NURS 6630 Post-Traumatic Stress Disorder (PTSD)
NURS 6630 Post-Traumatic Stress Disorder (PTSD)
The case highlights a 46-year-old white male presenting with chest tightness, shortness of breath and feeling of impending doom. The patient has a history of mild hypertension and tonsillectomy, which has been accompanied by unremarkable medical history. The patient cites occasional shortness of breath, chest tightness, feelings of impending doom and the need to ‘escape’ or ‘run’ from one place. He confesses using ETOH to combat worries about work since the management at his place of work is harsh, and he fears for his job. The patient’s symptoms are characteristic of generalized anxiety disorder.
Anxiety can be a normal part of life, with worries about health, family issues, and money temporarily dominating people’s lives. Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder characterized by nightmares, flashbacks, and intrusive thoughts associated with traumatic events in a person’s life (Ostacher & Cifu, 2019). PTSD is triggered by traumatic and terrifying events. It is a potentially debilitating condition that affects direct victims or witnesses of traumatic events such as car accidents, natural disasters, bereavement, violent assaults such as rape, war, and other life-threatening events. The events can set off an obsessive, recurring, and repetitive pattern of behavior that heightens feelings of fear, worry, helplessness, and hopelessness (Ostacher & Cifu, 2019). Nightmares, intrusive memories, and flashbacks are common in people who have had traumatic experiences in the past, increasing the risk of panic disorders.
Adults are more likely to suffer from generalized anxiety disorders, with PTSD manifestations appearing months after the traumatic and terrifying event. The symptoms of anxiety disorders can be harmful, but they do subside, easing the struggle with coping and self-care. Anxiety disorders, according to Holmes (2022), are mental conditions that impair quality of life by altering the action of neurotransmitters. Individuals suffering from anxiety disorders experience increased worry and fear.
Psychopharmacological therapy targets relieving symptoms rather than curing the disorders. The recommended medications in the management of anxiety disorders include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), antipsychotics, beta and adrenergic medications, antihistamines and GABAergic medications (Garakani et al., 2020). The treatment decisions will reflect the drug pharmacokinetics, pharmacodynamics, and ethical considerations in using the pharmacotherapeutic approach. The paper highlights three decisions on Generalized Anxiety Disorders.
I’m no longer at the mercy of my PTSD, and I would not be here today had I not had the proper diagnosis and treatment. It’s never too late to seek help.
—P.K. Philips, PTSD patient
For individuals presenting with posttraumatic stress disorder (PTSD) and other anxiety disorders, everyday life can be a constant challenge. Clients requiring anxiolytic therapy may present with anxiousness, depression, substance abuse issues, and even physical symptoms related to cardiovascular, respiratory, and gastrointestinal ailments. As a psychiatric nurse practitioner, you must be prepared to address the many needs of individuals seeking treatment for PTSD and other anxiety disorders.
This week, as you study anxiolytic therapies and PTSD treatments, you examine the assessment and treatment of patients with PTSD and other anxiety disorders. You also explore ethical and legal implications of these therapies.
Reference:
Philips, P. K. (n.d.). My story of survival: Battling PTSD. Anxiety and Depression Association of America. https://adaa.org/living-with-anxiety/personal-stories/my-story-survival-battling-ptsd
Learning Objectives
Students will:
- Assess patient factors and history to develop personalized plans of anxiolytic therapy for patients
- Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring anxiolytic therapy
- Synthesize knowledge of providing care to patients presenting with anxiolytic therapy
- Analyze ethical and legal implications related to prescribing anxiolytic therapy to patients across the lifespan
- Assess psychopharmacologic approaches to treatment for patients across the lifespan
Learning Resources
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Required Readings (click to expand/reduce)
Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e Sá, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier.
Medication Resources (click to expand/reduce)
Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
Review the following medications:
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Anxiety disorder is one of the most common mental illnesses across the world. In the United States, approximately 40 million adults above the age of 18 years are diagnosed with anxiety disorder every year (Curtiss et al., 2017). In most cases, this disorder is diagnosed at a later stage, as most people ignore the symptoms of anxiety disorder. Studies however show that early diagnosis of anxiety disorder promotes early interventions promoting the patient’s quality of life. Through evidence-based practices, several treatment options have been availed comprising of both pharmacological and psychotherapeutic approaches for the management of anxiety disorder (Strawn et al., 2018). The purpose of this paper is to illustrate the care plan of a middle-aged white adult male diagnosed with anxiety disorder. Every decision made on which psychotropic agent is most effective for the patient has been explained with consideration of both pharmacodynamic and pharmacokinetic factors displayed by the patient.
The provided case study demonstrates a 46 years old white male with a chief complaint of anxiety symptoms. He was referred to our clinic from the emergency room which he reported complaining of having a heart attack. Some of the symptoms demonstrated by the patient include shortness of breath, tightened chest, and the feeling of impending doom. He is also overweight. Past medical history reveals mild hypertension which he manages appropriately with a low sodium diet. His surgical history reveals the removal of tonsils at the age of 8 years. He takes 3 to 4 bottles of beer every night to manage his stress. He displayed a score of 26 upon administration of the Hamilton Anxiety Rating Scale (HAM-A). The patient however denies suicidal thoughts, visual or auditory hallucination. Currently, his primary diagnosis is generalized anxiety disorder (GAD).
Decision #1
Selected Decision
Begin Zoloft 50 mg orally daily
Reason for Decision One
Sertraline (Zoloft) belongs to the class of selective serotonin reuptake inhibitors (SSRIs) recommended by the FDA as the first-line medication for the management of GAD among adults (Strawn et al., 2018). The drug is absorbed in the GIT slowly with peak serum levels attained after 6 to 8 hours. Genetic factors such as CYP2B6 and CYP2C19 predominant among white patients, affect the metabolism of the drug with a prolonged half-life of 26 to 32 hours hence the once-daily dose, which promotes patient compliance (Strawn, Poweleit, & Ramsey, 2019). The drug takes between 8 to 12 weeks for complete remission of the patient’s symptoms.
Imipramine was not the best choice for the patient, as tricyclic antidepressant agents are most preferred among patients diagnosed with depression (Williams et al., 2020). Consequently, imipramine is associated with elevated systolic blood pressure, which might worsen the patient’s hypertensive condition.
Buspirone could also not be considered for this patient as a result of its cardiovascular side effects given the patient’s hypertensive condition (Williams et al., 2020). Consequently, the drug is associated with weight gain, which makes it inappropriate for patients who are overweight, just like the one in the provided case study.
Expected Outcome
The patient is expected to report back to the clinic after 4 weeks with at least 50% remission of symptoms such as chest tightness and dyspnea (Curtiss et al., 2017). He should regain confidence in life within this time, with a reduced feeling of impending doom. Lastly, his HAM-A score is expected to display ridings of less than 8.
Ethical Consideration
The PMHNP is expected to provide holistic care for the patient, which requires the involvement of the patient in making choices concerning the best intervention in the management of his mental condition (Williams et al., 2020). As such, the patient must be informed concerning the alternative psychotropic agents, including their benefits and side effects, and the reasons behind choosing a given drug over another.
Decision #2
Selected Decision
Increase Zoloft dose from 50mg to 75mg PO daily
Reason Behind Decision 2
The care outcome based on the first intervention reveals great compliance and adherence by the patient as no side effects were reported. Consequently, the patient displayed greatly managed symptoms, recording a reduced HAM-A score of 18. Studies show that Zoloft takes between 8 to 12 weeks for patients to enjoy complete remission of symptoms (Chen et al., 2019). As such, the recommended initial dose among adults is 50mg, which should be increased at dose intervals of 25 mg weekly as per the treatment outcome in the management of the patient’s symptoms. At this point, it is necessary to increase the dose to 75 mg once daily and monitor the patient for possible side effects.
Increasing the dose of Zoloft to 100mg is not necessary, as this is against the recommended guidelines for dose titration of the drug (Williams et al., 2020). Consequently, high doses of Zoloft are associated with severe side effects such as headache, nausea, dry mouth diarrhea, and nervousness.
Introducing another psychotropic agent is also necessary when the patient demonstrates great tolerance and adherence to the initial regimen (Curtiss et al., 2017). Otherwise, this will affect the patient’s compliance with the medication, as side effects might arise with the new medication.
Expected Outcome
Within the next 4 weeks, the patient is expected to display further remission of symptoms, with a HAM-A score of less than 8 (Williams et al., 2020). He should be able to regain his normal interest in daily activities and increased energy levels within this time.
Ethical Considerations
Legal and ethical requirements for the PMHNP are to promote patient’s well-being and prevent suffering (Chen et al., 2019). Given that the patients displayed great adherence to Zoloft, the PMHNP must maintain the drug and alter the dose as recommended to promote the patient’s safety.
Decision #3
Selected Decision
Maintain Zoloft 75mg PO daily and continue to monitor progress
Reason Behind Decision 3
The patient displayed a 61% remission of symptoms which demonstrates great adherence and compliance with the treatment regimen. He also recorded a HAM-A score of 10 which indicates mild anxiety. According to evidence-based practice, Zoloft can take up to 8 to 12 weeks to attain complete remission of the patient’s symptoms (Williams et al., 2020). The patient’s dose could be increased if he had displayed less than 50% remission of symptoms which is not the case. As such, continuing the same dose is necessary for further management of his symptoms, and to avoid the occurrence of undesired side effects.
Increasing the dose of Zoloft to 100 mg is not necessary, as this will compromise the patient’s compliance and lead to undesired side effects such as fatigue, dizziness, insomnia, and skin rash (Williams et al., 2020). This intervention could be considered if the patient’s symptoms could not have been managed as desired.
Consequently, adding a new medication is not necessary as the drug has displayed great effectiveness as monotherapy (Curtiss et al., 2017). Buspirone is also associated with cardiovascular side effects which could otherwise complicate the patient’s hypertensive condition.
Expected Outcome
Within the next four weeks, the patient is expected to display complete management of anxiety symptoms, and a HAM-A score of less than 8. No side effects are expected at this point given the great adherence and compliance exhibited by the patient in the last 8 weeks (Strawn et al., 2018).
Ethical Considerations
Given that the patient is an adult, he is responsible for making decisions concerning his health (Chen et al., 2019). As such, the PMHNP must inform the patient on the best intervention required at this point and proceed with the patient’s approval to promote patients’ satisfaction and healthy relationship for continuous positive outcomes.
Conclusion
Anxiety is a common mental illness globally with several side effects which compromise the patient’s quality of life. Most patients normally ignore symptoms of anxiety disorder which leads to complications that are expensive and hard to manage. However, with early diagnosis, patients can greatly benefit from psychotherapy and pharmacological interventions (Curtiss et al., 2017). The PMHNP is however required to consider pharmacodynamic and pharmacokinetic factors when choosing the most appropriate psychotropic agent for the management of anxiety disorder. The provided case study displays an adult white male patient diagnosed with GAD. The patient is overweight and hypertensive. The initial intervention for the patient is Zoloft 50mg orally once daily, which is recommended by the FDA as the first line for the management of GAD (Strawn et al., 2018). The other options were not appropriate as a result of side effects that would otherwise worsen the patient’s hypertensive condition. Based on the treatment outcome of the first intervention, the patient displayed great adherence and compliance to the medication with minimal reduction of symptoms which led to the second intervention of increasing the dose to 75mg.
The patient displayed 61% remission of symptoms, which made it necessary to maintain the dose of Zoloft as the third intervention. The patient displayed no symptoms, as the actual outcome was consistent with the expected outcome. Several legal and ethical considerations were observed by the PMHNP such as confidentiality and involving the patient in making decisions concerning his health (Chen et al., 2019). As such, the nurse must ensure that the patient is well informed about the treatment options and their outcome for the patient to be able to contribute to what decision to pick. Consequently, the patient must be educated on the need for psychotherapy in promoting the healing process.
References
Chen, T. R., Huang, H. C., Hsu, J. H., Ouyang, W. C., & Lin, K. C. (2019). Pharmacological and psychological interventions for generalized anxiety disorder in adults: A network meta-analysis. Journal of psychiatric research, 118, 73-83. DOI: 10.1016/j.jpsychires.2019.08.014. Epub 2019 Sep 1.
Curtiss, J., Andrews, L., Davis, M., Smits, J., & Hofmann, S. G. (2017). A meta-analysis of pharmacotherapy for social anxiety disorder: an examination of efficacy, moderators, and mediators. Expert opinion on pharmacotherapy, 18(3), 243-251. DOI: 10.1080/14656566.2017.1285907
Strawn, J. R., Geracioti, L., Rajdev, N., Clemenza, K., & Levine, A. (2018). Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert opinion on pharmacotherapy, 19(10), 1057-1070. DOI: 10.1080/14656566.2018.1491966.
Strawn, J. R., Poweleit, E. A., & Ramsey, L. B. (2019). CYP2C19-guided escitalopram and sertraline dosing in pediatric patients: a pharmacokinetic modeling study. Journal of child and adolescent psychopharmacology, 29(5), 340-347 DOI: 10.1089/cap.2018.0160
Williams, T., McCaul, M., Schwarzer, G., Cipriani, A., Stein, D. J., & Ipser, J. (2020). Pharmacological treatments for social anxiety disorder in adults: a systematic review and network meta-analysis. Acta neuropsychiatric, 32(4), 169-176. DOI: 10.1017/neu.2020.6