PTI

Generalized Anxiety Disorder

BACKGROUND INFORMATION Middle-Aged White Male With Anxiety

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 Physician 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 1

Decision Point One (Select medication to give and the reason why the other wasn’t selected)

1. Begin Zoloft 50 mg po daily

2. Begin Imipramine 25 mg po BID

3. Begin Buspirone 10 mg po BID

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 medication to give and the reason why the other wasn’t selected)

Increase buspirone to 10 mg orally TID

Increase buspirone to 20 mg orally TID

Discontinue buspirone and begin Lexapro 10 mg orally daily

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 (Select medication to give and the reason why the other wasn’t selected)

Continue current dose and reassess in 4 more weeks

Augment with Ativan (lorazepam) 0.5 mg orally TID

Discontinue buspirone and begin Zoloft 50 mg orally daily

Decision Point Three

Discontinue buspirone and begin Zoloft 50 mg orally daily

READ VERY IMPORTANT!!!!!!!

Guidance to Student on the above three decisions.

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).

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,#2,#3

· 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?

CONCLUSION: Also include how ethical considerations might impact your treatment plan and communication with clients