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Introduction

Generalized anxiety disorder is a condition where one has excessive anxiety on most days. It is normal to anxious about things that happen, however, when there are physical symptoms associated with the anxiety this becomes a disorder. Symptoms in this case are fatigue, restlessness, muscle tension, insomnia, irritability, and problems with concentration among others.  This is a common disorder in people as statistics show that 7 percent of the populations are victims of this (Burke, 2012; Richards & Borglin, 2011). Women are more prevalent than men. The main cause of the disorder is not clear, however, there are various factors that are believed to be key contributors to it. One of them is the genetic makeup of an individual as at times this may be inherited. The disorder may also be brought about by childhood traumas such as rape or death of a parent. The last factor that is contributes much to the disorder is stress in life which may be triggered by what we meet in our daily life (Bauer et al. 2012). The main problem is to help the victims of the disorder recover since at times it may be long-term and completely change the lives of the victims. This will be a case analysis of Mary, 42 years of age, who is a victim of generalized anxiety disorder. It will seek to see how the patient can be helped and the methods to use in this.

Using DSM to Guide Diagnostic Processes

There is a criteria spelled out in Diagnostic and Statistical Manual of Mental Disorders (DSM) that people to be diagnosed with generalized anxiety disorder must meet. This is a manual published by the American Psychiatric Association (APA) with the aim of helping mental health professionals diagnose mental conditions in patients and for insurance companies to reimburse for treatment (Aldao et al. 2010; Andrews & Hobbs, 2010). In this case the DSM diagnostic process for Mary will be as a follows:

1. Excessive anxiety and worry, occurring in most days for a period not less than 6 months, about a number of events or activities (Andrews et al. 2010). This has being evident in Mary since her divorce 5 years ago. This is the main reason for her being depressed.

2. The victim finds it difficult to personally control the worry (Gask et al. 2012). With Mary this is the case as she has at times gone for medical services where she was counseled and got some improvements in her symptoms.

3. The patient’s anxiety and worry have being evident in a period not less than three of the six symptoms in the DSM manual. The symptoms are:

    1. Restlessness or feeling on edge.
    2. Being easily fatigued
    3. Difficulties in concentration or at times the mind going blank
    4. Irritability
    5. Muscle tension
    6. Sleep disturbance which may be seen either in difficulties in falling asleep or getting unsatisfying sleep

From the diagnosis of Mary she showed the following symptoms:

  1. Muscle tension
  2. Sleep disturbance which was seen in difficulties in getting sleep and frequent waking
  3. Irritability
  4. Restlessness

4. The focus of the anxiety and worry is not confined to features of an Axis I disorder like a Panic Attack, social phobia or a feeling of being embarrassed in public, contamination or Obsessive-Compulsive Disorder, separation from relations or Separation Anxiety Disorder, weight gain as in Anorexia Nervosa, or a serious illness like it is in Hypochondriasis, and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder (Pine et al. 2010; Torre et al. 2012). This is the case with Mary as she does not follow in any of the above. She is with her children and mother and thus, cannot be suffering from the separation anxiety disorder. She is also not gaining weight or showing any symptoms of a serious disease.

5. The anxiety, worry, or physical symptoms make the victim stressed to a level of seeking medical help besides causing impairment in social, occupational, family or other important areas of functioning (Chien, 2012). Mary has looked for medical attention in the past showing that the problem is serious.

6. The anxiety and worry is not as a result of substance use like medication or drug abuse or a general medical condition like hyperthyroidism and does not occur exclusively alongside other disorders like mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder. This is the case with Mary as she does not abuse any drugs nor does she drink alcohol. In addition, the conditions leading to the disorder are openly seen.

Discussion of Introduction of Pharmacology

It is the belief of many GAD patients that the use of medication can help them lower the feeling of anxiety. The exact value of the medication is that it can make one feel less anxious rapidly, but the results of this will not be long-lasting. However, there are situations where medication can be crucial part of the treatment as other methods of treatment like therapy are still upheld (Pine et al. 2011).  In the case of Mary she had already used some medication to get her problem solved, however, the outcomes are not long-lasting and this is why she is back to a clinician looking for medical help.

In the medication, one or more types of anti-anxiety medicines may be used. These are the same drugs that are used to treat depression and other mental disorders. The medicines that may be considered include:

Antidepressant medicines

As the name suggests these are drugs that are commonly used in treating depression, but they can help to an extent in reducing the symptoms of anxiety even if the victim is not depressed. Research shows that half of people with GAD can have their symptoms eased by these medicines (Dugas et al. 2010). The medicines work by interfering with neurotransmitters such as serotonin which are mostly involved in causing anxiety symptoms.

It should be noted that antidepressants do not work straight as it is estimated to take between 2 to 4 weeks before their effect builds up in the body (Gordon & Heimberg, 2011; Heiden, 2011). It is because of this that many people stop using the medicine after a week complaining that it does have any positive effects to their problem. However, the strategy is that the drugs should be given time to work.

These drugs are not addictive like it is with tranquillizers. They are usually in different types with each of them having its own cons and pros. They normal differ when it comes to side effects. They way they work in patients may also differ (Kendler & First, 2010). In the case of Mary the drug may be prescribed in case the situation becomes worse and medical attention is seen as the best option. It should come alongside other medical interventions because it does not provide long-lasting solutions to the problem.  

Tranquillizers

These are drugs that are commonly described for anxiety with the most prescribed one being diazepam. The medicine work effectively in easing the symptoms, however, they have been shown to be very addictive and they can lose their effective when one takes them for a long duration. The medicines also make one drowsy. In the case of Mary this may not be the best option as it will make the problem persistent rather than addressing it. GAD is persistent disorder and thus, this medicine cannot be used to help Mary.

Buspirone

This is a drug that at times is used as an option to lower the symptoms of GAD. It is different from many other drugs used in treatment of anxiety. It is not well known how it works in the body, however, to some extent it has been shown to affect serotonin. The latter is a brain chemical that is believed to be a cause of anxiety symptoms. The drug has less drowsiness; however, it is addictive and can only be used for a short duration (Rasic, 2010). In the case of Mary this drug should not be administered since she has used drugs before and drugs that are addictive and short time functioning should not be administered to her.

Hydroxyzine

This drug is said to be an antihistamine administered in rare occasions to lower the symptoms of anxiety. They are associated with drowsiness and thus, in the case of Mary they should not be administered.

Beta-blocker medicines

Beta-blockers (for example propranolol) are best in short-lived anxiety and not long-lived ones like GAD. However, at times they are prescribed for GAD patients as they ease some physical symptoms like trembling (Murray & Mahoney, 2012). They do not have any mental influence and thus, they cannot be prescribed for Mary as her problem is in the mind. Most of the symptoms she shows are arising from the mind and thus, this drug will not be effective as it will only address the physical symptoms which are the least in her case.

In starting the medical therapy the clinician must ensure that the effective treatment is available. This means that pharmacology should not be used as the only intervention to help the patient. In the case of Mary this has to be considered such that the medicines are just administered as the right combination of interventions is been looked into. Therefore, the medicines should only be used for short time. The respond rate in the patient has to be looked into so that the medicines do not make the symptoms persistent or worse. The effects have to be eased in the shirt time as the right medical interventions are looked into (Peyrot et al. 2013).  This is because the treatment should be aimed at providing a long-term solution since the patient has suffered for 5 years showing that it is a serious problem. It has also to be understood that the patient has used drugs before to address her problem.

In case the pharmacotherapy is continued it should go for 12 months so that relapse is prevented. In terminating the medication the necessary risks have to be considered. This may be analyzed from the type of drug that was administered to the patient. Some patients may accept the treatment before the 12 months come to an end, and thus in such a case other interventions like psychotherapy may be left out.

Importance of Psych-Education

In the case of Mary who is a victim of GAD, psych-education should be aimed at combating her low-level and ever-present anxiety. This is seen through difficulties in relaxing, poor planning skills and high stress levels. The most important to consider in this is relaxation because the clinician can play a key role in helping the patient relax through effective teaching.

In this case relaxation techniques and skills have to be taught to the patient. This can be done through meditation, yoga and biofeedback (Naik et al. 2011). Much exercise should be considered as this helps in elevating moods and improving the overall health of the patient. In this case the specific needs of the patient must be considered so that other types of therapy can be offered. Education of relaxation should begin with the small things like deep breathing. Biofeedback also termed as the ability to allow the patient hear feedback in the physiological state is beneficial. Progressive muscle relaxation can be considered (Burke, 2012). The clinician must make sure that the patient learns these skills as they are vital in reducing the low-level anxiety levels. The life of the Mary can significantly be improved through this education as she will be made more productive and active. The patient must consider the importance of this such that she continues with the exercises even when not with the therapist. The therapy sessions should be used for more education and the real practice should be done at the comfort of the patient for instance when she is at home. The sessions should be twice per day with each taking a minimum of 20 minutes for effective outcomes to be realized. The patient should be encouraged to set her own schedule for relaxation so that regularity is enhanced.

Psych-education also helps in lowering stress and increasing the overall coping skills in the patient. The life of the patients is made active through the education they get. It is through this that they are in a position to live better and have good relationships with others more so in the family. They are in a position to understand life from another direction (Aldao et al. 2010). This makes them to avoid the constant worries. They also avoid boredom which catalyzes the symptoms of the disorder. When this is done they less worry and the patient becomes in a position to do other things that may be of help. For instance, with the education Mary may leave alone what has happened in the past and get her family together.

The education also makes the patients to accepting. In most cases GAD patients do not accept their problem and they find it difficult to communicate it to their friends. They feel very awkward when they communicate their problem to others, however, this should not be confused with social phobia. In the start of the process the clinician must evaluate to see whether it is social phobia or it is the distress making it difficult for the victim to communicate (Chien, 2012). This at times even affects their social life. As the old adage goes ‘a problem shared is a problem half solved’ and thus, this is still the scenario when the patient is in a position to share her problem. A skill that may be used in the health facility is placing patients into groups so that they can share what they go through. This will mean putting Mary in a group of other GAD patients. This is the best strategy to employ as the patients have similarities and will be in a position to share much which is also relevant.

Using the stepped care Method for Risk Assessment and Provision of Care

The stepped care method is a framework of organized pathways of care designed to reduce the burden to patient while increasing health gain. The method is based on two principles including interventions offered in a less restrictive environment and secondly self-correcting’ monitoring and feedback systems. The stepped care method for risk assessment and provision of care for Mary is as below:

Step 1: Identification and assessment

Identification

This will mean asking the patient whether she is a victim of depression and possible somatic symptoms she has experienced. This may not be obvious just because Mary is a victim of GAD. In the identification there is much which is known and could have been assumed. The last month should be considered much to know what the patient has gone through.  There must be two questions in this including:

  1. During the last month, have you often been bothered by feelings of hopelessness and depression?
  2. During the last month, have you often been bothered by having little interest or desire in doing things?

If the answer to the above is yes, the patient will have qualified for assessments. 

The ability of the patient to fight the anxiety should be considered as this may help in getting the best medical intervention (Burke, 2012).  A close family member may be involved in this to clearly identify the symptoms the patient is going through.

 Assessment

If the answers to the questions in the identification part indicate a possible common mental disorder, but the clinician is not competent to perform a mental health assessment the patient should be referred to the right medical professional. This happens through referral.  If the practitioner is competent the he should perform a review of the mental state of the patient. This should be associated with the functional, interpersonal and social difficulties of the patient.

Risk assessment should be done to identify the extent of the mental disorder. This should be done by looking at the potential of the mental disorder causing harm to others. In addition, the risk of significant self-neglect and severe functional impairment should be established.

Steps 2 and 3: Treatment and referral for treatment

In most cases the two steps are treated separately, however, it is done easily when they are combined. This should begin by identifying the correct treatment options. This should consider the past experience of the patient. In this case the patient has undergone some medical treatment, but has been ineffective (Bauer et al. 2012). The trajectory of symptoms has also to be established.  Any functional impairment arising from the disorder should also be identified and considered in treatment. External factors that may have influence on the patient’s disorder have to be analyzed. In this case divorce, the children and the sick mother are factors that need to be considered in the external environment.

A discussion should ensue between the clinician and the patient. This should establish the needs, expectations and thinking of the patient. This also establishes evidence to use in the treatment.

Step 4: Complex treatment

This stage may not be reached, however, in cases of complex treatment it has to be considered. In case functional impairment, self-neglect and high risk of human harm are noted in the patient then this stage will be reached (Pine et al. 2010). It will call for referral for a highly specialist treatment such as psychological treatment regimens. .

Use of K10

K10 is a measure to psychological distress that is done through a questionnaire with a score range. The measure decreases as the patients complete the course. In case the decrease is not simultaneous a review should be arranged with the patient.

The questions are answered in the following ranges: All of the time, Most of the time, some of the time, A little of the time, none of the time

The questions include:

  1. How often did you feel fatigued for no good reason?
  2. How often did you feel nervous?
  3. How often did you feel very nervous that nothing could help calm you down?
  4. How often did you feel hopeless?
  5. How often did you feel restless?
  6. How often did you feel so restless you could not sit still?
  7. How often did you feel depressed?
  8. How often did you feel that everything was an effort?
  9. How often did you feel so sad that nothing could cheer you up?
  10. How often did you feel worthless?

Role of Care Coordination with Client Complex needs

There should be coordination with client’s complex needs. This can be done best through communication with not only the patient, but also her family members. The communication is believed to be cornerstone in providing quality health care. Communication helps to reveal important information which otherwise could have been assumed in the treatment. It helps the clinicians to change their strategies so that they can meet the goals of the medical intervention. The communication can best be done through interactions with the patients and having follow-up instructions.

When patients see coordination in the care given, this alone helps to lower the anxiety in them. Through interaction patients feel that they are powerful and are not vulnerable as they thought.

Medical practitioners are expected to respect patient-centered values, preferences, and expressed needs. This can only happen through care coordination. Therefore, care coordination ensures that the clinicians perform their duties as expected in the law.

The last thing that is crucial in care coordination of GAD patients is that it ensures transition and continuity (Heiden, 2011). For instance, in this case Mary has already had some medical interventions and thus, it is through care coordination that such will be brought to table and used in the current treatment. In case the clinicians working on the patient are not available others can take over provided there is care coordination.

References

  1. Aldao, A., Mennin, D. S., Linardatos, E., & Fresco, D. M. (2010). Differential patterns of physical symptoms and subjective processes in generalized anxiety disorder and unipolar depression. Journal of anxiety disorders, 24(2): 250-259.
  2. Andrews, G., & Hobbs, M. J. (2010). The effect of the draft DSM-5 criteria for GAD on prevalence and severity. Australian and New Zealand Journal of Psychiatry, 44(9): 784-790.
  3. Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev, 10.
  4. Beesdo, K., Pine, D. S., Lieb, R., & Wittchen, H. U. (2010). Incidence and risk patterns of anxiety and depressive disorders and categorization of generalized anxiety disorder. Archives of General Psychiatry, 67(1): 47.
  5. Beesdo-Baum, K., Winkel, S., Pine, D. S., Hoyer, J., Höfler, M., Lieb, R., & Wittchen, H. U. (2011). The diagnostic threshold of generalized anxiety disorder in the community: a developmental perspective. Journal of psychiatric research, 45(7): 962-972.
  6. Burke, E. M. (2012). Coordination of Medical and Dental Care for HIV-Positive Clients in Community Health Centers in Philadelphia (Doctoral dissertation, Drexel University).
  7. Caldwell, B. A., Sclafani, M., Piren, K., & Torre, C. (2012). The Evolution of the Advanced Practice Role in Psychiatric Mental Health in New Jersey: 1960-2010. Issues in Mental Health Nursing, 33(4): 217-222.
  8. Chien, W. T. (2012). An overview of quality care of people with complex health needs. Contemporary nurse, 40(2): 142-146.
  9. Dugas, M. J., Anderson, K. G., Deschenes, S. S., & Donegan, E. (2010). Generalized anxiety disorder publications: Where do we stand a decade later? Journal of anxiety disorders, 24(7): 780-784.
  10. Gordon, D., & Heimberg, R. G. (2011). Reliability and validity of DSM-IV generalized anxiety disorder features. Journal of anxiety disorders, 25(6): 813-821.
  11. Heiden, C. (2011). On the Diagnosis, Assessment, and Treatment of Generalized Anxiety Disorder. Erasmus University Rotterdam.
  12. Kendler, K. S., & First, M. B. (2010). Alternative futures for the DSM revision process: iteration v. paradigm shift. The British Journal of Psychiatry, 197(4): 263-265.
  13. Murray, J. S., & Mahoney, J. M. (2012). An integrative review of the literature about the transition of pediatric patients with intestinal failure from hospital to home. Journal for Specialists in Pediatric Nursing, 17(4): 264-274.
  14. Oosterbaan, D. B., Verbraak, M. J., Terluin, B., Hoogendoorn, A. W., Peyrot, W. J., Muntingh, A., & van Balkom, A. J. (2013). Collaborative stepped care v. care as usual for common mental disorders: 8-month, cluster randomized controlled trial. The British Journal of Psychiatry, 5 (4): 6.
  15. Patel, V., Weiss, H. A., Chowdhary, N., Naik, S., Pednekar, S., Chatterjee, S., & Kirkwood, B. R. (2011). Lay health worker led intervention for depressive and anxiety disorders in India: impact on clinical and disability outcomes over 12 months. The British Journal of Psychiatry, 199(6): 459-466.
  16. Rasic, D. (2010). Countertransference in child and adolescent psychiatry-a forgotten concept? Journal of the Canadian Academy of Child and Adolescent Psychiatry, 19(4): 249.
  17. Richards, D. A., & Borglin, G. (2011). Implementation of psychological therapies for anxiety and depression in routine practice: two year prospective cohort study. Journal of affective disorders, 133(1): 51-60.
  18. Woltmann, E., Grogan-Kaylor, A., Perron, B., Georges, H., Kilbourne, A. M., & Bauer, M. S. (2012). Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. American Journal of Psychiatry, 169(8): 790-804.

 

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