e Sá, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier.
  2. American Psychiatric Association. (2010a). Practiceguideline for the treatment of patients withacute stress disorder and posttraumatic stress disorder.https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorder
  3. American Psychiatric Association. (2010c). Practice guideline for the treatment of patients withpanic disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf
  4. Bendek, D. M., Friedman, M. J., Zatzick, D., & Ursano, R. J. (n.d.). Guideline watch (March 2009): Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorde watch.pdf
  5. Cohen, J. A. (2010). Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 49(4), 414–430. https://jaacap.org/action/showPdf?pii=S0890 8567%2810%2900082-1

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