NURS6640 Week 5 Anxiolytic Therapy & PTSD Treatment
“I’m no longer at the mercy of my PTSD, and I would not be here today had I not had the proper diagnosis and treatment. It’s never too late to seek help.”
—P.K. Philips, PTSD patient
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.
This week, as you study anxiolytic therapies and PTSD treatments, you examine the assessment and treatment of clients with PTSD and other anxiety disorders. You also explore ethical and legal implications of these therapies.
Photo Credit: [shironosov]/[iStock / Getty Images Plus]/Getty Images
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.
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
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
REQUIRED READINGS
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 9, “Anxiety Disorder and Anxiolytics”
Stahl, S. M., & Grady, M. (2010). Stahl’s illustrated anxiety, stress, and PTSD. New York, NY: Cambridge University Press.
To access the following chapters, click on the Illustrated Guides tab and then the Anxiety, Stress, and PTSD tab.
Chapter 4, “First-Line Medications for PTSD”
Chapter 5, “Second-Line, Adjunct, and Investigational Medications for PTSD”
Strawn, J. R., Wehry, A. M., DelBello, M. P., Rynn, M. A., & Strakowski, S. (2012). Establishing the neurobiologic basis of treatment in children and adolescents with generalized anxiety disorder. Depression and Anxiety, 29(4), 328–-339. doi:10.1002/da.21913
Note: Retrieved from Walden Library databases.
Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0
Note: Retrieved from Walden Library databases.
REQUIRED MEDIA
Laureate Education. (2016b). Case study: A middle-aged Caucasian man with anxiety [Interactive media file]. Baltimore, MD: Author.
Note: This case study will serve as the foundation for this week’s Assignment.
OPTIONAL RESOURCES
Lupi, M., Martinotti, G., Acciavatti, T., Pettorruso, M., Brunetti, M., Santacroce, R., & … Di Giannantonio, M. (2014). Pharmacological treatments in gambling disorder: A qualitative review. Biomed Research International, 2014. doi:10.1155/2014/537306
To prepare for this Assignment:
Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.
The Assignment
Examine Case Study: A Middle-Aged Caucasian Man With Anxiety. 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.
At each decision point stop to complete the following:
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.
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?
Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
CASE STUDY
// Generalized Anxiety Disorder
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
Answer: Begin Zoloft 50 mg orally daily
// Generalized Anxiety Disorder
Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety
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
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
ANSWER 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
Select what the PMHNP should do next:
Maintain current dose
Increase current dose of medication to 100 mg orally daily
Add augmentation agent such as BuSpar (buspirone)
// Generalized Anxiety Disorder
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)
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.
NURS6640 Week 5 Anxiolytic Therapy & PTSD Treatment
**Decision #1: Begin Zoloft 50 mg orally daily**
*Why this decision?*
Zoloft (sertraline) is a commonly prescribed selective serotonin reuptake inhibitor (SSRI) for generalized anxiety disorder (GAD) due to its efficacy and tolerability [Stahl, S. M., 2013]. Given the client’s presentation of symptoms consistent with GAD, including chest tightness, shortness of breath, and feelings of impending doom, initiating Zoloft can help alleviate these symptoms and improve overall functioning.
*Expected outcome:*
By initiating Zoloft, the goal is to reduce the client’s symptoms of anxiety, including chest tightness, shortness of breath, and worries about work. The expected outcome is a significant improvement in anxiety symptoms, leading to better quality of life and functioning. The decrease in HAM-A score from 26 to 18 indicates a partial response, suggesting a reduction in anxiety symptoms.
*Difference in expectation vs. results:*
The decision to begin Zoloft was expected to lead to a reduction in anxiety symptoms and improved functioning, as indicated by the decrease in the HAM-A score. The client reported some improvement in symptoms, including decreased worries about work, but the reduction in HAM-A score was not as substantial as anticipated. This suggests that further intervention may be necessary to achieve optimal symptom relief.
**Decision #2: Increase dose to 75 mg orally daily**
*Why this decision?*
Increasing the dose of Zoloft to 75 mg orally daily is a logical next step to optimize the client’s response to treatment [Stahl, S. M., 2013]. Since the client has shown some improvement in symptoms with the initial dose of 50 mg, increasing the dosage may lead to further reduction in anxiety symptoms and better overall outcomes.
*Expected outcome:*
By increasing the dose of Zoloft, the goal is to achieve a more robust reduction in anxiety symptoms, including chest tightness, shortness of breath, and worries about work. The expected outcome is a significant improvement in the client’s overall functioning and well-being, as reflected by a further decrease in the HAM-A score.
*Difference in expectation vs. results:*
The decision to increase the dose of Zoloft was expected to lead to a more pronounced reduction in anxiety symptoms and improved overall functioning. The client reported an even further reduction in symptoms, with a decrease in the HAM-A score to 10, indicating a 61% reduction in symptoms. This outcome exceeded expectations, suggesting that the client is responding well to the increased dosage of Zoloft.
**Decision #3: Maintain current dose**
*Why this decision?*
Given the client’s significant improvement in symptoms with the increased dose of Zoloft and absence of adverse effects, maintaining the current dose is a prudent decision [Stahl, S. M., 2013]. The client has achieved a substantial reduction in anxiety symptoms, and further dose escalation may not provide additional benefit while increasing the risk of side effects.
*Expected outcome:*
By maintaining the current dose of Zoloft, the goal is to sustain the client’s improvement in symptoms and prevent relapse of anxiety symptoms. The expected outcome is continued symptom relief and stability, as reflected by a sustained decrease in the HAM-A score over time.
*Difference in expectation vs. results:*
The decision to maintain the current dose of Zoloft was expected to sustain the client’s improvement in symptoms and prevent relapse. The client continued to report a further reduction in symptoms, indicating ongoing improvement in anxiety symptoms and overall functioning. This outcome aligns with expectations, supporting the decision to maintain the current dose of Zoloft.
**Ethical Considerations:**
Ethical considerations in treating clients with anxiety disorders include ensuring informed consent, respecting autonomy, beneficence, and nonmaleficence. It is essential to involve the client in treatment decisions, provide comprehensive education about the risks and benefits of medications, and respect their autonomy in choosing treatment options. Additionally, healthcare providers must prioritize the client’s safety and well-being, balancing the potential benefits of medication therapy with the risk of adverse effects. Open and honest communication with the client is crucial to building trust and promoting shared decision-making in the treatment process.
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