Assessing and Treating Clients With Anxiety Disorders

Case study

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. Clients 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 PFMNP should do next :
1. 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)
2. Begin Tofranil (imipramine) 25 mg orally BID
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client reports a slight decrease in symptoms
Client’s states that he no longer gets chest tightness, but still has occasional episodes of shortness of breath
HAM-A score decreased from 26 to 22
3. Begin Buspirone 10 mg orally BID
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client reports slight decrease in symptoms
Client states that he still feels very anxious
HAM-A score decreased from 26 to 23

Decision point two
select what the PFMNP should do next :
1. Increase buspirone to 10mg orally TID
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client reports no change in his anxiety
HAM-A score has decreased from 23 to 22

2. Increase buspirone to 10mg orally TID

RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client reports nausea, dizziness, nervousness, headaches, and dry mouth
HAM-A score reveals no change and he reports that he still feels anxious

3. .Discontinue buspirone and start Lexapro 10mg orally dailly

RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client reports that he feels great
Client states that his anxiety is getting better
HAM-A score has decreased from 23 to 13
Client does report that he sometimes feels sleepy for a few hours after taking the medication, but perks up by early to midafternoon

Decision point three
select what the PFMNP should do next :
1.increase Lexapro to 15 mg orally daily in AM
Guidance to Student
At this point, the client reports that he is feeling great with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the clients symptoms. The PMHNP could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.

The most prudent course of action would be to continue the same dose of medication, but change the administration time to bedtime. This way, the client will not be troubled by the sedating effects of the medication, and sleep may be enhanced which could also improve overall anxiety.

At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.
2. Continue same dose of Lexapro but change administration time to bedtime.

Guidance to Student
At this point, the client reports that he is feeling great with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the clients symptoms. The PMHNP could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.

4. Guidance to Student
At this point, the client reports that he is feeling great with a decrease in symptoms from an initial HAM-A score of 26 down to 13. This represents a 50% decrease in symptoms in just 4 weeks. Recall that an adequate trail can be as long as 12 weeks, we may not need to increase the drug any more at this point as we do not know how much more the current dose will improve the clients symptoms. The PMHNP could increase the dose but this could increase the risk of side effects- especially the sleepiness that the client is complaining about in the morning after taking the medication. It is plausible that an increase in the dose would increase morning sedation.

At this point, nothing in the client presentation suggests the need to augment his Lexapro with any other agents. Therefore, buspirone augmentation would not be an appropriate response.