mental illness and continued therapies
mental illness and continued therapies
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The Case:
The sleepy woman with anxiety
This week’s discussion presents a case study involving a 44-year old woman with a chief complaint of anxiety beginning at age 15 years old. She has a long history of mental illness and continued therapies. The purpose of this discussion is to analyze her case history to determine medication and treatment effectiveness.
Client Questions
Question 1. Are you having feelings of harming yourself or harming someone else?
Rationale: This is a possibly uncomfortable yet important set of questions to ask each client. Primary care providers may be in a unique position to prevent suicide due to their frequent interactions with suicidal patients. Reviews suggest that among patients who committed suicide, 80 percent had contact with primary care clinicians within one year of their death, whereas only 25 to 30 percent of decedents had contact with psychiatric clinicians within the year of their death (Stene-Lars & Reneflot, 2017).
Question 2. What was happening in your life as a teenager when the anxiety started and you began to self-medicate?
Rationale: Per our report, this patient began suffering signs and symptoms of anxiety at 15-years old. Asking these types of questions we may gain insight into an underlying cause or triggering event. Anxiety disorders are the most common psychiatric disorders with onset in childhood, with prevalence estimates ranging from 10 to 30 percent. Nearly 37 percent of behaviorally inhibited preschool-age children had social anxiety disorder at age 15, compared with 15 percent of non- behaviorally inhibited children. Children with anxiety disorders are more likely to have persistent anxiety disorders into adulthood. (Rapee, 2014).
Question 3. What was happening in your life a year ago when these symptoms returned and became debilitating? Let’s discuss what the triggering events may have been.
Rationale: Self-discovery of triggering events may help the client to come to terms with the determinants of her anxiety and depression. Studies have shown that specific types of stressors were found to differentially predict increases in specific facets of anxiety sensitivity; health-related stressors predicted increases in disease-related concerns and fear of mental incapacitation, whereas stressors related to family discord predicted increases in fear of feeling unsteady, fear of mental incapacitation, and fear of having publicly observable symptoms of anxiety (McLaughlin & Hatzenbuehler, 2009).
Support System
The support system as reported by our client is her husband. She states he is supportive and has little to no contact with the family of origin. She has a few friends and a few outside interests. As PMHNP, discussing relationships with the client is one avenue to gain insight into anxiety patterns and coping mechanisms as seen by outside support. With the client’s permission, speaking to her husband may assist us in this situation. Learning how the patient functions at home, what critical changes have occurred with this recent bout of depression and what coping mechanisms are utilized by the couple may assist us in reaching a state of remission. In addition, these disorders are associated with significant decreases in patient well-being and social functioning and can cause considerable pain and suffering, not only for affected individuals but for their family and friends as well. Despite the availability of proven treatments, both disorders remain underrecognized and undertreated (Ballenger, 2000).
Are you aware of when your wife is entering a state of anxiety or depression?
What have you noticed happening in your lives when this occurs?
When these events occur, what response does that create for you?
What coping mechanisms do you utilize for yourself and your relationship when these events occur?
Physical Exams and Diagnostic Tests
First a complete physical assessment of the patient is required to rule out any underlying medical issues. This would also include a full blood panel with CBC, CMP, TSH and urinalysis and toxicology. Research findings suggest that mood and anxiety symptoms result from a disruption in the balance of impulses from the brain’s limbic system. A 2015 study reported that individuals with comorbid depression and anxiety have increased resting-state functional connectivity of the limbic network when compared with depression or anxiety alone. FK506 binding protein 51 (FKBP5) is a co-chaperone binding protein which modulates the function of glucocorticoid receptors. In a study examining allelic variants of FKBP5, the T allele was more frequent among patients with comorbid depression and anxiety (Pannekoek et al., 2015). Additionally, rating scales have shown good reliability for assessing anxiety and depression. The Depression and Anxiety Stress Scale (DASS) is suitable for assessing clients with co-occurring depression and anxiety.
Differential Diagnoses
