Assignment: Assessing and Treating Clients With Anxiety Disorders

Assignment: Assessing and Treating Clients With Anxiety Disorders

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

· Which decision did you select?

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

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

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

· Decision #2

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

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

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

· Decision #3

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

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

· 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 com 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

munication with clients.

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

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)

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

Maintain current dose

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.

Decision Point Three

Increase current dose of medication to 100 mg orally daily

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.

Decision Point Three

Add augmentation agent such as BuSpar (buspirone)

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.

Begin Imipramine 25 mg po BID

Decision Point One

Begin Tofranil (imipramine) 25 mg orally BID

RESULTS OF DECISION POINT ONE

· Client returns to clinic in four weeks

· Client reports a “slight” decrease in symptoms

· Client's states that he no longer gets chest tightness, but still has occasional episodes of shortness of breath

· HAM-A score decreased from 26 to 22

Decision Point Two

Increase Tofranil to 50 mg orally BID

RESULTS OF DECISION POINT TWO

· Client returns to clinic in four weeks

· Client client reports that he was taken to the Emergency Room two weeks after the medication dose was increased. He was at work, and co-workers stated that he appeared to get “spacy” and lost consciousness. He states that the physician in the ER suggested that he stop taking the Tofranil because of an issue with his heart. The client brought a copy of his records from the ER, which included an EKG. The EKG shows right bundle branch block which was believed to have caused the clients syncopal episode.

Decision Point Three

Restart Tofranil at 25 mg orally BID

Guidance to Student At this point, it is important that the PMHNP discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction. The most appropriate course of action for the PMHNP to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent. BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.

Decision Point Three

Discontinue Tofranil and begin SSRI

Guidance to Student At this point, it is important that the PMHNP discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction. The most appropriate course of action for the PMHNP to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent. BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.

Decision Point Three

Discontinue Tofranil and begin BuSpar at 5 mg orally TID

Guidance to Student At this point, it is important that the PMHNP discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction. The most appropriate course of action for the PMHNP to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent. BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.

Decision Point Three

Discontinue Tofranil and begin SSRI

Guidance to Student At this point, it is important that the PMHNP discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction. The most appropriate course of action for the PMHNP to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent. BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.

Generalized Anxiety Disorder Middle-Aged White Male With Anxiety

 

Decision Point One

Begin Tofranil (imipramine) 25 mg orally BID

RESULTS OF DECISION POINT ONE

· Client returns to clinic in four weeks

· Client reports a “slight” decrease in symptoms

· Client's states that he no longer gets chest tightness, but still has occasional episodes of shortness of breath

· HAM-A score decreased from 26 to 22

Decision Point Two

Increase Tofranil to 50 mg orally BID

RESULTS OF DECISION POINT TWO

· Client returns to clinic in four weeks

· Client client reports that he was taken to the Emergency Room two weeks after the medication dose was increased. He was at work, and co-workers stated that he appeared to get “spacy” and lost consciousness. He states that the physician in the ER suggested that he stop taking the Tofranil because of an issue with his heart. The client brought a copy of his records from the ER, which included an EKG. The EKG shows right bundle branch block which was believed to have caused the clients syncopal episode.

Decision Point Three

Discontinue Tofranil and begin BuSpar at 5 mg orally TID

Guidance to Student At this point, it is important that the PMHNP discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction. The most appropriate course of action for the PMHNP to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent. BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.

Decision Point One

Begin Tofranil (imipramine) 25 mg orally BID

RESULTS OF DECISION POINT ONE

· Client returns to clinic in four weeks

· Client reports a “slight” decrease in symptoms

· Client's states that he no longer gets chest tightness, but still has occasional episodes of shortness of breath

· HAM-A score decreased from 26 to 22

Decision Point Two

Continue current dose and reassess in 4 weeks

RESULTS OF DECISION POINT TWO

· Client returns to clinic in four weeks

· Client reports that he has had no change in his level of anxiety

· Client reports that his anxiety may be getting a bit “worse” because he has been having the strange bouts of dizziness

Decision Point Three

Increase Tofranil to 50 mg orally BID

Guidance to Student Tofranil can cause orthostatic hypotension. This may be a transient side effect and the PMHNP should discuss this with the client as these symptoms can be dangerous. Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects. While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action. Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some PMHNPs will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea).

Decision Point Three

Explain that the dizziness will pass and maintain current dose until next appointment

Guidance to Student Tofranil can cause orthostatic hypotension. This may be a transient side effect and the PMHNP should discuss this with the client as these symptoms can be dangerous. Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects. While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action. Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some PMHNPs will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea).

Decision Point Three

Discontinue Tofranil and begin Lexapro 5 mg orally daily for 7 days, then increase to 10 mg orally daily until next appointment

Guidance to Student Tofranil can cause orthostatic hypotension. This may be a transient side effect and the PMHNP should discuss this with the client as these symptoms can be dangerous. Increasing the Tofranil would not be ideal as the side effects can be dose dependent. Increasing the dose may increase the side effects. While the client may acclimate to the current dose of the medication, the client is still quite anxious, and Tofranil, a second-line agent, appears to have contributed minimally to the treatment of the anxiety symptoms. At this point, waiting to provide the client with symptom relief may not be the best course of action. Discontinuation of Tofranil and beginning Lexapro 5 mg orally daily would be the most prudent course of action. It should be noted that Lexapro is an SSRI and a first-line agent that is FDA approved to treat generalized anxiety disorder. 5 mg is lower than the recommended starting dose, but some PMHNPs will initiate lower doses for 7 to 10 days in order to minimize the possibility of side effects (which may include sexual dysfunction in men as well as gastrointestinal side effects like nausea, decreased appetite, constipation, dry mouth, vomiting, and diarrhea).

Begin Buspirone 10 mg po BID

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