Week 8 Discussion 1: Anxiety Case Study

Post#1 Anxiety Case Study by Olber Lacosta

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

Some things that I would like to know that were not included in the case study includes the family psychiatric history, patient's past psychiatric history, allergies, and other past medications. In the case study, the provider assesses a lot of information, including the patient's symptoms. However, she does not evaluate the patient's past psychiatric history, genetic factors, various drugs or foods that the patient is allergic to as well as the past medications. I would evaluate such factors to determine the risk of the patient to mental disorders.

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

The psychiatric symptoms that are a treatment priority for this case are excessive worrying, increased heartbeat, panic attacks, poor concentration, and avoidance of situations. In the case study, the patient experiences excessive worrying; she is always worried about going to the pub because she feels that she might actually get ill, which would be embarrassing for everybody. The patient also reports increased heartbeat; she says that her heart starts to race whenever she experiences triggering factors such as when it is hot. She also reports panic attacks on various occasions and poor concentration at her workplace. Besides, she has been avoiding multiple situations or events such as exercises. Prioritizing such factors is essential since it can help develop the best treatment plan and direct the patient to the most appropriate referrals.

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

Some non-pharmacologic issues that the medications cannot address include avoidance of situations and events and panic attacks. Avoidance of situations and panic attacks occurs when the patient experiences the anxiety disorder triggers. To manage such symptoms, the patient needs to engage in cognitive behavioral therapy to change her thoughts and perceptions. Although the medications can help in such a scenario, they cannot adequately address these two issues.

Medication Choice 1

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

One medication that would be appropriate for this case is Ativan (Lorazepam). This medication is approved for the treatment of anxiety symptoms that results from stress (Stahl, 2017). To treat anxiety, the patient requires an initial dose of 2 to 3 mg/day given two times a day or three times a day. This can be increased as per the patient progress. Should not exceed 10 mg/day.

5. Describe your clinical decision-making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice and the neurotransmitters and areas of the brain on which the medication is proposed to act.

Ativan is an appropriate medication to treat anxiety because it is a benzodiazepine, a class of drugs that is highly recommended in the treatment of anxiety disorders. When it comes to the mechanism of action, Ativan binds to benzodiazepine receptors on the postsynaptic GABA-A ligand-gated chloride channel neuron to enhance the inhibitory effects of GABA, which later increases the conductance of chloride ions into the cell (Stahl, 2013). This calms the central nervous system, exerting a tranquilizing effect on the mind and body. As a result, the patient can manage the anxiety symptoms, including avoidance, increased heart rate, and panic attacks that come after experiencing the triggers.

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

Before administering the medication (Ativan), various lab tests are considered. The first test is the CBC; this is carried out to determine various substances in the blood that might alter the proper functioning of the medication. Another essential lab test to assess before administering Ativan is the respiratory test. If the patient exhibits any interruption in respiratory rate (apnea) or signs of respiratory depression such as oxygen desaturation, more complications are probable if such a patient takes Ativan (Nobis et al., 2018). Such tests can, therefore, help ensure improved effects of the medication. And the last lab test required is the liver function tests; these help determine how well the lungs create albumin and how well it disposes of bilirubin.

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

Various contraindications or safety issues associated with this medication are as follows. One of them is that individuals with a low amount of albumin proteins in the blood should not take Ativan (Andrew et al., 2018). This medication is highly protein bound to albumin and is cleared by capacity-limited metabolism; thus, individuals with low albumin proteins might have complications after taking it. Another safety issue is that individuals with impaired brain function due to liver disease should not take the medication because it can result in hepatic encephalopathy. Finally, individuals with acute angle-closure glaucoma should avoid Ativan because it can cause severe symptoms such as more severe vision.

Non pharmacologic Interventions

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

Some non-pharmacologic interventions that I would recommend in the case study are as follows. The first intervention is Cognitive Behavioral Therapy; CBT identifies and addresses how an individual's thoughts and behaviors interact to create anxiety. In our case study, the provider would work with the patient to determine how her negative thoughts patterns impact her feelings and behaviors (Norton & Kazantzis, 2016). For example, the patient’s thoughts about her father's heart problems create worries in her life, resulting in avoidance of situations and events. The provider would, therefore, help the patient change these negative symptoms to healthy ones. Another intervention that can help the patient manage the disorder is meditation; this can slow the patient’s racing thoughts, making it easier to manage stress and anxiety.

Safety Risk Assessment

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

The safety concerns associated with the case study include; cognitive strategies (e.g., distraction), avoidance of events and situations, and taking substances to cope with the worries. Whenever the patient experiences anxiety, she is likely to avoid certain events and situations or even engage in substance abuse to calm her anxiety. To address such issues, the patient can be linked to family members and close friends to deal with the severity of the symptoms.

10. When would you follow up with this patient?

The first follow-up is after one week, then in two weeks, depending on her progress.

References

Andrew, H. W., Ling, L., Lee, A., & Joynt, G. M. (2018). Altered pharmacokinetics in prolonged infusions of sedatives and analgesics among adult critically ill patients: a systematic review. Clinical therapeutics, 40(9), 1598-1615.

Nobis, W. P., Schuele, S., Templer, J. W., Zhou, G., Lane, G., Rosenow, J. M., & Zelano, C. (2018). Amygdala‐stimulation‐induced apnea is attention and nasal-breathing-dependent. Annals of neurology, 83(3), 460-471.

Norton, P. J., & Kazantzis, N. (2016). Dynamic relationships of therapist alliance and group cohesion in transdiagnostic group CBT for anxiety disorders. Journal of consulting and clinical psychology, 84(2), 146.

Stahl, S. M. (2013). Stahl's essential psychopharmacology: neuroscientific basis and practical applications. Cambridge university press.

Stahl, S. (2017). Stahl's essential psychopharmacology prescribers guide (6th ed.). Cambridge University Press.