NURS6640 WU Week 5 Anxiolytic Therapy & PTSD Treatment
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 patientFor 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 ImagesAssignment: Assessing and Treating Clients With Anxiety DisordersCommon 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 ObjectivesStudents will:Assess client factors and history to develop personalized plans of anxiolytic therapy for clientsAnalyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring anxiolytic therapyEvaluate efficacy of treatment plansAnalyze ethical and legal implications related to prescribing anxiolytic therapy to clients across the lifespanLearning ResourcesNote: 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 ReadingsNote: 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.21913Note: Retrieved from Walden Library databases.Hamilton, M. (1959). Hamilton Anxiety Rating Scale. Psyctests, doi:10.1037/t02824-0Note: Retrieved from Walden Library databases.Required MediaLaureate 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 ResourcesLupi, 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:10.1155/2014/537306To prepare for this Assignment:Review this week’s Learning Resources. Consider how to assess and treat clients requiring anxiolytic therapy.The AssignmentExamine 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 #1Which 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 #2Why 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 #3Why 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 DisorderGeneralized Anxiety DisorderMiddle-Aged White Male With AnxietyBACKGROUND INFORMATIONThe 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 EXAMThe 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 OneSelect what the PMHNP should do:Begin Zoloft 50 mg po dailyBegin Imipramine 25 mg po BIDBegin Buspirone 10 mg po BID Answer: Begin Zoloft 50 mg orally daily // Generalized Anxiety DisorderGeneralized Anxiety DisorderMiddle-Aged White Male With AnxietyRESULTS 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 TwoSelect what the PMHNP should do next:Increase dose to 75 mg orally dailyIncrease dose to 100 mg orally dailyNo change in drug/dose at this time ANSWER Increase dose to 75 mg orally dailyRESULTS 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 ThreeSelect what the PMHNP should do next:Maintain current doseIncrease current dose of medication to 100 mg orally dailyAdd augmentation agent such as BuSpar (buspirone) // Generalized Anxiety DisorderGeneralized Anxiety DisorderMiddle-Aged White Male With AnxietyDecision Point OneBegin Zoloft 50 mg orally dailyRESULTS 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 TwoIncrease dose to 75 mg orally dailyRESULTS 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 ThreeMaintain current doseGuidance to StudentAt 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.
