Anxiety, Case Study Example

This is a case of a 47-year-old female social worker suffering from repeated episodes of clinical anxiety. In the background information given (which I won’t repeat here), the attacks appear unrelated to any specific factor — they happen spontaneously. Her physical exam was normal, which I also take to mean she has avoided her family’s alcoholism, and had slept well before. I will also assume that brain-scans have been either performed or ruled out as unneeded.

The first question is about the need for immediate intervention, and what kind it should be. Given that the patient is middle-aged, in apparent good physical health, and has a regular job, we should find out who else knows about her problem. In my own view, the answer can be critical and may largely determine a patient’s ability to fully recover, but there are conflicting points of view in this regard. Some believe that hiding a mental condition brings self isolation (Mayo Clinic). I disagree, feeling that the stigma is itself far more isolating, and that the fewer people who know of such a condition, the better. We should advise her to be careful on this matter, and to prefer caution to informal communication, especially at work.

Next, she should be advised to get ready to schedule a vacation in the near future, but not to take one immediately. (An abrupt change in routine from work to leisure only serves to remind the patient that something has gone seriously wrong, and paradoxically increases stress.)

The next goal is to keep her working and interacting normally in the meantime. This will mean a pharmacological backup intervention, a drug to be used not as a long-term regimen, but rather as needed in the hopes of fending off any future attacks as they happen. Only if that doesn’t work should she be put on a daily medication. Finally, we should schedule regular psychological counseling, if possible taking place before or after her normal working hours. But being expensive, such counseling may be beyond her reach. If counseling is covered by her employer’s insurance, it would alert her Human Resources (HR) department. It’s virtually a given that word would leak out (Green, 2010). We should recommend guarded contact with HR.

Pharmacological intervention will depend on whether her condition: 1) goes away; 2) stays about the same; or 3) gets worse. Those are our most basic variables. For #1, the outcome itself solves the problem. She should be advised that such attacks may return, but having receded before, may well do so again. For #2, we should try to keep the patient on the backup-drug plan. If the patient enjoys talking about her attacks and has included her social circle in those talks, and if we get the impression that she just wants attention, plan #2 might involve a placebo. If real treatment is indicated, we should gauge whether any withdrawal symptoms might worsen the patient’s vulnerability towards anxiety. If that hurdle is cleared, treatment should begin with a benzodiazepine like Xanax, because they can be used on an as-needed basis and are fast acting (Longo & Johnson, 2000). However, given her family history of addictive behavior, we should bear in mind their addictive properties if her attacks continue.

If #3 proves necessary, our overall strategy would be to avoid a future addiction by alternating various long-term medications. We should probably begin with an antidepressant  like Prozac, as they have been found to help anxiety as well as depression (Smith, Robinson & Segal, 2012). However, these drugs can take over a month to become effective, so there will be a transition period from the Xanax to Prozac. This can cause serious side-effects.

Monitoring initially will be required, and this is where the vacation I mentioned comes into play. It is advisable that transitioning from one psychotropic drug to another be done during an extended stay home from work, not just over the weekend. Family members will probably have to be told the nature of the vacation, but HR and coworkers at least need not.

Throughout, our goal should be the reduction of stress, both present and anticipated.

References

Green, A. (2010, August 4). Does HR have to keep it confidential?. Retrieved from http://hrpeople.monster.com/benefits/articles/2853-does-hr-have-to-keep-it-confidential

Longo, L., & Johnson, B. (2000, April 1). Addiction: Part I. benzodiazepines—side effects, abuse risk and alternatives. Retrieved from http://www.aafp.org/afp/2000/0401/p2121.html

Mayo Clinic. (2011, May 26). Mental health: Overcoming the stigma of mental illness. Retrieved from http://www.mayoclinic.com/health/mental-health/MH00076

Smith, M., Robinson, L., & Segal, J. (2012, September) Anxiety medication: what you need to know about anti-anxiety drugs. Retrieved from http://www.helpguide.org/mental/anxiety_medication_drugs_treatment.htm