Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment

Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment

Generalized anxiety disorders

Anxiety disorders are the most common psychiatric illness in both adults and children. Types of anxiety disorders are separation anxiety, panic disorders, social phobias, agoraphobia, and generalized anxiety disorders. Generalized anxiety is worry about a stressful event that is anticipated to happen in the future and gradually changes the patient’s cognitive functions and behavior. Anxiety triggers neurotransmitters serotonin, norepinephrine, dopamine, muscarinic, and histamine hence, increasing body activity, poor concentration, insomnia, high blood pressure, heartbeat, chest pain, and abdominal pain. These are the symptoms of short-term and long-term stress responses in the body. According to the American psychiatric association, generalized anxiety disorder presents with chest pain/tightness, palpitations, sweating, choking, paresthesia, fear of dying, trembling, dizziness, and shortness of breath (Maron & Nutt, D. 2022)Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment.

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Causes of generalized anxiety disorder are substance use, alcohol intake, psychotropics, stressful work environment, childhood traumas, severe injury or diseases, and interpersonal conflicts or loss. There are no specific diagnostic tests available for anxiety disorders, hence diagnosis is made from history taking, mental state examination, and use of anxiety assessment tools.

Anxiety assessment tools include the Hamilton rating scale for anxiety, generalized anxiety disorder questionnaire GAD-7, personal health questionnaire, and Beck’s depression inventory. Hamilton rating scale for anxiety is the most common clinician-based questionnaire that defines the symptoms from not present to severe, mild anxiety, and moderate to severe according to their scores (Gale, et al, 2019). The patient has generalized anxiety disorder because he presents with chest tightness, a feeling of choking, a pounding heartbeat, and excessive worry. The triggers for anxiety are his stressful work environment, occasional use of ETOH, and responsibility for his aging parents. On examination, he is anxious and in a bleh mood. He scores 26 on the Hamilton rating scale for anxiety, indicating moderate to severe anxiety disorder. Treatment methods for generalized anxiety disorder include anxiolytics, antidepressants, and psychotherapy to reduce symptoms, restore behavior, and improve cognitive functions. In this essay, I will describe the three treatment decisions for the patient and the ethical principles to improve communication and treatment. Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment

Decision #1

Which decision did you select?

Paxil 10mg PO daily

Why did you select this decision?

Paxil is a selective serotonin reuptake inhibitor that reduces serotonin concentration with a weak affinity for muscarinic and alpha-adrenergic receptors to reduce anxiety symptoms such as chest pain, loss of concentration, mood symptoms, sweating, trembling, and shortness of breath (Dunham, K. E., & Venton, B. J. 2022). Paxil is a per oral drug, absorbed in the GIT, and undergoes fast-pass metabolism. It has over 60% bioavailability, plasm peak of 2-8hours, and plasma half-life of over 21hours. The common side effects are dry mouth, fatigue, change in weight, nausea, and headache. However, patients tolerating the drug well do not experience these side effects (Bui, et al., 2016)Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment. I selected this drug because it is more potent than other SSRIs and is FDA approved for anxiety disorders. Studies confirm its effectiveness in improving the symptoms and reducing disability within 8weeks of treatment.

Why did you not select the other two options provided in the exercise?

Imipramine is a tricyclic antidepressant that increases the level of the chemical in the brain by inhibiting the reuptake of serotonin and norepinephrine. To reduce the symptoms of anxiety such as agitation, tachycardia, and palpitations. It is completely absorbed in the body with a plasma peak time of 2 hours, a plasma half-life of 18 hours, and efficacy onset after two weeks of initiating the drug. I did not select the drug because it increases suicidal ideation in young adults. It can lead to seizures, tachycardia, dizziness, agitation, deliriums, and deliriums (Kumar, et al, 2018). Its anticholinergic effects increase the risk for dementia. Buspirone is an anxiolytic with a higher affinity for serotonin receptors and a moderate affinity for dopamine receptors. It is 4% bioavailable with a plasma peak time of 2 hours, and a half-life of three hours. It achieves its therapeutic effects after four to six weeks of treatment. It is more effective in augmenting an SSRI than when administered as a monotherapy (Park, 2020)Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment. I did not select this drug because it is not effective on its own and takes a longer duration to achieve therapeutic goals.

What were you hoping to achieve by making this decision?

The expectations of administering Paxil are to reduce the HAM-A scale and reduce symptoms of chest tightness, choking sensation, anxiety, and restlessness.

How ethical considerations may impact your treatment plan and communication

Ethical principles express moral approval of the expected standards in making decisions that create a positive impact. Examples of ethics in nursing are justice, beneficence, respect for autonomy, consent, and non-maleficence. At this decision point, the nurse considers consent and justice. Informed consent seeking permission to initiate treatment after giving full information about the illness. Justice is being kind or fair to the patient by being respectful in communication and assessment Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment.

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Decision #2

Which decision did you select?

Increase Paxil to 20mg

Why did you select this decision?

The patient returns to the clinic after four weeks reporting improved symptoms and there is a decrease in the HAM-A scale response to 18. Increasing the dose to 20mg will increase the efficiency to reduce the symptom. This is the best choice for the patient because 20mg is the optimal minimum dose.

Why did you not select the other two options provided in the exercise?

Increasing the dose to 40mg would improve the symptom because it is within the optimal dose. However, increasing abruptly to 4omg would precipitate drug adverse effects. FDA approves a 10mg alternative week increase of the dose while observing the side effects (Dunham & Venton, 2022)Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment. Maintaining the same dose of 10mg is not sufficient to achieve the desired therapeutic goal. The American psychiatric association recommends 20 to 50mg once daily.

What were you hoping to achieve by making this decision?

The expectation of making this decision was to improve the symptoms by 50% because of drug dosage optimization.

How ethical considerations may impact your treatment plan and communication

At this decision point, the nurse incorporates the principle of beneficence and non-maleficence. Beneficence is a strong connotation of doing good to the patients to improve their health outcomes. The nurse does this by adjusting to the optimum drug dose to achieve the therapeutic goal. Non-maleficence is the obligation of not inflicting harm on patients (Saunders, 2017)Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment. The nurse protects the patient from drug adverse effects by not increasing the dosage to 40mg abruptly.

Decision #3

Which decision did you select?

Maintain the current dose

Why did you select this decision?

The patient came back after four weeks and reported a further reduction of the symptoms and the HAM-A scale decreases to 10. 20mg is the optimum adult dose and has no side effects on the patient. Maintaining the current dosage is the best choice because the drug has achieved the therapeutic goal within 8weeks of treatment.

Why did you not select the other two options provided in the exercise?

I did not increase the drug to 30mg because the patient reports an improvement of the symptoms by more than 50%. I did not augment Paxil with buspirone because the patient is responding well to treatment. Buspirone helps in augmenting SSRIs when they do not achieve their therapeutic goals.

What were you hoping to achieve by making this decision?

The expectation of maintaining the dose is to achieve the optimum effects without triggering the side effects of Paxil. The patient will gradually reduce the symptoms and reduce the score to 0 over time Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment.

How ethical considerations may impact your treatment plan and communication

At this decision point, the patient’s symptoms have improved and the HAM-A score has reduced. It is important to advise the client to enroll in cognitive-based therapy to improve behavior and function. Additionally, advise the patient for psychiatric clinic follow-up for symptom monitoring. However, the patient should make that decision without the influence of the nurse. The principle of autonomy is the respect of a person’s decisions according to values or desires that are authentically one’s own.

Conclusion

Anxiety disorders are the most common psychiatric illness in both adults and children. The classical symptom is an excessive fear of the unknown. Generalized anxiety disorder presents with chest pain/tightness, palpitations, sweating, feeling of choking, paresthesia, fear of dying, trembling, feeling dizzy, and shortness of breath. Causes of generalized anxiety disorder are substance use, alcohol intake, use of psychotropics, stressful work environment, childhood traumas, severe injury or diseases, and interpersonal conflicts or loss. Hamilton rating scale for anxiety is the most common clinician-based questionnaire that defines the symptoms from not present to severe, mild anxiety, and moderate to severe according to their scores. Paxil is more potent compared to other SSRIs, it is FDA approved for anxiety disorders, and studies have confirmed its effectiveness in improving the symptoms and reduction of disability as early as 8weeks of treatment. Imipramine is a tricyclic antidepressant that leads to seizures, tachycardia, dizziness, agitation, deliriums, and deliriums. Its anticholinergic effects increase the risk for dementia. Buspirone is more effective in augmenting an SSRI than when administered as a monotherapy. Ethical principles express moral approval of the expected standards in making decisions that create a positive impact Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment.

References

Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e Sá, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier.

Dunham, K. E., & Venton, B. J. (2022). SSRI antidepressants differentially modulate serotonin reuptake and release in Drosophila. Journal of Neurochemistry.

https://doi.org/10.1111/jnc.15658 Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment

Gale, C., Glue, P., Guaiana, G., Coverdale, J., McMurdo, M., & Wilkinson, S. (2019). Influence of covariates on heterogeneity in Hamilton Anxiety Scale ratings in placebo-controlled trials of benzodiazepines in generalized anxiety disorder: systematic review and meta-analysis. Journal of Psychopharmacology, 33(5), 543-547.

https://doi.org/10.1177%2F0269881118822146

Kumar, D., Hidayathulla, S., & Rub, M. A. (2018). Association behavior of a mixed system of the antidepressant drug imipramine hydrochloride and dioctyl sulfosuccinate sodium salt: Effect of temperature and salt. Journal of Molecular Liquids, 271, 254-264. https://doi.org/10.1016/j.molliq.2018.08.147

Maron, E., & Nutt, D. (2022). Biological markers of generalized anxiety disorder. Dialogues in clinical neuroscience. https://doi.org/10.31887/DCNS.2017.19.2/dnutt

Park, Y. M. (2020). The Hypothesis on the Prediction of Treatment Response with Buspirone Augmentation along with Serotonergic Antidepressant in Patients with Major Depressive Disorder Using Loudness Dependence of Auditory Evoked Potentials: Two Cases and Review of the Literature for Evidence. Psychiatry Investigation, 17(3), 222. https://doi.org/10.30773%2Fpi.2019.0293

Saunders, B. (2017). First, do no harm: Generalized procreative non‐maleficence. Bioethics, 31(7), 552-558. https://doi.org/10.1111/bioe.12366

To prepare for this Assignment: Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment
Review this weekâ€™s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring anxiolytic therapy.
The Assignment: 5 pages
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 patient. Be sure to consider factors that might impact the patientâ€™s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page) 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. Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment
He admits that he still has problems with tightness in the chest and episodes of shortness of breath- he now terms these â€œanxiety attacks.â€ He will also report occasional feelings of impending doom, and the need to â€œrunâ€ or â€œescapeâ€ 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. Clientâ€™s self-reported mood is â€œblehâ€ and he does endorse feeling â€œnervousâ€. 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

DECISION 1
Decision Point One
Begin Paxil 10 mg po 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)Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment

Decision Point Two
No change in drug/dose at this time
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client reports no further decreases in anxiety and is wondering if this means that the medication will not be effective for him

Decision Point Three
Increase drug to 75 mg po daily
Guidance to Student

Increasing the drug to 75 mg po daily would be a prudent next step. At 4 weeks follow up, the client already demonstrated a partial response to this medication, so it would be appropriate to increase to 75 mg po daily. Nothing indicates that augmentation would be necessary as the client has not had an adequate trial of this drug at a therapeutic dose (only a starting dose). Similarly, nothing indicates failure of SSRI therapy and there is no compelling evidence that switch to an SNRI should occur at this time.

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page) Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

RESOURCES

Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e SÃ¡, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 61â€“71). Elsevier.

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd.pdf

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf

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https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf Therapy for Patients With Anxiety Disorders And PTSD Treatment Assignment

References
Hamilton, M. (1959). Hamilton Anxiety Rating Scale. PsycTESTS. https://doi.org/10.1037/t02824-000

https://www.jaacap.org/action/showPdf?pii=S0890-8567%2810%2900082-1

https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm