Assessing and Treating Patients With Anxiety Disorders
Assignment: Assessing and Treating Patients With Anxiety Disorders
Common symptoms of anxiety disorders include chest pains, shortness of breath, and other physical symptoms that may be mistaken for a heart attack or other physical ailment. These manifestations often prompt patients to seek care from their primary care providers or emergency departments. Once it is determined that there is no organic basis for these symptoms, patients are typically referred to a psychiatric mental health practitioner for anxiolytic therapy. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with anxiety disorders.
To prepare for this Assignment:
Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring anxiolytic therapy.
The Assignment: 5 pages
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 patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
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 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. CORE SKILL: matching the anxiety diagnosis to the mechanism-appropriate treatment, and knowing why the fastest-acting drug is usually the wrong first choice.
DIFFERENTIATE THE DISORDERS (they are treated differently): GAD (excessive worry, more days than not, ≥6 months, difficult to control, plus somatic symptoms); PANIC DISORDER (recurrent unexpected panic attacks + ≥1 month of persistent worry about attacks or maladaptive behavior change — note it is the ANTICIPATORY ANXIETY and avoidance, not the attacks alone, that define it); SOCIAL ANXIETY DISORDER (fear of scrutiny/negative evaluation); SPECIFIC PHOBIA; agoraphobia; OCD and PTSD (now in separate DSM-5-TR chapters — a detail worth getting right).
ALWAYS RULE OUT FIRST — and say so explicitly, because the prompt is built on this point: anxiety symptoms mimic and are mimicked by MEDICAL disease. Hyperthyroidism, PHEOCHROMOCYTOMA (episodic — headache, palpitations, diaphoresis, hypertension; check plasma free metanephrines), cardiac arrhythmia, asthma/COPD, hypoglycemia, pulmonary embolism. And SUBSTANCES: caffeine, stimulants, decongestants, albuterol, and — commonly missed — WITHDRAWAL from alcohol or benzodiazepines. Also: patients present to the ED convinced they are having a heart attack, so the differential runs in both directions.
PHARMACOLOGY:
— SSRIs/SNRIs ARE FIRST-LINE. Sertraline, escitalopram, paroxetine; venlafaxine, duloxetine. Counsel that ONSET TAKES 4–6 WEEKS and that there may be TRANSIENT ACTIVATION/worsened anxiety in the first 1–2 weeks — which is why you START LOW AND GO SLOW in anxious patients, and why failing to warn them is the commonest cause of early discontinuation. Watch: sexual dysfunction (a major adherence barrier — ask directly), GI upset, hyponatremia in the elderly, discontinuation syndrome with paroxetine and venlafaxine (short half-lives), and serotonin syndrome in combination.
— BENZODIAZEPINES: fast, effective — and the crux of the assignment. Tolerance, dependence, withdrawal (potentially fatal — seizures), falls and cognitive impairment in the elderly (Beers Criteria), and markedly increased overdose mortality WHEN COMBINED WITH OPIOIDS (boxed warning). The deeper argument, worth making: in panic disorder and in exposure-based therapy, benzodiazepines can act as a SAFETY BEHAVIOR that blocks extinction learning and undermines the therapy. So they are not merely risky — they can be counter-therapeutic. Reserve for short-term bridging.
— BUSPIRONE: 5HT1A partial agonist. No dependence, no sedation — but slow onset and ineffective for panic. Useful in GAD, particularly with substance-use history.
— HYDROXYZINE, propranolol (performance anxiety — blocks peripheral symptoms only), pregabalin (used in Europe).
PSYCHOTHERAPY: CBT with EXPOSURE is first-line and has durable effects that outlast medication; interoceptive exposure specifically for panic. Combination is often best.
FOR THE DECISION TREE: three decision points, each with evidence-based rationale, expected vs. actual outcome, and ethical considerations (informed consent, dependence risk disclosure, lifespan and cultural factors).
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