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

MY DECISION TREE CHOICES:

Begin Paxil 10 mg po 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 20 mg po 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 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 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.

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.
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Decision #1 (1 page)

• 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 page)

• 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 page)

• 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)

• 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 literature.

ADDITIONAL RESOURCES:

• Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.
  • Chapter 8,  “Anxiety, Trauma, and Treatment” (pp. 359-378)
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• American Psychiatric Association. (2010a). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorderLinks to an external site.. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd.pdf
• American Psychiatric Association. (2010c). Practice guideline for the treatment of patients with panic disorderLinks to an external site. (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf
• Bendek, D. M., Friedman, M. J., Zatzick, D., & Ursano, R. J. (n.d.). Guideline watch (March 2009): Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorderLinks to an external site.. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/acutestressdisorderptsd-watch.pdf
• Cohen, J. A. (2010). Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child and Adolescent PsychiatryLinks to an external site., 49(4), 414–430. https://jaacap.org/action/showPdf?pii=S0890-8567%2810%2900082-1
• Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of PsychiatryLinks to an external site., 2(6), e16–e18. 10.1192/bjpo.bp.116.003707. http://bjpo.rcpsych.org/content/2/6/e16
• Hamilton, M. (1959). Hamilton Anxiety Rating Scale (HAM-A)Links to an external site.. PsycTESTS. https://doi.org/10.1037/t02824-0
• Ostacher, M. J., & Cifu, A. S. (2019). Management of posttraumatic stress disorder. JAMALinks to an external site., 321(2), 200–201. https://doi.org/10.1001/jama.2018.19290
• 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 AnxietyLinks to an external site., 29(4), 328–339. https://doi.org/10.1002/da.21913