Case Study: A Man Who Is Displaying Sysmptoms Of Moderate Anxiety

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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.

Sample Solution

Case Study: Allen’s Anxiety and Palpitations

Initial Assessment:

Allen’s presentation suggests moderate anxiety with features such as:

  • Physical symptoms: Palpitations, sweating, chest pain, sleep disturbances.
  • Emotional symptoms: Feeling on edge, anxious, unable to socialize.
  • Functional impairment: Difficulty sleeping, avoiding social interactions.

However, the chest pain and palpitations raise concerns about potential underlying cardiac causes.

Differential Diagnosis:

  • Generalized Anxiety Disorder (GAD): The most likely diagnosis given Allen’s symptoms and presentation.
  • Panic Disorder: Less likely due to the absence of reported panic attacks.
  • Social Anxiety Disorder: Possible, considering Allen’s avoidance of social interactions.
  • Cardiac disorders: Myocardial ischemia, arrhythmias, cardiomyopathy – need to be ruled out due to chest pain and palpitations.

Further Investigation:

  • Physical examination: To assess vital signs, heart sounds, and other physical findings.
  • Electrocardiogram (ECG): To evaluate heart rhythm and electrical activity.
  • Blood tests: To rule out medical conditions like thyroid problems or electrolyte imbalances.
  • Additional tests: Chest X-ray or echocardiogram may be needed depending on ECG and physical exam findings.

Treatment Plan:

A. Medical Management:

  • Benzodiazepines: Short-term (2-4 weeks) as-needed medication for acute anxiety and relief of panic attacks, if present. Examples: Llorazepam, Alprazolam.
  • Selective Serotonin Reuptake Inhibitors (SSRIs): First-line medication for long-term management of GAD and social anxiety. Examples: Sertraline, Escitalopram.
  • Buspirone: Anxiolytic with a different mechanism of action than SSRIs and benzodiazepines, considered second-line for GAD.

B. Psychotherapy:

  • Cognitive-Behavioral Therapy (CBT): Effective for GAD and social anxiety, teaching coping skills and thought restructuring.
  • Acceptance and Commitment Therapy (ACT): Can help individuals accept anxiety and reduce its impact on life.

C. Education and Support:

  • Provide information about anxiety disorders and their management.
  • Encourage healthy lifestyle habits like regular exercise, relaxation techniques, and adequate sleep.
  • Connect Allen with campus resources for counseling and support groups.

Ongoing Monitoring:

  • Regular follow-up appointments to monitor treatment response and adjust medications as needed.
  • Continue assessing for underlying medical conditions if initial tests are inconclusive.
  • Track progress in therapy and provide additional support as needed.

Addressing Allen’s Concerns:

  • Emphasize the safety of seeking help: Validate his concerns and encourage him to consider it a sign of strength.
  • Explain the differential diagnosis: Briefly discuss the possibility of anxiety and underlying medical conditions, assuring him of thorough investigation.
  • Reassurance and education: Reassure him that anxiety is treatable and many coping mechanisms can help him manage it.
  • Collaboration with other providers: Coordinate care with the pharmacist and campus counseling center to ensure comprehensive support.

Prognosis:

With good adherence to treatment, Allen’s prognosis is good. Most individuals with GAD experience significant improvement with medication and therapy. Continued support and follow-up will be crucial to prevent relapse and manage future stressors.

Additional Considerations:

  • Cultural factors and stigma surrounding mental health should be considered when communicating with Allen.
  • The impact of his new job and potential workplace triggers for anxiety should be explored.
  • Allen’s support network (family, friends) should be involved in his treatment plan with his consent.

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