Sample Answer for NURS 6630 Anxiety Disorder Middle-Aged White Male With AnxietybIncluded After Question
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.
You administer 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 you should do:
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
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 you 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.
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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 you 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 you 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 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
Increase buspirone to 10 mg orally TID
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client reports no change in his anxiety
- HAM-A score has decreased from 23 to 22
Decision Point Three
Continue current dose and reassess in 4 more weeks
Guidance to Student
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, you can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.
Augmentation with an agent such as lorazepam 0.5 mg orally TID would not be appropriate at this time as the client needs a treatment plan for the long-term. You should never start someone on a benzodiazepine for an indefinite course of treatment as this could lead to addiction. Benzodiazepines should be used for a limited course of treatment for very specific therapeutic endpoints (for instance, to combat the initial activation which may be seen in the first few weeks after beginning an SSRI or SNRI).
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A Sample Answer For the Assignment: NURS 6630 Anxiety Disorder Middle-Aged White Male With Anxiety
Title: NURS 6630 Anxiety Disorder Middle-Aged White Male With Anxiety
Generalized anxiety disorder (GAD) is a common psychiatric condition that presents with excessive and uncontrollable anxiety or worries about various things or events. The anxiety or worry occurs for more days than not for more than six months. The cause of GAD is unknown, but it usually coexists in individuals with panic disorder, major depression, and alcohol use disorder (Strawn et al., 2018). The purpose of this paper is to describe the treatment for a patient with GAD.
Introduction to the Case
The case depicts a 46-year-old man who comes to the psychiatric clinic following a referral by the PCP. The patient had gone to the ER after he experienced symptoms resembling a heart attack, including chest tightness, dyspnea, and a feeling of coming doom. He has a history of mild hypertension managed through a low sodium diet and weighs around 115 lbs. In addition, he has a history of tonsillectomy but no significant medical history. The patient’s EKG and physical exam were within the normal limits in the ER, and Myocardial infarction was excluded as a possible diagnosis. However, the patient mentions that he still experiences chest tightness and episodes of dyspnea. Besides, he experiences sporadic feelings of imminent doom and a need to flee from where he is.
The patient reports occasionally taking alcohol to alleviate work-related worries. He is single but is trying to take care of his old parents. He states that his workplace management is harsh and worries for his job. The MSE findings are unremarkable except for the endorsement of nervousness and blunted affect that improves severally during the assessment. The patient was administered the HAM-A, which he scored 26, and was diagnosed with GAD. Specific patient factors that may influence treatment decisions include the patient’s age, medical history of hypertension, the severity of GAD, and the patient’s overweight state (Garakani et al., 2020). Therefore, the treatment interventions used should have no potential effect on the patient’s weight and blood pressure to avoid worsening his medical condition.
Decision Point One
Start Zoloft 50 mg orally daily.
Why I Selected This Decision
Zoloft was the ideal drug because it is recommended in the first-line treatment of GAD in adults, among other SSRIs (Strawn et al., 2018). Guaiana et al. (2018) found that SSRIs are superior in alleviating GAD symptoms, and Zoloft was established to be effective and well-tolerated due to its modest side effects.
Why I Did Not Select the Other Options
Imipramine was not selected because of its documented antihistaminic effects as a TCA, which increase appetite resulting in weight gain. This would worsen the client’s overweight condition. Garakani et al. (2020) explain that although TCAs have similar efficacy to SSRIs, they are rarely prescribed because of side effects like weight gain, sedation, dry mouth, urinary hesitancy, arrhythmias, and mortality risk with overdose. Buspirone was not the best option because it has been established to have a delayed onset of action and is weak effective (Strawn et al., 2018). Thus, it cannot be prescribed as monotherapy in GAD, limiting its use in this patient.
What I Was Hoping To Achieve
The clinician anticipated that Zoloft would reduce the GAD symptoms and lower the HAM-A score by half. The patient reported a significant decrease in worry, dyspnea, and feeling of imminent doom. Lewis et al. (2019) found that Zoloft improves anxiety, self-rated mental health, and quality of life in GAD patients, which is clinically important. Besides, Strawn et al. (2018) established that SSRIs like Zoloft have a significant treatment response rate of 30-50% in patients with GAD and would thus significantly reduce the patient’s GAD symptoms.
Ethical Considerations Impact on the Treatment Plan and Communication
The ethical principle of beneficence may affect the treatment since the clinician has to select the intervention established to have the best outcomes in GAD. For example, the PMHNP selected Zoloft because studies support its efficacy in suppressing GAD symptoms and is tolerable. In addition, autonomy may affect communication since the PMHNP had to obtain consent from the patient to begin treatment.
Decision Point Two
Increase dose to 75 mg OD.
Why I Selected This Decision
Zoloft was increased because of the evident improvement in the patient’s GAD symptoms and partial decrease in HAM-A score with Zoloft therapy. According to Edinoff et al. (2021), SSRIs like Zoloft should be gradually increased to enable the clinician to monitor the adverse effects. Strawn et al. (2018) found that patients increasingly demonstrated improvement in anxiety symptoms when the Zoloft dose was increased by 25 mg.
Why I Did Not Select the Other Options
Increasing Zoloft to 100 mg was not the best option because the PMHNP may be unable to monitor side effects with a high dose increase. Edinoff et al. (2021) explain that patients can be sensitive to SSRIs, and thus, gradually increasing SSRIs is vital in achieving the desired treatment outcomes. The dose was not also maintained at 50 mg since the client demonstrated only a partial response to treatment. Lewis et al. (2019) established that Zoloft leads to decreased anxiety symptoms and improved mental health within six weeks, but a complete reduction of symptoms takes longer and is more modest. Thus, maintaining the dose would have delayed achieving complete remission of GAD.
What I Was Hoping To Achieve
The clinician expected that the patient’s GAD symptoms would decrease further with an increased dose, and the patient would achieve a better clinical response after four weeks. Mangolini et al. (2019) found that increasing the SSRI dose results in a better clinical response in GAD. Furthermore, Edinoff et al. (2021) found sertraline to be more effective in the acute phase (6-12 weeks) of treatment than other SSRIs.
Ethical Considerations Impact on the Treatment Plan and Communication
The ethical principle of nonmaleficence (do no harm) impacted the treatment since the PMHNP had to make the decision associated with the least adverse effects. For example, the dose was increased to 75 mg rather than 100 mg for the clinician to monitor side effects. The right to autonomy affected communication since the PMHNP had to involve the patient in decision-making. The client was asked about his treatment response and was involved in deciding whether to increase the dose.
Decision Point Three
Maintain the Zoloft 75 mg dose.
Why I Selected This Decision
The PMHNP maintained Zoloft at 75 mg because the patient exhibited a satisfactory positive response to the dose, with a 61% reduction in anxiety symptoms. Furukawa et al. (2019) found that 80% occupancy of serotonin transporters occurs at minimum therapeutic doses in Zoloft. Besides, increasing transporter occupancy > 80% does not lead to better treatment efficacy. Strawn et al. (2018) also assert that SSRIs in the lower therapeutic range (50 mg-100 mg) are adequate in achieving the desired effect.
Why I Did Not Select the Other Options
Increasing Zoloft to 100 mg was not ideal because the patient had achieved a satisfactory therapeutic response. According to Edinoff et al. (2021), increasing Zoloft can lead to further reduction of symptoms, but it increases the risk of side effects, compromising treatment compliance. Augmenting treatment with Buspirone was not ideal since the client had an adequate therapeutic response with Zoloft. Mangolini et al. (2019) assert that augmentation causes polypharmacy and should thus be avoided if there is an adequate response with monotherapy.
What I Was Hoping To Achieve
The practitioner hoped that continuing with the 75mg dose would increasingly alleviate GAD symptoms and help achieve complete remission of symptoms within 4-6 weeks (Furukawa et al., 2019). Strawn et al. (2018) established that flexibly dosing Zoloft significantly reduces GAD symptoms.
Ethical Considerations Impact on the Treatment Plan and Communication
Beneficence (duty to do good) and confidentiality may impact treatment and communication in this case. For example, beneficence impacted treatment as the PMHNP had to select the decision that would have the best outcomes without compromising patient safety. Besides, the PMHNP has to be confidential with the patient’s information and seek consent before sharing it with other providers.
Conclusion
The patient was diagnosed with GAD based on his history of having excessive worries about his job and the presence of symptoms like dyspnea, chest tightness, and feeling of imminent doom. Specific factors that may influence treatment decisions include the patient’s age, weight, history of hypertension, and severity of GAD (Garakani et al., 2020). The patient was initiated on Zoloft 50 mg since it is recommended as a first-line agent in treating GAD in adults. Besides, it has been established to be effective and tolerable due to its modest side effects (Guaiana et al., 2018). Imipramine was not ideal because it causes weight gain and would have affected the patient’s weight. Buspirone was not selected because it is not effective as a monotherapy.
Zoloft partially reduced the patient’s symptoms, leading to increasing the dose to 75 mg. The dose was gradually increased because it allowed the clinician to monitor the adverse effects (Strawn et al., 2018). Maintaining Zoloft at 50 mg was not ideal because the patient demonstrated a partial response. Increasing to 100 mg was not the best choice since the patient could have developed adverse effects from a high dose increase (Edinoff et al., 2021). The patient’s symptoms were further reduced to 61%, and the dose was then maintained at 75 mg. Increasing the dose to 100 mg would have had the disadvantage of side effects and, thus, not an ideal choice. Furthermore, augmenting with Buspirone was not ideal because it would have led to polypharmacy.
References
Edinoff, A. N., Akuly, H. A., Hanna, T. A., Ochoa, C. O., Patti, S. J., Ghaffar, Y. A., Kaye, A. D., Viswanath, O., Urits, I., Boyer, A. G., Cornett, E. M., & Kaye, A. M. (2021). Selective Serotonin Reuptake Inhibitors and Adverse Effects: A Narrative Review. Neurology International, 13(3), 387–401. https://doi.org/10.3390/neurolint13030038
Furukawa, T. A., Cipriani, A., Cowen, P. J., Leucht, S., Egger, M., & Salanti, G. (2019). Optimal dose of selective serotonin reuptake inhibitors, venlafaxine, and mirtazapine in major depression: a systematic review and dose-response meta-analysis. The Lancet Psychiatry, 6(7), 601-609.
Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in psychiatry, 1412. https://doi.org/10.3389/fpsyt.2020.595584
Guaiana, G., Barbui, C., & Abouhassan, R. (2018). Antidepressants versus placebo for generalized anxiety disorder (GAD). The Cochrane Database of Systematic Reviews, 2018(2), CD012942. https://doi.org/10.1002/14651858.CD012942
Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., … & Lewis, G. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomized trial. The Lancet Psychiatry, 6(11), 903-914.
Mangolini, V. I., Andrade, L. H., Lotufo-Neto, F., & Wang, Y. P. (2019). Treatment of anxiety disorders in clinical practice: a critical overview of recent systematic evidence. Clinics (Sao Paulo, Brazil), 74, e1316. https://doi.org/10.6061/clinics/2019/e1316
Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057–1070. https://doi.org/10.1080/14656566.2018.1491966