Anxiety Disorders: Treatment Considerations - Essay Example

Case Study Introduction: This case study is about a patient, whose identity will remain undisclosed for reasons of confidentiality. She will be termed Linda throughout this case study essay for reasons of convenience. Her story is as follows. Linda is a 28-year-old woman who presented to the emergency department with deep lacerations to both of her wrists inflicted by herself. Although this appeared to be a suicidal gesture, according to Linda, she had accidentally cut herself because of her overwhelming tiredness and fatigue which would have been caused by her inability to sleep at night. She described many episodes when she was unable to fall and stay asleep unless she used medication and/or alcohol to help her initiate the sleep. Upon interrogation, she also stated that she noticed a loss of appetite over the last three months. She also admitted to having lost interest in socialising due to her feelings of tension and nervousness among people. She also reported difficulty to concentrate, lack of motivation, and as a result, she has been feeling incapacitated enough to be unproductive at her work as a clerical officer for the Roads and Traffic Authority. Linda also stated that she had felt some tension and nervousness as long as she could remember, although this had definitely exacerbated with the death of her sister 13 months ago. Although Linda has an extensive family network in New Zealand, she has no significant extended family present in her life locally. She has no record of mental health history. Linda is vague and non-specific about her current use of prescribed or non-prescribed medications and is unable to remember how much alcohol she had drunk in the last week. Linda states that she has rung Lifeline on many occasions but did not follow up on their advice until now. She appeared well dressed, thin, and pale, had dark circles under her eyes, and continually wrung her bandaged hands in her lap. Stress can be described as a circumstance that disturbs, or is likely to disturb, the normal physiological or psychological functioning of a person, and such reactions are nonspecific, since the patients reaction is determined by the general life situation and perceptual appraisal of the stressful event. Stress is one of the most complex concepts in health and nursing. It is difficult to define, but its detrimental effects are well known. Stress is associated with manifestations of physical illness, mental disorders, and social disruption. This creates a problem with general adaptation. It is often viewed as a nonspecific response to any demand or stressor. Adaptation can be conceptualized as a person’s capacity to survive and flourish. Lack of adaptation affects three important areas, health, psychological well being, and social functioning. A period of stress such as in Linda has compromised all of these areas. She could not cope successfully with stress and therefore has been suffering from maladaptation. Obviously Linda has a poor social network with almost no interactions with the environment. Therefore her emotional supports are poor, thus decreasing her resources and her ability to cope with change. Her close family is away in New Zealand, and her she leads an isolated life. She has neither any intensity nor any reciprocity in her social network whatever available. The positive and harmonious interpersonal interactions that occur within a social relationship are missing from her life. She has neither emotional support nor informational support. Employment is a highly valued cultural norm, and the potential guilt associated with norm violation and the anticipated isolation from being ostracized are worse for that person than the physical and psychological pain. In that sense work is assigned significance beyond economic compensation. Work offers status, regulates life activities, permits association with others, and provides a meaningful life experience. Lindas inability to concentrate at work thus is further worsening her condition. When there is a healthy balance between work and home, women experience a low level of psychological stress. However, when the balance is disturbed, daily stressors contribute to health problems. There is a complex relationship between life changes and the development of illnesses. It has been hypothesized that people become ill after they experience life event changes. Her sisters demise, therefore, had been an initiating event of her illness. She clearly did not cope effectively with a difficult situation. Linda had significant emotional and behavioural symptoms in response to the identifiable stressful situation, but she had no coexisting psychiatric disorder, and therefore a diagnosis of adjustment disorder can be made. Her overwhelming tiredness, fatigue, loss of appetite, need for alcohol or drugs to fall asleep, loss of interest in socializing, tension and nervousness, lack of interest and motivation, tension and anxiety indicate a psychological state of mixture of anxiety and depressed mood. The assessment should begin with a careful health history focusing on past and present illnesses in the assessment. An illness or a recent trauma may be either a result of or a contributing factor to stress. History about coexisting psychiatric disorder should be taken. A systems review can elicit the person’s own unique response to stress and can also provide important data on the effect of chronic illnesses. In Lindas case clinically significant symptoms or behaviours were characterized by distress that was in excess of what would be expected from exposure to the stressor and caused a significant impairment in social and occupational functioning. Her symptoms did not represent bereavement. She had a positive stressor. Physical functioning usually changes during a stress response. Typically, sleep is disturbed, appetite either increases or decreases, body weight fluctuates, and sexual activity changes. In her case, sleep was disturbed, appetite reduced. Her amount of physical activity, tolerance for exercise, and usual exercise patterns were assessed. There was positive use of addictive substances. Many people begin or increase the frequency of using these substances as a way of coping with stress. In turn, substance abuse contributes to the stress behavior, which happened in case of Linda. If someone is using medication as a primary coping strategy, he or she may need further evaluation and referral to a mental health specialist (Antai-Otong, D. 2003). Symptoms of anxiety that negatively affect the individual’s ability to function in work or interpersonal relationships are considered symptomatic of an anxiety disorder. In case of Linda, it is causing paralyzing fear, leading to inaction. Her sleeplessness, fatigue, pale face, loss of appetite, nervousness and tension, difficulty to concentrate and focus attention, distractibility, inhibited behaviour, all point towards an anxiety state. Her anxiety is moderate in the sense that the client experiences a narrowing of the ability to concentrate, with the ability to focus or concentrate on only one specific thing at a time. According to diagnostic criteria, she is suffering from generalized anxiety disorder since it is characterized by unrealistic or excessive anxiety and worry occurring more days than not in a 6-month period. The concern is about several events, such as job or school performance, and the individual is unable to control the worry. At least three of the following six symptoms are reported: restlessness, fatigue, impaired concentration, irritability, muscle tension, and sleep disturbance. The anxiety interferes with social, occupational, or other important areas of functioning and is not the direct result of a medical condition or substance abuse. Anxiety disorders can be complex, presenting with confounding comorbidities that challenge even the most experienced nurse. The first step in the assessment process is to identify the clients level of anxiety and to determine whether a threat of self-harm or harm to others exists. A thorough history was obtained focusing on the clients physiologic, emotional, behavioral, and cognitive functioning, keeping in mind that the clients chief complaint and presenting problem may not be anxiety but one of vague physical or emotional complaints. She was depressed now with no significant past history. Obviously, there is a high chance that her perceptions were distorted. Linda is also having the behavioural symptom such as sleep disturbances. Sleep disturbances included sleep-onset insomnia and sleep-maintenance insomnia. The client was demonstrating nervous habits of wringing her injured wrists. Occupational functioning and social or family relationships were impaired. The client was asked how long the symptoms had persisted and what she had done to minimize them. Questions about the clients self-medication with over-the-counter drugs, prescription drugs, use of alcohol were elicited. A list of all medications the client takes for the management of clinical symptoms of medical and/or psychiatric disorders was obtained. Formulating nursing diagnoses for clients exhibiting clinical symptoms of anxiety is challenging because subjective data may be difficult to validate due to the clients increased level of anxiety. Consider factors that necessitate nursing care, such as activity level, communication, sleep pattern, self-perception, relationship with others, sexuality, and coping skills. The possibility that a medical problem could be causing the symptoms also must be considered (Carpenito-Moyet, L., 2004). The abuse of alcohol and other psychoactive substances has become an endemic problem throughout all levels of society. In terms of substance abuse or dependence, a substance can be defined as a prescribed drug, an illegal drug, or a substance used in an unintended manner to produce mood or mind-altering effect. Substance abuse may arise unintentionally from the initial use of a substance for its approved purpose. The individual frequently faces not only the psychological ramifications of a substance-related disorder, but also physiologic consequences resulting from substance use or abuse. A number of disorders can be induced through the use of a particular substance; in such cases, the symptoms cannot be explained by another condition or disorder and are related to substance use. In Lindas case, her state may be one of the following, Substance-Induced Anxiety Disorder, Substance-Induced Mood Disorder, Substance-Abuse Intoxication, and Substance-Induced Sleep Disorder (Rice, V.H., 2000). Linda has learned to use substances in certain situations with certain expectations as to the effects of the substance such as, relaxation and disinhibition. As she has experienced the desired effects, this may reinforce the desire to use the substance. Moreover, in her case, substances might have been used to relieve anxiety or as a means of coping with other traumatic events. She has never met criteria for substance dependence, since the history does not reveal a pattern of substance use over 12 months that has resulted in functional impairment. Her pattern of use is not characterized by the development of withdrawal or tolerance. CAGE tool was used to assess her alcohol use, and DAST was used to assess drug abuse. Laboratory testing was ordered, and no states of drug intoxication or withdrawal can be identified through the presence of physiologic and behavioral symptoms associated with the use of a particular substance. From her assessment, tolerance to the substance as evidenced by a need for increased amounts to achieve the desired effect and a diminution of effect while using the same amount were also not evidenced. There were no withdrawal symptoms either. During the assessment process, which occurred in the emergency room questions were directed toward identifying the substances used, amount and frequency of use, duration of use, and route of administration if substances other than alcohol are involved. Information regarding any prior treatment for a substance-related disorder also was collected. Lindas physiologic stability was assessed, it did not reveal anything other than confusion. Apart from anxiety and depression, there was no evidence of medical complications. She was anaemic, although this could be related to her dietary deficiencies. There were no risk taking behaviours, and it was a part of her coping mechanism to her maladjustment to stress, and she agreed that she uses substance in stress provoking situations. The nursing diagnoses were risk for Injury related to effects of the substance and ineffective coping related to life stressors with risk for self-directed violence, powerlessness, self-care deficit, and imbalanced nutrition, less than body requirements (Dawe, S., Loxton, N. J., Hides, L., Kavanagh, D. J., & Mattick, R. P., 2002). Nursing Role to Adapt to Stress: Because the experience of stress and the ability to cope are a result of the appraisal of the person–environment relationship, interventions that affect the environment are important. People who are coping with stressful situations can often benefit from interventions that facilitate family unit functioning. Since Lindas family is not available here, the nurse should assist the patient to consider expanding her social network. Numerous psychological interventions help reduce stress and support coping efforts. All the interventions are best carried out within the framework of a supportive nurse–patient relationship. In the behavioural domain, these interventions are behavior therapy, cognitive therapy, communication enhancement, coping assistance, patient education, and psychological comfort promotion. People under stress can usually benefit from several biologic interventions. Their activities of daily living are usually interrupted, and they often feel that they have no time for themselves. Stress is commonly manifested in the areas of nutrition and activity. During stressful periods, a person’s eating patterns change. To cope with stress, a person may either overeat or become anorexic. Both are ineffective coping behaviors and actually contribute to stress. Educating the patient about the importance of maintaining an adequate diet during the period of stress will highlight its importance. It will also allow the nurse to help the person decide how eating behaviors can be changed. Exercise can reduce the emotional and behavioural responses to stress. In addition to the physical benefits of exercise, a regular exercise routine can provide structure to a person’s life, enhance self-confidence, and increase feelings of well-being. The person under stress tends to be tense, nervous, and on edge. Simple relaxation techniques help the person relax and may improve coping skills. If these techniques do not help the patient relax, the nurse may teach distraction or guided imagery to the patient. People who are stressed are often not receptive to the idea of exercise, particularly if it has not been a part of their routine. Exploring the patient’s personal beliefs about the value of activity will help to determine whether exercise is a reasonable activity for that person (Helmuth, L., 2003). Using therapeutic communication techniques, the nurse assesses a person’s emotional state in a nurse–patient interview. According to the stress, coping, and adaptation model, there are two types of coping: problem-focused coping and emotion-focused coping. Problem-focused coping is effective when the person can accurately assess the situation. In this case, the person sets goals, seeks information, masters new skills, and seeks help as needed. Emotion-focused coping is effective when the person has inaccurately assessed the situation and coping corrects the false interpretation. Among the various emotion-focused coping strategies are minimizing the seriousness of the situation and projecting, displacing, or suppressing feelings. The nurse should consider a nursing diagnosis of Ineffective Coping for patients experiencing stress who do not have the psychological resources to effectively manage the situation (Happell, B., Cowin, L., Roper, C., Foster, K., & McMaster, R., 2008). Factors for Self Harm; The need to be loved and accepted, along with a desperate wish to communicate feelings of loneliness, alienation, worthlessness, helplessness, and hopelessness, often results in intense feelings of anxiety, depression, and anger or hostility directed toward the self. If no one is available to talk to or listen to such feelings of insecurity or inadequacy, a suicide attempt may occur in an effort to seek help or end an emotional conflict. This has been the case with Linda. This has been an anomic suicide attempt on the part of Linda. Anomic suicide refers to suicide that occurs when an individual has difficulty relating to others, adapting to a world of overwhelming stressors, or adjusting to expected normal social behavior, and her nonitegration to any social group has further accentuated her response to stressors. This act of cutting the wrists by Linda may be parasuicidal behaviour since she has engaged in self injury but did not wish to die. Self-injury is often a coping method used to deal with disturbing thoughts or emotions or to relieve tension. Self-injury occurs in approximately 30% of clients who abuse substances orally. During a crisis, a person is open to learning new ways of coping to survive the current crisis. The outcome of a crisis is governed by the kind of interaction that occurs between the person and his or her key social contacts (Yeager, K. R., & Roberts, A. R., 2003). Obviously, at the moment of cutting her wrists, Linda had been having a severely stressful experience for which coping mechanisms failed to provide any adaptation. It was a time-limited acute event that triggered a biopsychosocial response to a developmental, situational, or interpersonal experience. Her stress escalated to crisis when her coping mechanisms with drugs and alcohol failed, and with no social supports, she did this attempt. Her coping methods were insufficient to deal with the threat, tension rises, and normal functioning such as occupational, social, or familial was disrupted (Stuart, G.W., & Laraia, M.T., 2005). Protective Factors: One of the most common crisis-provoking events is the loss of a loved one. Normally, the death of a loved one produces feelings of grief. The goal for people experiencing a crisis is to return to the pre-crisis level of adaptation. The nurse’s role is to support the patient through the crisis and to facilitate the use of positive coping skills. Since Linda is experiencing a crisis nursing management can easily serve as a framework for care. To determine the level of effectiveness of the coping mechanisms of the client, the nurse should assess unusual behaviours and determine the level of involvement of the client with the crisis; assess the client’s perception of the problem, availability of the support mechanisms, and his/her coping capabilities. The strengths in case of Linda are that she is employed, and that can be used to develop a social network for her. Her alcohol and drug use is not in the stage of abuse or dependence, and therefore, interventions can be designed to get rid of those, and the need for the amount of support needed would be available from the assessment and both coping mechanisms and support mechanisms can be invoked to solve her problems. Counseling reinforces healthy coping behaviors and interaction patterns. Counseling, which focuses on identifying the person’s emotions and positive coping strategies for the corresponding nursing diagnosis, helps the person integrate the effects of the crisis into his or her life. At times, telephone counseling may provide the person with enough help that face-to-face counseling is not necessary (Caspi, A., et al. 2003). A crisis often disrupts the person’s social network, leading to changes in available social support. Sometimes, the development of a new social support system can help the person more effectively cope with the crisis. Supporting the development of more contacts within the social network can be done by referring the person to support groups or religious groups (Newman, M., Erickson, T., Przeworski, A., & Dzus, E., 2003). Conclusion: From this case study, it is apparent that this client had a stress response and related anxiety and depressive episode that were triggered by loss of a loved one. This has produced a situation of crisis, and perhaps, this was further accentuated by lack of social support. Apart from therapeutic interventions to stabilize these patients, it is important for the nurse to analyse the clinical situation of such patient and help them to enter into a social network, where they can share their feelings. Counseling is the very basic mainstay of such managements, and nurses, through build-up of a therapeutic relationship can help these people recover at least to the extent, where an event can be prevented. Reference List Antai-Otong, D. (2003). Anxiety disorders: Treatment considerations. Nursing Clinics of North America, 38(1), 35-44. Becker, S. H., & Knudson, R. M. (2003). Visions of the dead: Imagination and mourning. Death Studies, 27(8), 691–716. Caspi, A., et al. (2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science, 301(5631), 386-389. Carpenito-Moyet, L. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Dawe, S., Loxton, N. J., Hides, L., Kavanagh, D. J., & Mattick, R. P. (2002). Review of diagnostic screening instruments for alcohol and other drug use and other psychiatric disorders (2nd ed.). Publications Production Unit (Public Affairs, Parliamentary and Access Branch) Commonwealth Department of Health and Ageing. Happell, B., Cowin, L., Roper, C., Foster, K., & McMaster, R. (2008). Introducing mental health nursing: A consumer-oriented approach. Crows Nest, NSW: Allen & Unwin. Helmuth, L. (2003). In sickness or in health? Science, 302(5646), 808-810. Stuart, G.W., & Laraia, M.T. (2005). Principles and practice of psychiatric nursing (7th ed.). St. Louis: Mosby. Newman, M., Erickson, T., Przeworski, A., & Dzus, E. (2003). Selfhelp and minimal contact therapies for anxiety disorders: Is human contact necessary for therapeutic efficacy? Journal of Clinical Psychology, 59(3), 251–274. Rice, V.H. (2000). Handbook of stress, coping, and health: Implications for nursing research, theory, and practice. Thousand Oaks, Calif.: Sage. Yeager, K. R., & Roberts, A. R. (2003). Differentiating among stress, acute stress disorder, crisis episodes, trauma, and PTSD: Paradigm and treatment goals. Brief Treatment and Crisis Intervention, 3:1. Read More