Discussion Board Due 7.5.2020 by 9PM EST

Original Post

Kristen is a 38 year-old divorced mother of two teenagers. She has had a successful, well-paying

career for the past several years in upper-level management. Even though she has worked for the

same, thriving company for over 6 years, she’s found herself worrying constantly about losing

her job and being unable to provide for her children. This worry has been troubling her for the

past 8 months. Despite her best efforts, she hasn’t been able to shake the negative thoughts.

Ever since the worry started, Kristen has found herself feeling restless, tired, and tense. She often

paces in her office when she’s there alone. She’s had several embarrassing moments in meetings

where she has lost track of what she was trying to say. When she goes to bed at night, it’s as if

her brain won’t shut off. She finds herself mentally rehearsing all the worse-case scenarios

regarding losing her job, including ending up homeless.

Respond to classmate 1:

Presenting Problem: Kristen is a 38-year old successful mother of two. Despite a well-paying

career, she constantly worries about losing her job. This has persisted for 8 months despite her

best efforts to shake these negative thoughts. This has caused her to feel restless, tired, and tense.

Karen suffers from Generalized Anxiety Disorder 300.02 (F41.1).

Predisposing Factors: Kristen is divorced so is likely the sole breadwinner. She has two teenaged

children to care for.

Precipitating Factors: The worry is causing her to feel restless, tired, and tense. This is impacting

her work because she often paces when she’s alone and loses focus. She’s worried about losing

her job and becoming homeless.

Perpetuating Factors: This worry is almost a self-fulfilling prophecy. She worries about losing

her job. The worry is causing her to lose sleep and ultimately lose focus on her job. She has

embarrassing moments already and she’s afraid that she’s going to lose her job.

Protective/Positive Factors: Kristen is obviously a talented woman. She’s worked for the same

company for over 6 years and has already found herself in an upper-level management position.

This is her greatest strength. She has two teenagers that could be a source of encouragement.

Case formulation: Kristen presents with constant worry, negative thoughts, restlessness, fatigue,

and tension. The problem seems to be precipitated by her fear of losing her job and not being

able to support her two teenage children; ultimately ending up homeless. The primary

predisposing factor is the divorce from her husband, leaving her to be the sole breadwinner in the

home. The current problem seems to be maintained by her increasingly poor performance at

work. She paces when alone and loses track of what she’s saying in meetings. She has trouble

sleeping so is often tired and tense. However, the client has a number of strengths and supports

including a successful, well-paying career in upper-level management and two teenage children

that would likely be supportive of their mother.

Treatment Planning: For treatment, I would recommend cognitive behavior therapy directed at

Kristen’s anxieties of losing her job. Medication may be helpful, especially in the evening. It

seems as though lack of sleep is compounding the problems that she is experiencing at work, and

medication may help her relax and allow her brain to shut off.

Respond to Classmate 2:

Conceptualization as follows in the case of the 38 year-old divorced mother (Kristen) who has

two teenagers and who has a successful, well-paying career for the past several years in upper-

level management in a thriving company for 6 years

Level 1 Cross-Cutting Symptom Measure

In Kristen’s case, she appears to be suffering from an anxiety disorder based off the dialogue on

the discussion board and they are discussed below in which I assessed scores, presented

problems, the predisposing factors, precipitants, perpetuating factors;

8 months of being worrisome (5) score (Severe)

Negative thoughts (5) score (Severe)

Restless (5) score (Severe)

Tired (5) score (Severe)

Tense (5) score (Severe)

Unable to think at night (5) score (Severe)

Worse Case scenarios in losing job (5) score (Severe)

Presenting the problem

Worrisome

Negative thoughts

Tired

Tense

Unable to think

Predisposing Factors

Her job

Precipitants

Stress and worrying

Perpetuating Factors

All of the above conditions and if treatment plan is not in effect then patient will become worse

My diagnoses is she suffers from Generalized Anxiety Disorder 300.02 (F41.1) and the features

depicted within the prior information consist of the following key features;

The key features of generalized anxiety disorder are persistent and excessive anxiety and worry

about various domains, including work and school performance that the individual finds difficult

to control. In addition, the individual experiences physical symptoms, including restlessness or

feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank;

irritability; muscle tension; and sleep disturbance.

I will use a patient-centered approach for this diagnosis, which means that the patient (Kristen)

will be engaged in communication with myself, she makes needs and preferences known, and

she shares in the decision-making process.

Treatment Plan and Considerations

Acute Treatment Goals

• Reduce severity of symptoms

• Achieve remission

• Improve functional status

• Minimize adverse drug reactions

Considerations

• What is the history of this patient (e.g., chronicity, course and severity of prior episodes,

precipitating factors)?

• Are there medical or other conditions that would affect treatment selection?

• Does the patient have a preference for psychological or pharmacotherapy?

• How severe are the symptoms on presentation?

• How functionally impaired is the patient?

• Are factors such as cost or availability of therapy important?

Maintenance Treatment Goals

• Prevent relapses

• Improve quality of life

• Minimize adverse drug reactions

Considerations

• Are there comorbid conditions that may affect the course of GAD (e.g., depression or other

psychiatric diagnoses)?

• Will the patient require combination therapy for long-term improvement?

• How well will the patient adhere to treatment recommendations?

• Avoid long-term benzodiazepine therapy, whenever possible

Step 1: Potential GAD

• Obtain medical history and physical examination to identify any potential medical concerns or

causes

• Identify the anxiety/worry complaints

• Screen for GAD

• Assess for other mental illnesses (e.g., depression), substance abuse, sleep patterns, and

insomnia

• Apply the DSM-5 criteria to confirm the diagnosis of GAD

• These factors should be reconsidered at each treatment step when patient has an inadequate

response

Step 2: GAD has been confirmed upon the following determinations

• Determine the severity and level of functional impairment (for severe symptoms that cause

significant impairment, move to step 4 and begin psychotherapy or pharmacotherapy)

• Establish a therapeutic alliance, a supportive care environment, and a “patient-centered”

approach

• Establish agreed-on goals of therapy

• Initiate patient education about evidence-based treatment options

• Connect the patient with national educational sites such as National Alliance on Mental Illness,

National Institute of Mental Health, Anxiety and Depression Association of America

• Counsel on lifestyle changes

• Educate family and elicit support

• Provide self-help information about relaxation techniques

• Initiate active monitoring and follow-up for lifestyle changes and symptoms

Step 3: Initiate self-directed approaches and support Poor or partial response in step 2

• Begin low-intensity psychotherapeutic interventions such as online CBT, guided self-help,

supportive groups

• Consider mindfulness-based interventions

• Monitor to determine whether symptoms continue

Step 4: Initiate psychotherapy or pharmacotherapy

Poor or partial response in step 3

• Discuss options of psychotherapy and pharmacotherapy with the patient, and make a shared

decision

• Initiate therapy with one modality and generally not a combination of CBT and medication

• Psychotherapy: Provide or refer for clinician-delivered CBT or applied relaxation therapy

• Pharmacotherapy: Initiate SSRI. May consider short-term benzodiazepine for severe symptoms

or impairment if there is an urgent need to control symptoms and no history of substance abuse.

Allow 4–6 wk after achieving therapeutic dose to assess response. Alternatives include an SNRI,

buspirone, hydroxyzine, pregabalin, and bupropion

• Monitor initially every 2 week

• Continue medication for at least 12 months after response

Step 5: Modify psychotherapy or pharmacotherapy Poor or partial response in step 4

• Assess for complications that may reduce response: review diagnosis, complete medication

review including adherence, ongoing psychosocial stressors, relationship issues, work problems

• If psychotherapy inadequate, consider increasing number of sessions or adding

pharmacotherapy

• If pharmacotherapy inadequate, consider the following:

1. Poor response: Change to another antidepressant (SSRI or SNRI)

2. Partial response: Can augment first antidepressant with buspirone, hydroxyzine, pregabalin, or

short course of BZD; change to another antidepressant; or add CBT, depending on clinical and

patient preference

• Continue chosen option for at least 12 months if the patient has a good response to the chosen

option

Step 6: Modify psychotherapy or pharmacotherapy

Poor or partial response in step 5

• Consider specialist referral

• Reassess diagnosis, psychiatric comorbidities, and other explanations for treatment failure

• Add psychotherapy to pharmacotherapy, if not already done• Pharmacotherapeutic options1.

Poor response: Try an SNRI if not already used. Try alternative antidepressants (mirtazapine,

bupropion, vortioxetine, imipramine). Try other agents such as buspirone, hydroxyzine,

pregabalin, or BZD2. Partial response: Try any of the augmenting agents listed earlier

Step 7: Modify pharmacotherapy

Poor or partial response in step 6

• Poor response: Change to another combination of antidepressant and augmenting agent not

used earlier

• Partial response: Try augmenting with another agent listed previously not already used or an

SGA (quetiapine, risperidone) or valproate

Step 8: Continue to modify pharmacotherapy

Poor or partial response in step 7

• Reassess diagnosis, comorbidities, and adherence• Consider less-preferred medications with

some data to support use

1. Aripiprazole

2. Ziprasidone

3. Olanzapine

4. Gabapentin