Assessing and Treating Clients With Anxiety Disorders Essay

Assignment: Assessing and Treating Clients with Anxiety 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 clients to seek care from their primary care providers or emergency departments. Once it is determined that there is no organic basis for these symptoms, clients are typically referred to a psychiatric mental health practitioner for anxiolytic therapy. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with anxiety disorders. Learning Objectives Students will: • Assess client factors and history to develop personalized plans of anxiolytic therapy for clients • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring anxiolytic therapy • Evaluate efficacy of treatment plans • Analyze ethical and legal implications related to prescribing anxiolytic therapy to clients across the lifespan To prepare for this Assignment: The Assignment Examine Case Study: A middle-age white male with anxiey (decisions have already been made in the attached case study) 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. I want you to answer the questions given to you (decision points one, two, and three) before you click on the option. Assessing and Treating Clients With Anxiety Disorders Essay. The answers will be based on your decisions made and patient outcomes during the decision tree. I am looking for an essay that is long enough to cover the topic BUT short enough to keep my interest. I do not need you to tell me the treatment options available to you – I am very familiar with the cases. Remember this is a Pharmacology class that incorporates Pharmacotherapy and not a class on diagnosing disease. I want you to tell me why you selected an option (why is it the best option- using clinically relevant and patient specific data) AND why you did not choose the other options (with clinically relevant and patient specific data). At each decision point stop to complete the following: * Decision #1 Select what the PMHNP should do next: • You decided to start patient on 50 mg orally daily • Why did you select this decision? Support your response with evidence and references to the Learning Resources. • Why did you not choose Buspirone (Buspar) 10 mg orally twice daily or Imipramine (Tofranil) at 25 mg BID • 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 Select what the PMHNP should do next: • You decide to increase Zoloft to 75 mg orally daily.(see attachment for result of decision#1) • Why did you select this decision? Support your response with evidence and references to the Learning Resources. • Why did you not choose the options to either Increase Zoloft to 100mg or continue same dose and reassess in 4 weeks. • 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 Select what the PMHNP should do next: • You decide to continue same dose and reassess in 4 weeks (see attachment for result of decision#1) • Why did you select this decision? Support your response with evidence and references to the Learning Resources. • Why did you not choose the options to either Increase Zoloft to 100mg or add augmentation agent such as Buspar. • 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 communication with clients.

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This assignment will focus on a 46-year-old male who presented to the emergency room with complaints about chest tightness, shortness of breath, and feeling of impending doom. ER and ECK were normal and therefore myocardial infarction was ruled out. The Hamilton Anxiety Rating Scale (HAM-A) yielded a score of 26. The client was diagnosed with generalized anxiety disorder. Accordingly, three decisions will be made regarding the client’s medication to be prescribed to the client. In addition, factors that may influence the client’s pharmacokinetic and pharmacodynamic processes will be taken into consideration during the decision-making process.

Decision Point One

The selected decision point one is to start Zoloft 50 mg orally daily. The rationale for selecting Zoloft is because the medication is an SSRI that has been shown to be effective in treating GAD. Zoloft works by increasing the level of serotonin within the brain (Allgulander et al, 2015). Serotonin is a neurotransmitter that conveys signals between brain cells and is important in mood regulation (Bandelow et al, 2017). Zoloft obstructs the reabsorption of serotonin within the brain and thus increases the availability of serotonin in the brain. Anxiety disorders such as GAD are associated with lengthy stress periods and this causes depletion of serotonin levels within the brain and therefore this is the reason Zoloft is effective in the treatment of GAD (Bandelow et al, 2017). Assessing and Treating Clients With Anxiety Disorders Essay.

The reason Buspirone (Buspar) 10 mg orally twice daily or Imipramine (Tofranil) at 25 mg BID were not selected is because SSRIs are considered to be the first line treatment choices for anxiety disorders. In addition, Buspirone (Buspar) has many side effects such as dizziness, headache, nausea, fatigue, sleep problems, blurred vision, tremors, muscle stiffness etc (Bystritsky et al, 2013). On the other hand, Imipramine (Tofranil) is an antidepressant utilized in the treatment of depression symptoms (Rogers & Clay, 2015).

With this decision, it was hoped that the anxiety symptoms for the client such as chest tightness and breath shortness would improve.  It was also hoped that the anxiety symptoms about work would improve. This is because evidence shows that Zoloft is effective and well-tolerated in treating GAD by improving both somatic and psychic anxiety symptoms (Allgulander et al, 2015).

The actual outcome and the expected outcome of the selected decision were similar because after four weeks the client reported that he was no longer experiencing breath shortness or chest tightness. In addition, his worries about work have reduced and HAM-A score also reduced from 26 to 18 indicating a partial response.

Decision Point Two

The selected decision is to increase Zoloft dose to 75 mg orally daily. The rationale for choosing this decision is to increase the client’s response to treatment. This is because the outcome of decision point 1 shows that the client is responding to Zoloft dose 50mg as indicated by improved anxiety symptoms (Allgulander et al, 2015). However, the response to the treatment was inadequate and partial as indicated by the decrease of HAM-A score from 26 to 18. Accordingly, increase the dose to 75 will further increase the amount of serotonin in the brain and further improve the client’s response to treatment (Allgulander et al, 2015). In addition, evidence supports the increase of SSRIs for non-responsive patients (Bandelow et al, 2017). Another reason for selecting this decision is because the client is not showing any noticeable side effects and therefore he is tolerating the current dose well; therefore, increase the dosage to 75mg is similarly expected to also have minimal side effects (Gautam et al, 2017).  The reason why the option of increasing Zoloft to 100mg was not selected is because the dose increase should be gradual and it is recommended that dose be increased by 25 mg at 1-week intervals. In addition, increasing the dose from 50 mg to 100 mg may make the client experience some side effects due to high dosage since the client seems to be well tolerated the current dose without any side effects (Bandelow et al, 2017). The reason for not selecting the option to continue with the same dose and reassess in 4 weeks is because the client responded to the current dose partially.

With this decision, it was expected that GAD symptoms for the client would further reduce and that the HAM-A score would significantly reduce indicating an almost complete response to the treatment. The actual outcome for the decision was similar to the expected results because the client reported a further decrease in his symptoms and the HAM-A score reduced to 10 indicating a 61% decrease in symptoms.

Decision Point Three

The selected decision is to maintain the current dose. The rationale for selecting this decision is because the client is showing significant improvement with the current dose as indicated by the significantly reduced HAM-A score and the self-report.  According to Gautam et al (2017) normally medications are supposed to be started at lower doses and then titrated in accordance with the response and the experienced side effects. The client is responding satisfactorily without any side effects and therefore the current dose should be maintained. Options to increase Zoloft to 100mg or add augmentation agent such as Buspar were not selected because the client is satisfactorily responding to the current treatment.

With this decision, it was hoped that the GAD symptoms will continue improving and over time the client will show a complete response to the treatment with full remission.

How Ethical Considerations might Impact Treatment Plan

Informed consent and autonomy are the key ethical factors that may influence the treatment plan. Assessing and Treating Clients With Anxiety Disorders Essay.  Before any treatment is provided, informed consent must be sought from the client. This means that the client will be informed about the recommended treatment options, including the side effects so that the client can make an informed choice (Murgic et al, 2015). Regarding autonomy, the client has the right to decide about to accept or refuse the recommended treatment options. If the client refuses to accept the recommended treatment, this should be respected (Murgic et al, 2015).

References

Allgulander C, Dahl A, Austin C, Morris P, Clary C, Stan K, Rana F et al. (2015). Efficacy of Sertraline in a 12-Week Trial for Generalized Anxiety Disorder. The American Journal of Psychiatry. 1(1).

Bandelow B, Michaelis S & Wedekind D. (2017). Treatment of anxiety. Dialogues Clin Neurosci. 19(2), 93–107.

Bystritsky A, Sahib K, Cameron M & Jason S. (2013). Current Diagnosis and Treatment of Anxiety Disorders. P T. 38(1), 30-38.

Gautam S, Jain A, Gautam M, Vahia V & Grover S. (2017). Clinical Practice Guidelines for the management of Depression. Indian J Psychiatry. 59(1), S34–S50.

Murgic L, Bebert P, Sovic S & Gordana P. (2015). Paternalism and autonomy: views of patients and providers in a transitional (post-communist) country. BMC Medical Ethics.16(65).

 Rogers S & Clay P. (2015). A Statistical Review of Controlled Trials of Imipramine and Placebo in the Treatment of Depressive Illnesses. The British Journal of Psychiatry. 127(6), 599-603.

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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”.  Assessing and Treating Clients With Anxiety Disorders Essay.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

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. Assessing and Treating Clients With Anxiety Disorders Essay.