NURS 4430 Assignment Assessing and Treating Patients With Anxiety Disorders

Common symptoms of anxiety disorders include chest pains, shortness of breath, and other physical symptoms that may be mistaken for a heart attack or other physical ailment. These manifestations often prompt patients to seek care from their primary care providers or emergency departments. Once it is determined that there is no organic basis for these symptoms, patients are typically referred to a psychiatric mental health practitioner for anxiolytic therapy. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with anxiety disorders.

To prepare for this Assignment:

  • Review this week’s Learning Resources, including the Medication Resources indicated for this week.
  • Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring anxiolytic therapy.

The Assignment: 5 pages

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 patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select.

Be sure to research each option using the primary literature.

Introduction to the case (1 page)

  • Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

  • Which decision did you select?
  • Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
  • Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

  • Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
  • Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

  • Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
  • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
  • Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

  • Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20 293632).

All papers submitted must use this formatting.

By Day 7

Submit your Assignment.

Pharmacotherapy of Anxiety Disorders Sample Paper

Introduction

Anxiety is an alerting signal that warns an individual of impending danger, thereby enabling them to take the necessary measures to deal with the threat. Normal anxiety is experienced by all humans and is therefore a normal accompaniment of change, growth, and of experiencing something that is new and untried. Anxiety can also be pathological. Pathological anxiety is when one has an inappropriate response to a given stimulus by virtue of its duration and intensity. Anxiety disorders are a syndrome of mental disorders that are characterized by a diffuse, unpleasant vague sense of apprehension. 

These disorders may be accompanied by physical symptoms such as palpitations, restlessness, headache, tightness in the chest, perspiration and stomach discomfort (Johnson et al., 2019). The DSM-5 (2013) classifies anxiety disorders as separation anxiety disorder, panic disorder, selective mutism, agoraphobia, specific phobia, social anxiety disorder, substance induced anxiety disorder and generalized anxiety disorder.

The focus of this assignment is on a 46-year-old who presented with symptoms similar to the ones seen in an anxiety disorder. These included a feeling of impending doom, shortness of breath and chest tightness. An EKG was done to rule out a myocardial infarction and the results showed no anomalies. The patient reports occasional feelings of impending doom. A HAM-A test was administered and it yielded a score of 26. A diagnosis of generalized anxiety disorder (GAD) was made. 

After the diagnosis, three decisions will be made regarding the treatment regimen that will be most appropriate for this patient. A rationale for each decision will be provided and this will be supported by clinical evidence. The patient also uses alcohol and consumes about 3-4 beers a night. This is relevant as it may impact the pharmacokinetics and pharmacodynamics of the drugs chosen when making decisions (Bhatt et al., 2019). The ethical considerations that are likely to have an impact on the patient’s treatment plan will also be discussed.

Decision 1

Several drugs have been developed over the years for the treatment of anxiety disorders. Selective serotonin reuptake inhibitors (SSRI) are generally indicated as the first-line treatment for GADs (Bandelow et al., 2017). Sertraline (Zoloft) being an SSRI is therefore the best choice for treatment of this patient. The starting dose will be 50 mg PO daily. The mechanism of actions of SSRIs is that they inhibit the reuptake of serotonin in the brain therefore increasing their concentration in the brain and serotonin activity. 

SSRIs have little to no effect on other brain neurotransmitters such as norepinephrine and dopamine. Because anxiety depletes the levels of serotonin in the brain, anxiety symptoms are greatly improved by SSRIs because they exert their action by countering this effect. SSRIs replace the depleted levels of serotonin in the brain (Bhatt et al., 2019).

Imipramine and buspirone were not selected because SSRIs are the first-line choice of treatment for anxiety disorders (Bandelow et al., 2017). Furthermore, these two medications are not well tolerated as sertraline. With Zoloft 50 mg, it is expected that the symptoms manifested by the patient will gradually clear away. It is also expected that the HAM-A score would significantly reduce, therefore indicating an improvement of the symptoms. Zoloft has been shown to be effective in the treatment of GAD (Patel et al, 2018). 

It is also expected that Zoloft should have minimal side effects and evidence shows that SSRIs are well tolerated (Locher et al., 2017). The expected outcome will not be that different because when the patient comes back for a review, he manifests some improvement in the symptoms. This shows that even though just partial improvement, the patient is still responding to treatment.

Decision 2

The second decision is to maintain the patient on the same medication, Zoloft, but to increase the dose to 75 mg PO daily. The reason behind this decision is mainly attributed to the observed drop in the patient’s HAM-A score. This indicates a response to treatment but only partially. This is a positive sign as it shows that the initial medication works so the most logical thing would be to increase the dose from 50mg to 75mg. 

This increase will increase the availability of serotonin which improves symptoms of anxiety. Evidence supports the increase of the dosage if the initial response to treatment is not satisfactory (Patel et al, 2018). Another reason for choosing this decision is due to the fact that the patient tolerates Zoloft well with minimal side effects. With the increase in dosage, it is expected that the symptoms will continue reducing (Clevenger et al, 2018). The HAM-A score is also expected to drop significantly.

However, there was a little noticeable difference between the two decisions because the patient’s anxiety symptoms had further reduced and the HAM-A score had also reduced when the patient came to the clinic.

Increasing the dosage of Zoloft 50mg to 100mg was not chosen because it is recommended that the dosage should be increased gradually. This is to ensure the patient tolerates the medication well with few adverse effects. On the other hand, the option to continue the patient on the same dose was not chosen because the patient had only partially responded to this initial treatment. It is therefore imperative to increase the dosage so that the patient may elicit a more positive response to the treatment (Bandelow et al., 2017).

Decision 3

The third decision is to maintain the patient on the current does of Zoloft 75 mg PO daily. This is because the patient is showing an improvement of the symptoms on the current dose. This is indicated by a significant reduction in the HAM-A score. The subjective data also shows an improvement in the patient’s condition. This shows that the patient is responding adequately to the treatment on the current dose. 

The patient also does not report any side effects with the medication and is tolerating it well. Clinical guidelines recommend that medication should be titrated according to the patient’s response (Jakobsen et al, 2017). The patient responds well to this dosage and therefore there is no need to adjust the dosage upwards any further.

The option to change the medication to other alternatives like imipramine or buspirone, or to increase the dosage to 100 mg was taken because of the satisfactory response to 75 mg. By sticking to the second decision, the expectation is that the patient registers improvement and shows a complete response to treatment (Locher et al., 2017). The patient should exhibit no symptoms and the patient should report this as well. The HAM-A score is expected to reduce significantly.

Ethical considerations

Ethical considerations for this patient will encompass patient education, informed consent, modification of dosage, proper administration, patient autonomy and confidentiality. First it is essential to educate the patient on his condition and what to expect during medication and after. It is at this point that the patient should be enlightened about the potential side effects of the drug. This will help the patient to understand that they might need to stick to a certain medication even if they may not want to do so.

Secondly, it is important to obtain informed consent from the patient before commencing any treatment. The patient should be aware of all the necessary information before agreeing to treatment. Also, the patient’s privacy should be respected. This means that any information about the patient, his condition as well as treatment should be kept confidential and should not be disclosed to anyone without the patient’s permission.

Modification of a dose for any disorder is an ethical consideration. This allows for the appropriate adjustment of doses according to the patient’s condition. Proper administration is also a consideration as it reminds physicians to follow the instructions recommended for any particular drug. For instance, when increasing the dosage for sertraline, it should be titrated by small margins from the previous dosage.

Lastly, the patient holds all the right to accept or decline any treatment and therefore patient autonomy should be respected. The patient should be able to accept or decline treatment and should not be coerced. Any decision the patient makes should be respected.

Conclusion

Anxiety is a part of everyday life but it can also be a disability especially if it occurs inappropriately or disproportionately to a given stimulus. Many treatment options have been developed to help in managing such cases. For this paper, the patient in the case study had all the classical symptoms of an anxiety attack and was diagnosed with general anxiety disorder (GAD). The selected first decision to manage this patient was to start him on Zoloft (sertraline) 50 mg PO daily. 

The rationale was that SSRIs are the preferred first-line treatment for anxiety disorders.  This decision yielded a slight improvement in the patient’s symptoms and therefore a second decision had to be made. The second decision was to increase the dosage to 75 mg PO daily. By increasing the dose, a satisfactory response would be elicited. 

The third decision was to maintain the patient on the current dose primarily because the patient was responding well to the treatment as shown by the reduction in the HAM-a score, a reduced symptom as shown in the subjective data. Finally, there were ethical considerations for the management of this patient and these included patient education, informed consent, modification of dosage, proper administration, patient autonomy and confidentiality.

References

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM–5). 5th ed. https://www.psychiatry.org/psychiatrists/practice/dsm.
  • 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
  • Bhatt, N. V., Baker, M. J., & Jain, V. B. (2019). Anxiety Disorders. Medscape. Retrieved from https://emedicine.medscape.com/article/286227-.
  • Clevenger, S., Devvrat, M., Dang, J., Vanle, B. & William I. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Therapeutic Advances in Psychopharmacology, 8(1), 49–58. https://doi.org/10.1177/2045125317737264
  • Jakobsen, J. C., Katakam, K. K., Schou, A., Hellmuth, S. G., Stallknecht, S. E., Leth-Møller, K., Iversen, M., Banke, M. B., Petersen, I. J., Klingenberg, S. L., Krogh, J., Ebert, S. E., Timm, A., Lindschou, J., & Gluud, C. (2017). Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis. BMC Psychiatry, 17(1), 58–86. doi:10.1186/s12888-016-1173-2
  • Johnson, S. U., Ulvenes, P. G., Øktedalen, T. & Hoffart, A. (2019). Psychometric Properties of the General Anxiety Disorder 7-Item (GAD-7) Scale in a Heterogeneous Psychiatric Sample. Frontiers in Psychology, 10(), 1713–1721. doi:10.3389/fpsyg.2019.01713
  • Locher, C., Koechlin, H., Zion, S. R., Werner, C., Pine, D. S., Kirsch, I. & Kossowsky, J. (2017). Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Psychiatry. 74(10), 1011–1020. https://doi.org/10.1001/jamapsychiatry.2017.2432
  • Patel, D. R., Feucht, C., Brown, K., & Ramsay, J. (2018). Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners. Translational Pediatrics, 7(1), 23–35. https://doi.org/10.21037/tp.2017.08.05