NURS 6630 Anxiety Disorder Middle-Aged White Male With Anxiety

NURS 6630 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.

You administer 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 you should do:

Begin Zoloft 50 mg po daily

Begin Imipramine 25 mg po BID

Begin Buspirone 10 mg po BID

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 you 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.

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NURS 6630 Anxiety Disorder Middle-Aged White Male With Anxiety
NURS 6630 Anxiety Disorder Middle-Aged White Male With Anxiety

Decision Point One

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
Decision Point Two

Increase Tofranil to 50 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client client reports that he was taken to the Emergency Room two weeks after the medication dose was increased. He was at work, and co-workers stated that he appeared to get “spacy” and lost consciousness. He states that the physician in the ER suggested that he stop taking the Tofranil because of an issue with his heart. The client brought a copy of his records from the ER, which included an EKG. The EKG shows right bundle branch block which was believed to have caused the clients syncopal episode.
Decision Point Three

Restart Tofranil at 25 mg orally BID

Guidance to Student
At this point, it is important that you discontinue the Tofranil due to the client’s bundle branch block. Recall that Tofranil can cause orthostatic hypotension, sudden death, arrhythmias, tachycardia, and QTc prolongation. It should not be used in clients who have already been identified as having an abnormality of cardiac conduction.

The most appropriate course of action for you to take would be the discontinuation of Tofranil and the initiation of an SSRI, such as Paxil (paroxetine) or Zoloft (sertraline), as these are considered first-line agents for the treatment of generalized anxiety disorders. Tofranil is considered a second-line agent.

BuSpar is also considered a second-line agent. It may have a role to play in the care of this client but not until an adequate trial of a first-line agent has been undertaken.

Decision Point One

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

Increase buspirone to 10 mg 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
Decision Point Three

Continue current dose and reassess in 4 more weeks

Guidance to Student
It is clear that buspirone has resulted in treatment failure as the client’s original HAM-A score was 26- a change in score from 26 to 22 is less than a 25% improvement in symptoms which constitutes treatment failure. It would not be appropriate to continue the same dose and reassess in 4 weeks as onset of therapeutic action for buspirone is around 2 weeks. At least a modest improvement should have been noted by now, if the drug were to work. If the client is having no side effects, you can discuss the possibility of increasing dose and re-evaluating in another 4 weeks. However, if the client remains distressed by his symptoms, the appropriate course of action would be to discontinue the buspirone and begin SSRI therapy with an agent such as Zoloft 50 mg orally daily.

Augmentation with an agent such as lorazepam 0.5 mg orally TID would not be appropriate at this time as the client needs a treatment plan for the long-term. You should never start someone on a benzodiazepine for an indefinite course of treatment as this could lead to addiction. Benzodiazepines should be used for a limited course of treatment for very specific therapeutic endpoints (for instance, to combat the initial activation which may be seen in the first few weeks after beginning an SSRI or SNRI).