Assessing and Treating Clients 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 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.

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

At each decision point stop to complete the following:
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?

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

Decision Point One
Select what the PMHNP should do:

Begin Zoloft 50mg orally daily
RESULTS:
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 2: Increase dosage to 75mg daily
RESULTS:
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 3: 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.

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Date Assessing and Treating Clients with Anxiety Disorders

Introduction

Anxiety disorders are characterized by a significant feeling of anxiety and fear which causes symptoms such as fast heartbeat and shakiness. The common types of anxiety disorders are agoraphobia, generalized anxiety disorder, social anxiety disorder, and panic disorder (Locke et al., 2015). The client in the presented case study reported symptoms such as chest tightness, breath shortness, and a feeling of impending doom. A heart attack diagnosis was ruled out after an ECG and ER while his HAM-A score was 26 and thus the client was diagnosed with generalized anxiety disorder (GAD). The paper will discuss three treatment choices for the client and conclude by discussing the ethical considerations relevant during his treatment.

Decision Point One

The first decision selected for this client is to start Zoloft 50 mg. The medication was chosen because it is an SSRI and SSRIs are the first-line treatment options for anxiety disorders. SSRIs increase the level of serotonin in the brain; serotonin is a chemical responsible for regulating mood and thus improves the symptoms of GAD (Patel et al., 2018). Buspirone and Imipramine were not selected because SSRIs are the first-line treatment options for anxiety disorders. Moreover, Zoloft has fewer side effects when compared to these two medications.

It is expected that after starting Zoloft 50 mg the symptoms of GAD would start improving. This will be indicated by the reduced HAM-A score and reduction of symptoms such as excessive fear, chest tightness, and shortness of breath. This is due to the efficacy of Zoloft in improving symptoms of GAD (Patel et al., 2018). It is also hoped that the client would tolerate the medication and the dose and report no or minimal side effects (Clevenger et al., 2018).

After four weeks, the client reported that he was no longer having symptoms such as chest tightness, worrying about work, and shortness of breath. The HAM-A score reduced indicating that the client was partially responding to the Zoloft medication. This is due to the efficacy of Zoloft in improving GAD symptoms (Clevenger et al., 2018). The client also tolerated the medication.

Decision Point Two

It is appropriate to increase the Zoloft dose to 75 mg since the client manifested a partial response to Zoloft 50 mg. Dose increment will increase the level of serotonin in the brain and thus increase the efficacy of the medication in improving the GAD symptoms (Jakubovski et al., 2016). Increasing the dose to 100 mg was not selected because dose increment should be gradual to examine the tolerability of the client towards the increased dose. Maintaining the same dose of Zoloft 50 mg was not selected since the client manifested a partial response towards this dose and thus there is a need to increase the dose to ensure improved efficacy of the medication (Jakubovski et al., 2016).

As expected, the client reported and manifested increased response to the increased dose as indicated by the significant reduction of GAD symptoms and further reduction of the HAM-A score. This is due to the availability of more serotonin in the brain with the increased dose symptoms (Jakubovski et al., 2016). Moreover, the client did not experience any side effects with the increased dose.

Decision Point Three

The client is responding adequately to the increased dose of Zoloft 75 mg and thus the appropriate decision is to maintain the dose. He is also not experiencing side effects. According to Jakobsen et al (2017), clinical guidelines and evidence recommend titration of the dose as per the client’s response to the treatment. Options to augment the Zoloft with Buspar and to increase the Zoloft dose to 50 mg were not selected since there is no client is manifesting adequate response with the Zoloft 75 mg and also there is no clinical reason to augment the medication.

Maintaining the Zoloft 75 mg hopes that the client would continue responding to the medication and eventually report complete symptom remission. It is also hoped that the client would continue tolerating the medication, without any side effects.

Ethical Considerations

The relevant ethical decisions when treating this client include autonomy, informed consent, and confidentiality. The PMHNP has to obtain informed consent from the client by explaining to the client regarding the available medications, including their side effects. The client will make an informed treatment decision. The PMHNP should respect the confidentiality of the client and not share his health information with others, without the client’s consent. It is important to respect the autonomy of the client and respect the decision of the client to refuse or accept the treatment (Bipeta, 2019). Lastly, SSRIs such as Zoloft are associated with dependency and thus the PMHNP should educate the client about the possible dependency with Zoloft.

Conclusion

The first decision is for the client to start Zoloft 50 mg since SSRIs are the first-line treatment choices during the treatment of anxiety disorders such as GAD because of their efficacy and tolerability. The client showed a partial response to Zoloft 50 mg and thus the second decision was increasing the dose to 75 mg to facilitate increase response to treatment due to increased efficacy with the higher dose. The third decision is the maintenance of Zoloft 75 mg since he is manifesting adequate response to the dose and tolerating the medication/dose. The relevant ethical considerations when treating this client are confidentiality, informed consent, and autonomy. It is also important for the PMHNP to educate the client regarding the possible dependency on Zoloft.

References

Bipeta R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19.

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. Ther Adv Psychopharmacology, 8(1): 49–58.

Jakubovski E, Anjali V, Freemantle N, Taylr M & Bloch M. (2016). Systematic Review and Meta-Analysis: Dose-Response Relationship of Selective-Serotonin Reuptake Inhibitors in Major Depressive Disorder. Am J Psychiatry, 173(2): 174–183.

Jakobsen J, Kumar K, Timm A, Gluud C, Ebert E et al. (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(58).

Locke A, Faafp M, Krist N & Shultz C. (2015). Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. Am Fam Physician, 1;91(9),617-624.

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.

Patel D, Feucht C, Brown K & Ramsay J. (2018). Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners. Transl Pediatr, 7(1): 23–35.