Case Study: A Man Who Is Displaying Sysmptoms Of Moderate Anxiety
Allen, a university graduate aged 21 years, attends the pharmacy of the campus counseling health center and asks to speak to the pharmacist in private. He states he is worried about heart palpitations that he has been experiencing. He is visibly sweating and looks on edge. The pharmacist calls the provider on duty at the psychiatric clinic for the counseling health center and she arrives.
Assessment
As the PMHNP on duty, you invite Allen into the consultation room and ask him about his symptoms. He states that he has started a new job and that the palpitations start when he is feeling anxious. His symptoms are occurring most days of the week and he says it makes him “feel on edge.” He adds that he does not want to socialize with his co-workers. It is starting to affect his sleep and he does not know what to do. He also states that he has occasional pain in his chest.
Treatment options
Allen is demonstrating symptoms of moderate anxiety, given his desire to avoid socializing, and has a degree of functional impairment. However, as he has potential cardiac symptoms, these issues could be related to another condition.
When questioned, he confirms he has no other problems with his health, but you feel the patient needs further investigation. For example, tests to measure the electrical activity of his heart to rule out underlying cardiac problems should be considered. His presentation concerns you and you feel he needs these tests today to assess the differential diagnosis, as you are worried about his chest pain and palpitations.
Vitals:
138/80
4
20
78
99%
5’10”
188 lbs.
Advice and recommendations
You encourage Allen by saying that it is great that he felt he could talk to a pharmacist about this, but explain that he would benefit from continued management with you as the PMHNP and possibly some additional psychotherapy. You explain that his symptoms could be related to anxiety and that you think he may need something to help him manage. He agrees to let you continue the assessment and design a treatment plan.
Allen, a new employee experiencing anxiety-related palpitations, chest pain, and social withdrawal, presents a complex clinical picture requiring a multifaceted treatment approach. As the PMHNP on duty, your primary goal is to manage his anxiety while ruling out any potential underlying cardiac issues. This plan outlines the assessment, diagnosis, and treatment options for Allen, considering both his mental and physical health needs.
Assessment and Diagnosis:
- Mental Health: Allen's symptoms, including palpitations triggered by anxiety, difficulty sleeping, social avoidance, and "feeling on edge," suggest a diagnosis of moderate anxiety disorder, potentially generalized anxiety disorder (GAD) due to the pervasive nature of his concerns.
- Physical Health: Allen's chest pain and palpitations raise concerns about potential cardiac issues. An ECG, Holter monitor, or echocardiogram are crucial to rule out any underlying cardiac pathology, such as arrhythmias or coronary artery disease.
- Anxiety disorders: GAD, panic disorder, social anxiety disorder
- Depression with anxious features
- Substance use disorders
- Physical health conditions: Thyroid disorders, arrhythmias, coronary artery disease, panic attacks
- Addressing Anxiety:
- Psychotherapy: Cognitive-behavioral therapy (CBT) is the first-line treatment for anxiety disorders and has proven highly effective in managing symptoms like worry, avoidance, and negative thought patterns. Refer Allen to a qualified therapist specializing in CBT for anxiety.
- Medication: Consider pharmacotherapy as an adjunctive treatment to CBT, especially if symptoms are severe or interfere significantly with daily life. Options include selective serotonin reuptake inhibitors (SSRIs) like escitalopram or sertraline, benzodiazepines for short-term relief of acute anxiety attacks, or beta-blockers to manage physical symptoms like palpitations.
- Lifestyle modifications: Encourage healthy coping mechanisms like regular exercise, relaxation techniques (meditation, deep breathing), adequate sleep, and maintaining a balanced diet.
- Ruling out Physical Causes:
- Cardiac evaluation: Based on Allen's chest pain and palpitations, prioritize a thorough cardiac evaluation with an ECG, Holter monitor, or echocardiogram to rule out any underlying cardiac conditions.
- Blood work: Consider ordering blood tests to rule out thyroid dysfunction or other potential medical causes of anxiety and physical symptoms.
- Follow-up and Monitoring:
- Schedule regular follow-up appointments: Monitor Allen's progress with both the PMHNP and therapist, adjusting treatment plans as needed.
- Communication and collaboration: Maintain close communication with Allen's therapist and any other healthcare professionals involved in his care to ensure a comprehensive and coordinated approach.
- Education: Provide Allen with educational resources about anxiety disorders and their treatment options.
- Support networks: Encourage Allen to connect with support groups or therapist-led groups to share experiences and learn coping strategies from others with similar challenges.
- Workplace accommodations: If necessary, advocate for workplace accommodations to reduce anxiety triggers and promote a supportive work environment.