Assignment: Assessing and Treating Clients With Anxiety Disorders

Assignment: Assessing and Treating Clients With Anxiety Disorders

For individuals suffering from posttraumatic stress disorder (PTSD) and other anxiety disorders, everyday life can be a constant challenge. Clients requiring anxiolytic therapy may present with anxiousness, depression, substance abuse issues, and even physical symptoms related to cardiovascular, respiratory, and gastrointestinal ailments. As a psychiatric mental health nurse practitioner, you must be prepared to address the many needs of individuals seeking treatment for PTSD and other anxiety disorders. Assignment: Assessing and Treating Clients With Anxiety Disorders

This week, as you study anxiolytic therapies and PTSD treatments, you examine the assessment and treatment of clients with PTSD and other anxiety dAssignment: Assessing and Treating Clients With Anxiety Disordersisorders. You also explore ethical and legal implications of these therapies.

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Assignment: 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. Assignment: Assessing and Treating Clients 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.

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Assignment: Assessing and Treating Clients With Anxiety Disorders

Assessing and Treating Clients with Anxiety Disorder

Assessing and Treating Clients with Anxiety Disorders.

Anxiety disorders are the most prevalent category of mental illness and are characterized by chronic anxiety causing distress and interference in the individual’s life. According to DSM-5, excessive anxiety and worry must cause significant distress or impairment and occurs on more days than not for at least six months for diagnostic criteria (Stein et al., 2015) The disorder can be effectively treated with medication, psychotherapy, or a combination of the two modalities.

This paper addresses the pharmacology approach in treating a 46 year- old white male who is experiencing anxiety, and the impact pharmacokinetic and pharmadynamic processes will be explored to guide for the appropriate treatment.  Assignment: Assessing and Treating Clients With Anxiety Disorders

Case Scenario

A 46-year-old white male who initially presented to ER with a complaint of chest pain and cardiac work- up was negative, and a PMHNP consult was sought for psychiatric evaluation. The client ‘s Hamilton Anxiety Rating Scale( HAM-A) was 26 indicating moderate to severe anxiety phase. The PMHNP decides to start the client on medications.

Options: Zoloft 50 mg Po Daily, imipramine 25 mg po BID, buspirone 10 mg BID. 

Decision: Zoloft 50 mg PO daily.

Rationale: Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs ) benzodiazepines, buspirone, and α2δ ligands such as pregabalin and gabapentin are recommended as first line treatments for anxiety disorders spectrum (Stahl, 2017) However,  SSRI and SNRIs are efficacious in the treatment of generalized anxiety disorder (GAD) and panic attack as in the case of our patient in the scenario. Additionally, in cases of co-occurring GAD and depression, a common comorbidity, SSRIs can provide effective treatment for both GAD and major depression ( Johnson & Coles, 2014) . Assignment: Assessing and Treating Clients With Anxiety Disorders

Selecting sertraline (Zoloft) was based on the fact it belongs to the family of SSRI, and well recognized in the treatment of GAD and panic attack. Secondly, possible side effects of Zoloft which include sexual dysfunction, gastrointestinal abnormalities (nausea and diarrhea), insomnia, weight gain, and agitation and/or hyperactivation (Kamo et al.,2016) were explored prior selecting Zoloft. The patient was overweight (15 lb), hence a healthy lifestyle will be important for education, and the rest of side effects can be monitored and managed early in treatment.  Assignment: Assessing and Treating Clients With Anxiety Disorders

Sertraline affects the serotonin neurotransmitter in the synaptic cleft by blocking the serotonin transporter from returning the remaining serotonin to the presynaptic cell. Sertraline is well absorbed in gastrointestinal tract, highly protein bound, predominantly metabolized by CYP 450 system  with half-life of 24- 26 hrs and removed primarily  by kidneys ( Woo & Wayne, 2013).

Imipramine, a tricyclic antidepressant was not my first choice because its possible side effects: blurred vision, dry mouth, urinary retention, drowsiness, weight gain, hypotension, and seizures (Stahl,2017) Assignment: Assessing and Treating Clients With Anxiety Disorders

Buspirone (Buspar), a serotonin receptor partial agonist can be appropriate for augmentation but not as first line treatment of GAD. Additionally, Buspirone takes longer (2 – 4 weeks) to have a full effect, and due to its sedation side effect, it would not be appropriate in our patient who has history of increased alcohol intake.

The goals of treatment of anxiety disorders are resolution of symptoms and prevention of relapse.

The client returns in four weeks, responding well to medication, anxiety decreased HAM A 18 from 26.

Options : Increase dose to 75 mg daily, increase dose to 100 mg daily, no change in drug/ dosage

Decision # 2 Increase dose to 75 mg daily. 

Rationale: Sertraline dosing in panic, PTSD, and social anxiety begin with 25 mg/day; increase to 50 mg/day after 1 week thereafter, usually wait a few weeks to assess drug effects before increasing dose; maximum generally 200 mg/day; single dose (Stahl,2017). Assignment: Assessing and Treating Clients With Anxiety Disorders

Moreover, increasing dosage slowly will reduce the possibility of acquiring side effects from the medication (Stein et al., 2014)

The client returns in four weeks, reports further reduction in anxiety symptoms HAM- A 10 (mild anxiety)

Options: Maintain current dose, increase to 100 mg daily, add Buspirone. 

Decision: Maintain current dose

Rationale: Major errors in psychopharmacological treatment of anxiety disorders include not achieving full remission of symptoms but instead accepting partial response, and not providing an adequate trial of medications (8 to 12 weeks ) before switching, discontinuing, or augmenting ( Woo & Wayne, 2013) . The patient was responding pretty well to medication ( 50% reduction in symptoms) , and reported no side effects. Therefore, continuing the same dosage, providing regular follow up with the patient to ensure medication adherence would be appropriate to meet the goals of remission.  Assignment: Assessing and Treating Clients With Anxiety Disorders

References

Johnson, E. M., & Coles, M. E. (2014). Failure and Delay in Treatment-Seeking Across Anxiety Disorders. Community Mental Health Journal, 49(6), 668-674. Retrieved from https://web-a-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=29&sid=7eabbc3a-b3a4-4cbf-b934-aa75c2e5b6fd%40sessionmgr4007

Kamo, T., Maeda, M., Oe, M., Kato, H., Shigemura, J., Kuribayashi, K., & Hoshino, Y. (2016). Dosage, effectiveness, and safety of sertraline treatment for posttraumatic stress disorder in a Japanese clinical setting: a retrospective study. BMC Psychiatry, 16(1). Retrieved from https://web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=6&sid=2ee0b7c6-b1c7-44e7-9b93-42c3b9a745c3%40sessionmgr102

Stein, D. J., Craske, M. A., Friedman, M. J., & Phillips, K. A. (2014). Anxiety Disorders, Obsessive-Compulsive and Related Disorders, Trauma- and Stressor-Related Disorders, and Dissociative Disorders in DSM-5. American Journal of Psychiatry, 171(6), 611-613. Retrieved from https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.14010003 Assignment: Assessing and Treating Clients With Anxiety Disorders

Woo, T. M., & Wynne, A. L. (2013). Pharmacotherapeutics for nurse practitioner prescribers(3rd ed.). Philadelphia, PA: F.A. Davis Co.

 

  • 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. Assignment: Assessing and Treating Clients With Anxiety Disorders
    • 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?

Assignment: Assessing and Treating Clients With Anxiety Disorders