Week 8 Discussion 1: Anxiety Case Study

6

My-Case Study Anxiety Disorder (Just as a reference)

What information, if any, would you like to know that was not included in the case?

For Julie Thomas, it would be important to inquire whether the current situation has affected his sleeping patterns. For instance, has she had to wake up in the middle of the night because of her racing heart? Has she experienced prolonged periods without sleep because her heart was racing? Does she feel scared to sleep following the panic attacks? Further, it would be necessary to inquire from Julie how her nutritional patterns or feeding habits. Panic attacks and anxiety disorder manifest with nausea in most cases. Persistent nausea is then accompanied by vomiting and gradual loss of appetite. Thus, establishing Julie’s feeding habits would be useful in determining the effects of the panic attacks on her overall health. The clinician should also inquire Julie has experienced any weight loss signs in the past six months. Weight loss can be a possible outcome for patients experiencing panic attacks especially because of the altered feeding habits (Ströhle et al., 2018). It is also important to establish whether the patient has any habits, behaviors, or rituals that she has been using to control the symptoms or to calm down. The clinician should also seek to understand whether the patient has had any incidents where she may have intentionally hurt herself or thought of hurting herself. The frustrations associated with sudden heart racing, chest pains, loss of interest in previously enjoyable activities, and gradual loss of independence can force the individual into self-harm or suicidal thoughts. 

1. Which psychiatric symptoms are a treatment priority for this case? 

Psychiatric symptoms for anxiety disorder exhibited in this case study include the racing heart, hypervigilance, nervousness, fear of impending danger, and lack of concentration when performing daily activities at work or home. Panic disorder, a form of anxiety illness in this case study, is characterized by symptoms such as heart palpitations, chest aches, and choking sensations that are similar to those experienced during a heart attack. Patients with panic disorder frequently suffer tremendous anxiety about the onset of the next panic attack, and they typically avoid situations that cause panic attacks (Bandelow, 2015).

2. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?

In this case study, the non-pharmacologic concerns include social phobia, in which the patient avoids social situations to avoid panic attacks, as well as a dread of rigorous activity to avoid higher heart rates. The patient mentions that she has rejected a recent request by her husband to accompany him to the pub because she feared that the panic attacks would happen while she is there, and it could be embarrassing for everybody. The other non-pharmacological issue is the lack of interest or fear to engage in sex and intimacy with the husband. Julie is concerned that the intimacy/sex experience could trigger her racing heart. The third issue in Julie’s life is the pressure at the workplace. Julie admits that she works in a bank and a new computer system has been installed and she is now working under a new manager. These changes, she admits, have affected everyone at the workplace but she realizes that she is the most affected. 

3. List one medication that would be appropriate for this case. Include the name and starting dose.

A benzodiazepines treatment plan for anxiety disorder will be the most appropriate for this case study. Xanax 0.5mg thrice daily is considered an appropriate starting dosage for a patient like Julie who has no history of mental health disorders (Bandelow et al., 2017). 

4. Describe your clinical decision-making. What is your rationale for choosing this medication?

In the case of Julie, benzodiazepines such as Xanax or Valium are recommended as a first-line treatment for anxiety/panic disorders (Rickels & Moeller, 2019). Benzodiazepines work by triggering calmness, drowsiness, and sleep. These medications work by enabling the binding of the inhibitory neurotransmitter GABA to the respective GABA receptors. This process allows the chloride ions to enter the neurons. When the chloride ions enter the neuron, the neuron becomes negatively charged thus less reactive to excitation. The lesser levels of excitation are manifested by calmness and sedative outcomes for the patient to overcome the hyper outcomes associated with the anxiety/panic attacks. Despite the speedy response in the treatment of anxiety disorders, are associated with addictive behaviors prolonged (Ströhle et al., 2018). 

5. What laboratory testing/monitoring is needed for safely prescribing this medication?

Laboratory testing that is conducted before initiating the Benzodiazepines treatment plan is a blood test or Urine Drug Screening (UDS). A blood test is conducted to check whether there are traces of Benzodiazepines in the blood since previous prolonged use may interfere with the treatment plan. The blood test is also used to screen for misuse of other drugs that are illegally used such as opioids or marijuana which may decrease the efficacy of Benzodiazepines. A thyroid function test (TFT) would be useful to determine whether current symptoms are not associated with thyroid disorders which tend to present with closely similar symptoms. TFTs should be conducted before beginning the benzodiazepines since these medications tend to alter the concentrations of hormones. The TFT tests would therefore help in ruling out thyroid disorders thus avoiding possible misdiagnosis (Balon & Starcevic, 2020).

6. Are there any contraindications or safety issues associated with this medication?

The safety issues on prolonged use of benzodiazepines are linked to instances of tolerance, drug dependence, and withdrawal symptoms associated with the end of its use. Regular and prolonged use of benzodiazepines is associated with dependence and a gradual decrease in efficacy since patients will require elevated dosages over time to manage the symptoms. Further, when the drug is withdrawn abruptly instead of progressively, the patient risks developing withdrawal symptoms. Such withdrawal symptoms range from depression, insomnia, elevated anxiety, and autonomic hyperactivity. Secondly, Xanax and other benzodiazepines are associated with muscle relaxation. Thus, patients with respiratory conditions such as bronchitis, sleep apnea, or COPD as well as those with hypertension are likely to experience respiratory depression or elevated blood pressure levels (Ströhle et al., 2018).

7. What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complementary and holistic therapies?

Cognitive-behavioral therapy, psychological therapy, psychoeducation are the non-pharmacologic interventions that are recommended for treating anxiety disorders. Aucoin (2017) informs that CBT is the first-line non-pharmacologic intervention recommended in the treatment of anxiety disorders because it includes psychosocial support, exercise prescription, and training sessions. The CBT psychotherapy treatment plan focuses on changing the patient's behavior patterns to reduce anxiety disorder symptoms in as little as six months. The CBT process will help Julie change her perception of the pressure at the workplace and gradually adapt to it. Psycho-education will focus on enabling Julie to identify the triggers in the environment and learn the possible interventions on exposure including the right time to take the medications. Psychological therapy will be useful for Julie especially in managing her sex life and relationship. The intention is to enable her to develop a better perception of intimacy and sex through overcoming hypervigilance (Tuma & Maser, 2019). 

8. What are the safety concerns, if any, associated with this case? How will you address safety?

Despite the availability of various treatment plans for anxiety disorders, there is a need for regular risk assessment plans to ensure that the triggers that cause anxiety disorders are managed. In the case study, the patient will be given a prescription for changing behavior patterns. The patient may undergo counseling sessions to help in dealing with extreme fear of situations or apply cognitive therapy strategies to help the patient overcome the negative thinking (Aucoin, 2017). Julie admits to having to accompany the husband any time she is in town due to elevated attacks within the town. The patient is at considerable risk for accidents or falls in case she has an anxiety attack. Julie will be advised to negotiate with her supervisor on the possibility of working from home at least for two weeks to manage her condition. The nurse will provide documentation to support her request and also provide contacts in case the supervisor would require any clarification. 

9. When would you follow up with this patient?

The follow-up for Julie will be initiated at week 4. Benzodiazepines begin to demonstrate some benefits in the first two weeks. However, optimal outcomes are observed in week 4. Depending on the response, Julie’s dosage may have to be reduced to 0.25mg thrice daily or elevated to 0.75mg thrice daily. The positive behavioral change will necessitate stepping down the dosage to 0.25mg while low response as demonstrated by minimal or no behavioral changes will necessitate stepping up the dosage to 0.75mg (Spence, 2018).

References

Aucoin, M. (2017). Challenging Case in Clinical Practice: Multi-Modal Non-Pharmacologic Approach to Mood and Anxiety Disorders. Alternative and Complementary Therapies, 23(1), 11-13.

Bandelow, B., Michaelis, S., &Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93.

Bandelow, B., Lichte, T., Rudolf, S., Wiltink, J., &Beutel, M. E. (2015). The German guidelines for the treatment of anxiety disorders. European archives of psychiatry and clinical neuroscience, 265(5), 363-373.

Balon, R., & Starcevic, V. (2020). Role of benzodiazepines in anxiety disorders. Anxiety Disorders, 367-388.

Rickels, K., & Moeller, H. J. (2019). Benzodiazepines in anxiety disorders: Reassessment of usefulness and safety. The World Journal of Biological Psychiatry, 20(7), 514-518.

Spence, S. H. (2018). Assessing anxiety disorders in children and adolescents. Child and Adolescent Mental Health, 23(3), 266-282.

Ströhle, A., Gensichen, J., &Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. DeutschesÄrzteblatt International, 115(37), 611.

Tuma, A. H., & Maser, J. D. (Eds.). (2019). Anxiety and the anxiety disorders. Routledge.