PLEASE PAY ATTENTION TO THE CASE STUDY and CHAPTERS ATTACHED

PLEASE FOLLOW THE PROMPTS OF THE WAY THE QUESTIONS WERE ASKED.

ZERO PLAGIARISM

FIVE REFERENCES

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
    • 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?
  • Decision #2
    • 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 #2 and the results of the decision. Why were they different?
  • Decision #3
    • 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 #3 and the results of the decision. Why were they different?

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

Anxiety disorders and anxiolytics

This chapter will provide a brief overview of anxiety disorders and their treatments. Included here are
descriptions of how the anxiety disorder subtypes overlap with each other and with major depressive
disorder. Clinical descriptions and formal criteria for how to diagnose anxiety disorder subtypes are
mentioned only in passing. The reader should consult standard reference sources for this material.
The discussion here will emphasize how discoveries about the functioning of various brain circuits
and neurotransmitters – especially those centered on the amygdala – impact our understanding of
fear and worry, symptoms that cut across the entire spectrum of anxiety disorders.

The goal of this chapter is to acquaint the reader with ideas about the clinical and biological aspects
of anxiety disorders in order to understand the mechanisms of action of the various treatments for
these disorders discussed along the way. Many of these treatments are extensively discussed in
other chapters. For details of mechanisms of anxiolytic agents used also for the treatment of
depression (i.e., certain antidepressants), the reader is referred to ; for those anxiolyticChapter 7
agents used also for chronic pain (i.e., certain anticonvulsants), the reader is referred to .Chapter 10
The discussion in this chapter is at the conceptual level, and not at the pragmatic level. The reader
should consult standard drug handbooks (such as Stahl’s Essential Psychopharmacology: the

) for details of doses, side effects, drug interactions, and other issues relevant toPrescriber’s Guide
the prescribing of these drugs in clinical practice.

Symptom dimensions in anxiety disorders

When is anxiety an anxiety disorder?

Anxiety is a normal emotion under circumstances of threat and is thought to be part of the
evolutionary “fight or flight” reaction of survival. Whereas it may be normal or even adaptive to be
anxious when a saber-tooth tiger (or its modern-day equivalent) is attacking, there are many
circumstances in which

Figure 9-1. . Although the core symptoms ofOverlap of major depressive disorder and anxiety disorders
anxiety disorders (anxiety and worry) differ from the core symptoms of major depression (loss of interest and
depressed mood), there is considerable overlap among the rest of the symptoms associated with these
disorders (compare the “anxiety disorders” puzzle on the right to the “MDD” puzzle on the left). For example,
fatigue, sleep difficulties, and problems concentrating are common to both types of disorders.

the presence of anxiety is maladaptive and constitutes a psychiatric disorder. The idea of anxiety as
a psychiatric disorder is evolving rapidly, and is characterized by the concept of core symptoms of
excessive fear and worry (symptoms at the center of anxiety disorders in ), compared toFigure 9-1
major depression, which is

Antipsychotic agents

This chapter will explore antipsychotic drugs, with an emphasis on treatments for schizophrenia.
These treatments include not only conventional antipsychotic drugs, but also the newer atypical
antipsychotic drugs that have largely replaced the older conventional agents. Atypical antipsychotics
are really misnamed, since they are also used as treatments for both the manic and depressed
phases of bipolar disorder, as augmenting agents for treatment-resistant depression, and “off-label”
for various other disorders, such as treatment-resistant anxiety disorders. The reader is referred to
standard reference manuals and textbooks for practical prescribing information, such as drug doses,
because this chapter on antipsychotic drugs will

Figure 5-1. . ThroughoutQualitative and semi-quantitative representation of receptor binding properties
this chapter, the receptor binding properties of the atypical antipsychotics are represented both graphically and
semi-quantitatively. Each drug is represented as a blue sphere, with its most potent binding properties depicted
along the outer edge of the sphere. Additionally, each drug has a series of colored boxes associated with it.
Each colored box represents a different binding property, and binding strength is indicated by the size of the box
and the number of plus signs. Within the colored box series for any particular antipsychotic, larger boxes with
more plus signs (positioned to the left) indicate stronger binding affinity, while smaller boxes with fewer plus
signs (positioned to the right) represent weaker binding affinity. The series of boxes associated with each drug
are arranged such that the size and positioning of a box reflect the binding potency for a particular receptor. The
vertical dotted line cuts through the dopamine 2 (D ) receptor binding box, with binding properties that are more2
potent than D on the left and those that are less potent than D on the right. All binding properties are based on2 2
the mean values of published K (binding affinity) data ( ). The semi-quantitative depictioni http://pdsp.med.unc.edu

used throughout this chapter provides a quick visual reference of how strongly a particular drug binds to a
particular receptor. It also allows for easy comparison of a drug’s binding properties with those of other atypical
antipsychotics.

emphasize basic pharmacologic concepts of mechanism of action and not practical issues such as
how to prescribe these drugs (for that information see for example Stahl’s Essential

, which is a companion to this textbook).Psychopharmacology: the Prescriber’s Guide

Antipsychotic drugs exhibit possibly the most complex pharmacologic mechanisms of any drug class
within the field of clinical psychopharmacology. The pharmacologic concepts developed here should
help the reader understand the rationale for how to use each of the different antipsych

Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety

Middle aged male

 

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.

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

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-red.pngBegin Zoloft 50 mg po daily


https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-blue.pngBegin Imipramine 25 mg po BID

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-yellow.pngBegin Buspirone 10 mg po BID

Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety

Asian girl

 

Decision Point One

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-red.pngBegin 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)

Select what the PMHNP should do next:

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-red.pngIncrease dose to 75 mg orally daily

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-blue.pngIncrease dose to 100 mg orally daily

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-yellow.pngNo change in drug/dose at this time

Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety

Middle age male

 

Decision Point One

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-blue.pngBegin 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

Select what the PMHNP should do next:

Decision Point Two

Select what the PMHNP should do next:

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-red.pngIncrease Tofranil to 50 mg orally BID

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-blue.pngContinue current dose and reassess in 4 weeks

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/05/mm/generalized_anxiety_disorder/img/pill-yellow.pngAdd an augmentation agent such as BuSpar (buspirone) 5 mg orally TID

Generalized Anxiety Disorder
Middle-Aged White Male With Anxiety

Middle age male

 

Decision Point One