Assessing and Treating Clients With Anxiety Disorders

Generalized Anxiety Disorder Middle-Aged White Male With Anxiety

 

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

Generalized Anxiety Disorder Middle-Aged White Male With Anxiety

 

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)

Select what the PMHNP should do next:

Increase dose to 75 mg orally daily

Increase dose to 100 mg orally daily

No change in drug/dose at this time

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

Select what the PMHNP should do next:

Decision Point Two

Select what the PMHNP should do next:

Increase Tofranil to 50 mg orally BID

Continue current dose and reassess in 4 weeks

Add an augmentation agent such as BuSpar (buspirone) 5 mg orally TID

Generalized Anxiety Disorder Middle-Aged White Male With Anxiety

 

Decision Point One

Begin Buspirone 10 mg orally BID

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client reports slight decrease in symptoms

·  Client states that he still feels very anxious

·  HAM-A score decreased from 26 to 23

· Decision Point Two

· Select what the PMHNP should do next:

·

· Increase buspirone to 10 mg orally TID

·

· Increase buspirone to 20 mg orally TID

·

· Discontinue buspirone and begin Lexapro 10 mg orally daily

·