Description
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Questions: |
Remember to answer these questions from your textbooks and clinical guidelines to create your evidence based treatment plan. At all times, explain your answers.
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Goal:
To analyze and apply critical thinking skills in the pharmacokinetics and pharmacodynamics of psychopharmacological agents for patient treatment and health promotion while applying evidence-based research.
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Chapter 7, Case 1 |
Beth is a 23-year-old Asian American graduate student. She is currently in treatment with a psychologist for anxiety. She claims that her cognitive therapy has helped her control her worry and anxiety, but she has noticed that her symptoms have worsened this year with all of the pressures of school. In addition to worry, her mind races at night when she tries to sleep, and she claims it may often take her two to three hours to finally fall asleep. She describes herself as a ?type A? person who is rather ?anal? about doing well. She worries nonstop about grades but also worries nonstop about her health, money, her parents? health, and world affairs. She is very insightful about her condition and agrees the worry is excessive and unwanted. She admits that there is really no basis for the worry, as she has a full scholarship, she and her parents are in good health, and she currently has a 3.9 GPA. She claims that she has always been rather tense, but it didn?t get to the point that she sought treatment until her senior year in college. She was worried about getting accepted to grad school and ?obsessed? over getting straight A?s. She sought the help of a psychologist at the university counseling service, was placed on Paxil, and began therapy. For the most part, her symptoms disappeared, but she remembers feeling tired during the day. |
Chapter 7 ? Treatment of Anxiety Disorders
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nonstop about her health, money, her parents’ health, and world affairs. She is very insightful
about her condition and agrees the worry is excessive and unwanted. She admits that there is
really no basis for the worry, as she has a full scholarship, she and her parents are in good health,
and she currently has a 3.9 GPA. She claims that she has always been rather tense, but it didn’t get
to the point that she sought treatment until her senior year in college. She was worried about get-
ting accepted to grad school and “obsessed” over getting straight A’s. She sought the help of a
psychologist at the university counseling service, was placed on Paxil, and began therapy. For the
most part, her symptoms disappeared, but she remembers feeling tired during the day.
POSTCASE DISCUSSION AND DIAGNOSIS
Beth appears to have a rather classic case of Generalized Anxiety Disorder (F41.1). Her worry is
rather chronic, baseless, and interferes with sleep and concentration. After additional history, it
appears that both her mother and sister have had problems with anxiety, and her sister currently
takes Celexa to address the issue. Beth denies that she has ever had a panic attack and states that
she feels comfortable in most social situations. She has refrained from dating because she fears
that a boyfriend would distract her from her studies. She hopes to be accepted into a Ph.D. pro-
gram when she completes the M.A.
PSYCHOPHARMACOLOGICAL TREATMENT
In addition to psychotherapy, Beth was placed on Pristiq 50 mg every morning. While paroxetine
was helpful in the past, she did not like the sedation during the day. Since she also complains of
muscle tension in her neck, Pristiq and medicines like it help to reduce pain symptoms. In a
follow-up session with her psychiatrist two weeks after starting the medication, she reported
sleeping better and stated that her level of worry was drastically reduced. She still obsesses over
grades but expects to get into the doctoral program with her current GPA.
Case 2
CLINICAL HISTORY
Robert is a 24-year-old Hispanic male who recently took a job as a cable installer with a major
communications company. He had a series of low-paying jobs until he completed the training
and started this job two months ago. He always considered himself a little “anal” about his work
and often worries that he is doing a good job. Recently, at a meeting with his supervisor and five
other installers, his supervisor reminded them that someone would be going out to their jobs
after they were finished and inspecting them to make sure they were done properly. This news
made Robert very anxious, and soon he was having trouble sleeping at night and obsessing over
the quality of his work. He would check and recheck his work several times, often returning to
various homes after he had left the job. He also started to return to his truck several times while
on a job because he feared he had left the truck unlocked. This caused several of his customers
to ask him why he was doing this. This behavior was causing him to fall behind on his schedule,
thus upsetting his next customer. He started to notice that he was having difficulty falling asleep
at night as he would lie awake and wonder about a particular job and whether he had remem-
bered to install it correctly. He also began to notice that he would drive back to many jobs
because he thought he had left his tools there, only to find them later in the truck.
POSTCASE DISCUSSION AND DIAGNOSIS
Robert most likely has Obsessive Compulsive Disorder (F42). He appears plagued by a constant
need to check and recheck his work to alleviate his level of anxiety. It even interferes with his abil-
ity to relax and sleep at night and causes severe initial insomnia. Robert’s mother has severe GAD,
and his sister was diagnosed with OCD two years ago. Robert feels these behaviors are ruining
his life and driving him crazy, but he can’t seem to stop them on his own.
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Chapter 7 ? Treatment of Anxiety Disorders
TREATMENT REMINDERS AND CAUTIONS
For all patients with anxiety disorders, the therapist should advise them to eliminate or reduce the
consumption of caffeine and caffeine-based energy drinks. In fact, patients may wish to evaluate
their general diet and watch for excessive amounts of sugar or stimulants such as sodas, candy,
and cigarettes.
For most anxiety disorders, the four ?Bs? are used. These include benzodiazepines such as
diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin); bar-
biturates such as pentobarbital (Nembutal) and secobarbital (Seconal), which may potentiate
GABA but are very sedating and habit forming; buspirone (Buspar) for GAD; and beta blockers
for specific forms of social anxiety.
Side effects for anxiety medications vary according to the type used. Benzodiazepines are
usually well tolerated, and the side effects are minimal, but the symptoms of benzodiazepine
intoxication include slurred speech, severe sedation, dizziness, cognitive slowing, gait abnor-
malities, and an exaggerated sense of ?high.? Since some patients enjoy this feeling, therapists
must watch for tolerance and abuse. Benzodiazepines should be given cautiously to seniors
because an excess may lead to falls and broken bones. Failure to assess the patient for a more
serious depressive disorder or a psychotic disorder can result in a worsening of the condition
when treated with benzodiazepines alone. The therapist should warn the patient that sudden
withdrawal from benzodiazepines may cause an increase in anxiety and insomnia. Benzodiaz-
epines should never be taken with alcohol or other opioids, which will potentiate their effects
and could lead to overdose (Sun et al., 2017). Discontinuing the medication should be done
gradually, under medical supervision, and only after the patient has discussed other options
with the therapist and the prescribing professional (see Hood et al., 2014; Nardi et al., 2010).
The side effects for buspirone are usually mild and similar to those for antidepressants.
They include drowsiness, dry mouth, nausea, headache, dizziness, and insomnia. As with the
benzodiazepines, the patient must watch for dizziness, especially if operating heavy machinery.
Sleep aids should be used judiciously?that is, only when necessary and only for one to two
weeks maximum if taken daily. In some cases, patients may take sleep aids for long periods if they
use them only for intermittent insomnia. Side effects are minimal but include, of course, drowsiness,
amnesia, dizziness, falling, lethargy, disorientation, cognitive slowing, and possible depression.
In conclusion, since clinicians prescribing medication for anxiety disorders must make a
quick and accurate assessment of the condition, they need to have confidence that patients will
comply with treatment. Clinicians should obtain information about the duration and intensity of
the condition, as well as a history of substance abuse and previous treatment attempts.
CASE VIGNETTES
Case 1
CLINICAL HISTORY
Beth is a 23-year-old Asian American graduate student. She is currently in treatment with a psy-
chologist for anxiety. She claims that her cognitive therapy has helped her control her worry and
anxiety, but she has noticed that her symptoms have worsened this year with all of the pressures
of school. In addition to worry, her mind races at night when she tries to sleep, and she claims it
may often take her two to three hours to finally fall asleep. She describes herself as a “type A?
person who is rather “anal” about doing well. She worries nonstop about grades but also worries
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