Running Head: Anxiety Case Study 1

Anxiety Case Study

Allie Cannon
Auburn University School of Nursing
Anxiety Case Study 2

Anxiety
Anxiety, or a feeling of uneasiness due to a stressor or perceived stressor, is a normal part

of the human experience. But when this feeling becomes chronic or excessive and begins to

inhibit a patients ability to perform at their normal baseline function, it is called an Anxiety

Disorder, of which there are many different types (Halter & Varcarolis, 2014). Generalized

anxiety disorder (GAD), which is characterized by enduring and undue worry, is present among

3.1% of Americans. GAD is most commonly diagnosed in women during early and older

adulthood and oftentimes in patients with other health conditions. To be diagnosed with GAD,

symptoms must be present for at least 6 months (Stein & Sareen, 2015).
Case Study
On May 23, 2016, a 36-year-old white female with the initials M.A. was admitted to

the psychiatric unit at Brookwood Baptist Hospital. M.A. is recently divorced, has no children,

and moved to Birmingham to care for her mother, who has since passed away. M.A. came

voluntarily to the hospital after struggling to deal with this loss and financial difficulties. She

turned to marijuana, alcohol, and prescription drugs to relieve her anxiety and feelings of

helplessness and guilt. She also reports having been molested by her sister as a child. She was

brought here by friends from church who are very supportive of her decision to seek help. She

did not present with any suicidal or homicidal ideations, but reported feelings of intense anxiety

and an inability to sleep. Her chart states she suffered from altered mental status (due to a recent

use of marijuana and benzodiazepines), severe anxiety, insomnia, and delusional thinking upon

admission. In group therapy, she was described by therapists as being withdrawn her first day,

and manic every day after that.

Her primary psychiatric diagnosis is generalized anxiety disorder, which causes her

insomnia, delusional thinking, and desire to use drugs to cope. Along with her GAD, M.A. has

also been diagnosed with gastro-esophageal reflux disease (GERD) and eczema. While none of
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these illnesses are due to her anxiety, her anxiety certainly did nothing to alleviate her symptoms

of heartburn and itchiness. For these problems, M.A. is prescribed pantoprazole (for GERD) and

triamcinolone topical (for eczema).

M.A. was discharged on the 27th and voiced excitement and determination to use the

healthy coping skills she learned in group therapy to alleviate her anxiety, rather than her

maladaptive coping strategies of before. She stated that rather than using marijuana, alcohol, or

Ativan (a benzodiazepine she acquired illegally) to calm her nerves, she would work in her

garden instead. She also stated that her church offered her a job teaching yoga to the elderly

members, which she hoped would also help to relieve her anxiety. The patient has a very strong

support system in her friends at church, and expressed that she finds comfort in prayer.
Erik Erikson, a psychoanalyst that studied Freud, came up with the Eight Stages of

Development that he used to describe each patients current psychosocial crisis and how they

would present if they achieved to or failed to achieve the developmental task. As a 36 year old,

M.A. is placed in the Middle Adulthood task, Generativity vs. Self-absorption, which is

characterized by fulfilling life goals that involve family, career, and society and developing

concerns that embrace future generations. Despite her age, M.A. has not yet graduated from the

early adulthood task of Intimacy vs. Isolation because she stated an intense desire to grow closer

to her friends now that her mother has died and a desire to find a spouse since her divorce. It is

this desire that indicates that she is still working towards establishing bonds of love and

friendship in her new community (Halter & Varcarolis, 2014).

Generalized Anxiety Disorder
The present understanding of GAD is influenced by biology, genetics, and drug trials that

have shed light on the nature of the disorder. GAD is symptomatically characterized by worry

that is out of proportion to the stressor, anticipation of disaster, restlessness, agitation, muscle

tension, and a feeling of helplessness (Halter & Varcarolis, 2014). Biologically, functional
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neuroimaging studies have implied that GAD involves an increased response of the amygdala, a

decreased response of the prefrontal cortex, and a weakened relationship between the two

regions. The amygdala is involved in the fear response, whereas the prefrontal cortexs role

involves cognition; this mismatch of stimulation is embodied in irrational thinking and a

tendency towards apprehension. Along with the relationship of the amygdala and prefrontal

cortex, the neurotransmitters epinephrine, norepinephrine, serotonin, dopamine, and gamma-

aminobutyric acid (GABA), regulate anxiety. SSRIs (selective serotonin reuptake inhibitors) and

SNRIs (serotonin-norepinephrine reuptake inhibitors) strive to increase the levels of either

serotonin (in the case of SSRIs) or serotonin and norepinephrine (in the case of SNRIs) to

relieve anxiety, whereas benzodiazepine drugs bind to benzodiazepine receptors to further the

action of GABA, which also diminishes worry. Genetically, there is a heritability of 15-20% in

GAD. Genomic studies still in their infancy suggest a genetic association between GAD and

other anxiety conditions. In drug trials, physicians have found that psychotherapy,

pharmacotherapy, and lifestyle modifications are most effective in treating GAD. Of these

interventions, most agree that a combination of cognitive behavioral therapy and SSRIs or SNRIs

is most effective, although it is best to begin with therapy and add in medication if necessary

(Stein & Sareen, 2015).

While the specific cause of GAD in each patient is unclear, there are several theories in

play that provide arguable explanations for the source of this disease. Among these theories are

the psychodynamic theory, interpersonal theory, behavioral theory, and cognitive theory. The

psychodynamic theory, suggested by Freud, suggests that anxiety is caused by childhood

conflict. Sullivans interpersonal theory is characterized by the belief that anxiety can be

contagious and that early anxiety responses provide the foundation for later anxiety responses.

The behavioral theorists claim that anxiety is caused by learning responses and becoming
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conditioned to anxious behavior. Cognitive theory suggests that anxiety is the result of distorted

thinking and perception, or irrationality. Taking these theories into account and the diathesis-

stress model, which explains mental illness as the result of biological predispositions and

environmental trauma, the environmental causes of M.A.s GAD are clearly defined (Halter &

Varcarolis, 2014). Among M.A.s environmental trauma are the death of her mother, her recent

move to Birmingham, her financial struggles, her divorce, and the emotional trauma of being

molested as a child. A recent meta-analysis of previous studies analyzed the association between

early emotional traumas and later diagnoses of anxiety disorders and concluded that of patients

with GAD, 25% experienced sexual trauma. Of all the early emotional traumas studied, physical

and sexual abuse were found to have the most impact on the development of anxiety (Fernandes

& Osrio, 2015).

New evidence in the neurobiological field suggests that orexins, which are neuropeptides

located in hypothalamic neurons and project into the limbic system, are pivotal in the expression

and repression of fear memories. According to this research, when a person acquires a memory

that causes fear, they are able to regulate this fear memory to serve them in the future by forming

coping strategies. People unable to regulate or extinguish these fear memories then suffer from

anxiety. A significant percentage of patients with anxiety do not respond to pharmacological

treatment with SSRIs, SNRIs, or benzodiazepines, and this study suggests that orexin receptor

antagonists provide a promising future treatment for these patients (Flores et al., 2015).
Best Practice for M.A.
A meeting of some of the brightest minds in the study of anxiety described the current

state of anxiety treatment as outdated and sadly limited. The International Anxiety Disorders

Society Conference took place in Melbourne in 2014, and the attendees lamented the fact that,

currently, the best advice clinicians can offer for the treatment of anxiety is to prescribe either an

SSRI or SNRI, psychotherapy, or both. The SSRIs and SNRIs were widely regarded by the
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physicians in attendance of this meeting as the gold standard in treatment, recommended over

other antidepressants such as TCAs and MAOIs, anxiolytics, anticonvulsants, and antipsychotics.

But if these measures prove insufficient, current medical practice merely advises switching

between the two approaches: psychotherapy and psychotropic drugs (Hood, 2015). Physicians

also recommend a stepped care approach, in which initial care is begun and subsequent measures

are added when either medications or therapy lack effectiveness (Stein & Sareen, 2015). The

treatment M.A. is currently undergoing aligns perfectly with these held beliefs, as she is

receiving 225 mg of Venlafaxine, an SNRI, once a day. M.A. participated in group therapy while

at the hospital, undergoing both cognitive behavioral therapy and art therapy, but has no plans to

continue therapy upon discharge. As this is M.A.s first admission for her mental illness, it is

appropriate that she was prescribed an SNRI to treat her anxiety and Benadryl prn to help her

sleep, as insomnia is a symptom of her anxiety. A way to treat this insomnia using a

complementary approach is to practice sleep hygiene habits. Sleep hygiene mandates that the

patient does not use nicotine products or alcohol in the evening or use light emitting devices such

as laptops before bed. This is to induce a regular, clean sleeping cycle in the patient and help

diminish anxiety through relieving insomnia (Stein & Sareen, 2015).

Other research indicates that Cognitive Behavioral Therapy (CBT) is actually the

treatment best used to prevent relapse in patients with anxiety. As it is consistently the most

effective therapeutic option evidence suggests, CBT can be recommended as the gold standard in

anxiety treatment, while SSRIs/SNRIs are the gold treatment of pharmacotherapy. CBT for

patients with GAD encompasses cognitive therapy to deal with worry and irrational thinking and

relaxation therapy to treat tension. CBT also uses imaginary exposure to stressful images and

situations and teaches healthy responsive behavior (Otte, 2011). As M.A. underwent CBT during
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the acute phase of her anxiety, she will receive the benefits of this treatment and hopefully

continue to utilize her new coping mechanisms.

Treatment that would not be beneficial to M.A. includes the use of benzodiazepines,

marijuana, and alcohol. Many physicians present at the conference in Melbourne argued that the

use of Benzodiazepines in patients with anxiety is not beneficial to long term treatment and is

considered the pariah of pharmacotherapy. According to these physicians, benzodiazepines are

only to be used in acute settings to relieve the anxiety of patients quickly, but should not be

continued as a part of their pharmacotherapy due to the high risk of tolerance, dependence, and

psychomotor and cognitive impairments (Hood, 2015). M.A. has a history of abusing Ativan, a

type of benzodiazepine, which would cause significant danger for dependence and tolerance if it

were used in her treatment. M.A. also has a history of self-treating her anxiety with marijuana

and alcohol, which is in no way an effective treatment for GAD. Substance abuse is common

among patients with anxiety, and about 35% of people with GAD self-medicate with alcohol and

drugs (Stein & Sareen, 2015). M.A. has stated she now understands abusing marijuana, alcohol,

and Ativan is not an effective way to relieve her symptoms of anxiety and that she now plans to

use her relaxation skills learned in therapy and coping strategies such as yoga, prayer, and

gardening to find peace.

Conclusion
The study of the risk factors, biological factors, treatments, and therapies related to

generalized anxiety disorder best determines the course of treatment for patients such as M.A.

Studying her background, events leading up to admission, and former coping strategies is pivotal

to understanding how to provide education and symptom relief to this specific client, and to all

clients. The treatment of anxiety cannot be effective unless it is tailored to each patient, and it is

crucial to treat the client as a whole, complete person, rather than simply a set of diagnoses.
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Nurses are crucial in this process, and must take pains to establish rapport with the patient to

understand their level of development, cognition, and anxiety. In the case of M.A., gaps in the

evidence that lead to her admission include the fact that she is a poor historian due to her altered

mental status and that she has a history of drug use. This suggests that some of the information

M.A. provided may not be completely factual, but nurses must act as an advocate for the patient

and believe the story they tell. To act as a patient advocate, Nurses must understand what the

patients goals for improvement are and work to return the patient to baseline functioning. This

baseline looks different for each patient, and in the case of M.A., return to baseline meant a

return to her life with a new set of skills for managing her GAD through medication, prayer,

social support, and pleasure activities.

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References

Fernandes, V., & Osrio, F. L. (2015). Are there associations between early emotional trauma
and anxiety disorders? Evidence from a systematic literature review and meta-analysis.

European Psychiatry: The Journal of the Association of European Psychiatrists, 30(6),

756-764. doi:10.1016/j.eurpsy.2015.06.004
Flores, ., Saravia, R., Maldonado, R., & Berrendero, F. (2015). Orexins and fear: Implications
for the treatment of anxiety disorders. Trends in Neurosciences, 38(9), 550-559.

doi:10.1016/j.tins.2015.06.005
Halter, M. J., & Varcarolis, E. M. (2014). Varcarolis' foundations of psychiatric mental health
nursing: A clinical approach. St. Louis, MO: Elsevier.
Hood, S. D. (2015). Latest guidelines for the management of the anxiety disorders - a report from
The International Anxiety Disorders Society Conference, Melbourne 2014. Australasian

Psychiatry: Bulletin of Royal Australian and New Zealand College of Psychiatrists,

23(4), 388-391. doi:10.1177/1039856215588209

Otte, C. (2011). Cognitive behavioral therapy in anxiety disorders: Current state of the evidence.
Dialogues in Clinical Neuroscience, 13(4), 413421.
Stein, M. B., & Sareen, J. (2015). Clinical practice: Generalized Anxiety Disorder. The
New England Journal of Medicine, 373(21), 2059-2068. doi:10.1056/NEJMcp1502514