Therapy for Patients With Anxiety Disorders and PTSD Treatment Essay

Anxiety disorders are intrusive thoughts or concerns that can interfere with the daily functioning of an individual because they normally cause excessive fear, worry, nervousness, and apprehension. Anxiety disorders change how individual processes, emotions, and behaviors, leading to physical symptoms. while there are various anxiety disorders, the symptoms of a generalized anxiety disorder (GAD) include uncontrollable feelings of fear; restlessness, concentration difficulties, a feeling of being on the edge, increased irritability, and sleep difficulties (Chang et al., 2019). The presented case study involved a 46-year-old man who came for assessment and reported feelings such as chest tightness, a sense of impending doom, breath shortness, and constantly worrying about his work. The client reported that he was taking ETOH to reduce worries about work. He further reported that his workplace is punitive and stressful and this causes constant fear about work. The MSE revealed that he is well-oriented and his speech is clear and coherent. Additionally, he reports being nervous and his affect is blunted and broad, while his judgment is grossly intact. The findings from ER and ECK are normal, which ruled out myocardial infarction. His HAM-A score was 26, which confirmed the diagnosis of a generalized anxiety disorder (GAD). This paper presents the selected treatment decisions for the client and all decisions will be supported by the provided patient data and best available evidence. Moreover, the ethical considerations involved when making the selected decisions will be discussed.

Decision Point One

The prescribed medication is Zoloft 50 mg orally daily. Zoloft is a first-line treatment choice for anxiety disorders and an SSRI. SSRIs increase serotonin levels in the brain, which is a chemical brain that regulates mood and symptoms such as anxiety symptoms (Carhart-Harris & Nutt, 2017). Additionally, Zoloft is effective in improving the symptoms of GAD and has a few side effects. Buspirone and imipramine were not selected due to their many side effects.

Prescribing Zoloft for the client aimed to decreased GAD symptoms such as the reduced constant worry, chest tightness, sense of impending doom, and breath shortness. It is expected that the HAM-A score would decrease confirming the reduction of GAD symptoms. Moreover, Zoloft has a good safety profile and is associated with good tolerability and hence it is expected that the client will not experience adverse effects.

Zoloft 50 mg led to reduced GAD symptoms as the client reported reduced chest tightness, breath shortness, and he also reported that his constant worry about his job had reduced. There was also a significant reduction of the HAM-A score as it reduced from 20 to 18. This indicated a partial response to Zoloft 50 mg. The improvement evident from this client are attributable to the efficacy of the medication in treating symptoms of GAD (Clevenger et al, 2018).

When prescribing Zoloft for this client, informed consent was first sought where he was educated about this medication. Moreover, beneficence was applied as the medication selected was believed would lead to the best treatment outcome for this client.

Decision Point Two

The decision to have the Zoloft dose increased from 50 mg to 75 mg was chosen. This is because he showed a partial response to the initial Zoloft dose. Therefore, to ensure a good response, it was appropriate to increase the Zoloft dose. Increase Zoloft dose will avail more serotonin, leading to better symptoms (Clevenger et al., 2018). The dose was not increased to 100 mg because dose increment is supposed to be gradual to examine the tolerability and avoid unexpected side effects. The decision to maintain both Zoloft and the dose was not selected because he showed a partial response to Zoloft 50 mg.

Increasing Zoloft to 75 mg expects that there will be further symptom improvement and thus he will report more symptom decrease. According to Hieronymus (2019) increasing the dose of SSRIs like Zoloft leads to more serotonin and hence improves the efficacy. The client is expected to tolerate the increased dose without or with minimal side effects.

The client reported further symptom decrease as he was no longer worried about the work or experiencing anxiety symptoms. The HAM-A score further decreased to 10, which indicated 61% symptom reduction showing that he was having a good response towards Zoloft 75 mg. This is due to the increased efficacy of the higher Zoloft dose being an SSRI.

When increasing Zoloft dose to 75 mg, ethical principles of non-maleficence and beneficence were applied. This means that the risks and benefits involved in increasing the Zoloft dose to 75 were balanced while putting into consideration the decision likely to result in the best care outcomes (Girdler et al., 2018).

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Decision Point Three

This decision involved maintaining the same dose of Zoloft 75 mg for this client. The rationale of having the dose maintained is because the patient has shown a good response to Zoloft 75 mg as indicated by the significant reduction of the HAM-A score and the patient’s subjective data. The client also tolerated Zoloft 75 well as he did not report any adverse effects after being administered with this medication/dose. Evidence recommends that the titration of medications should be performed according to the response of the patient and tolerability to the dose increment (Schuck et al., 2016); therefore, because the client was showing a good response to Zoloft 75% and at the same time did not report any adverse effects, it is appropriate to maintain Zoloft 75 mg.

It is hoped that the maintenance of Zoloft 75 mg would lead to further symptom reduction and therefore a full symptom remission would be achieved by the client no longer worrying about his work and also the remission of anxiety symptoms. Secondly, the client would continue tolerating Zoloft 75 mg, without any adverse effects from the medication and the dose. This is due to Zoloft’s efficacy and a good safety profile (Feduccia et al., 2019).

The ethical principles of autonomy and confidentiality guided this treatment decision. This means that the PMHNP respected the autonomy of the client to continue with the treatment and at the same time ensured that the diagnosis and the treatment plan of this client were not disclosed to anyone, without the consent of the client (Rheeder, 2018).

Conclusion

The diagnosis of the client is GAD. The first pharmacological choice for the client is Zoloft 50 mg. The medication was chosen due to its effectiveness in the treatment of anxiety disorders like GAD as shown by the client manifesting a partial response (reduced HAM-A score) and the self-reported symptom reduction. Because the client showed a partial response to Zoloft 50 mg, the second decision was to have the dose elevated to 75 mg. When the Zoloft dose was increased to 75 mg, there was further symptom decrease as manifested by the further reduction of the HAM-A score, where there was a 61% symptom decrease. This indicated a good response to Zoloft 75 mg. He did not report any side effects after the dose increment. Therefore, the last decision was to maintain Zoloft 75 mg. This decision put into consideration that the client manifested a good response towards Zoloft 75 mg and also, he is tolerating this Zoloft dose as he did not report any side effects. While choosing the decisions, the ethical considerations that were applied included informed consent, confidentiality, autonomy, beneficence, and non-maleficence. This means that the confidentiality of the patient’s information was protected and he was educated about the available medications. Moreover, the client’s decision to accept or refuse treatment was respected. Finally, the selected decisions balanced the benefits and risks involved, while focusing on the best health outcomes.

References

Carhart-Harris, R. L., & Nutt, D. J. (2017). Serotonin and brain function: a tale of two receptors. Journal of Psychopharmacology, 31(9), 1091-1120.

Chang, S., Abdin, E., Shafie, S., Sambasivam, R., Vaingankar, J. A., Ma, S., … & Subramaniam, M. (2019). Prevalence and correlates of generalized anxiety disorder in Singapore: Results from the second Singapore Mental Health Study. Journal of anxiety disorders, 66, 102106.

Clevenger S, Devvrat M, Dang J, Vanle B & William I. (2018). The role of selective serotonin reuptake inhibitors in preventing relapse of major depressive disorder. Ther Adv Psychopharmacology, 8(1): 49–58.

Feduccia, A. A., Jerome, L., Yazar-Klosinski, B., Emerson, A., Mithoefer, M. C., & Doblin, R. (2019). Breakthrough for Trauma Treatment: Safety and Efficacy of MDMA-Assisted Psychotherapy Compared to Paroxetine and Sertraline. Frontiers in psychiatry, 10, 650. https://doi.org/10.3389/fpsyt.2019.00650

Girdler, S. J., Girdler, J. E., Tarpada, S. P., & T Morris T. (2018). Nonmaleficence in medical training: Balancing patient care and efficient education. Indian Journal of Medical Ethics, 2(4).

Hieronymus, F. (2019). Which antidepressant doses are optimal? The Lancet Psychiatry, 6(7), 552-554.

Rheeder, A. L. (2018). Respect for privacy and confidentiality as a global bioethical principle: Own reasons from a Protestant perspective. In die Skriflig, 52(3), 1-11.

Schuck, R. N., Pacanowski, M., Kim, S., Madabushi, R., & Zineh, I. (2019). Use of Titration as a Therapeutic Individualization Strategy: An Analysis of Food and Drug Administration-Approved Drugs. Clinical and translational science, 12(3), 236–239. https://doi.org/10.1111/cts.12626

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Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety
Middle age male

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).
rubric scores
Introduction to the case (1 page)

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 (1–2 pages)

• 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 (1–2 pages)

• 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 #3 (1–2 pages)

• 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.
Conclusion (1 page)

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• 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 liWritten Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement andintroduction are provided that delineate all required criteriaterature.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.

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