What medications are considered first-line best practices for treating anxiety? How long can they expect these medications to take full effect? Alternative to use? Selective serotonin r

Student 1: Judy

What medications are considered first-line best practices for treating anxiety? How long can they expect these medications to take full effect? Alternative to use?

Selective serotonin reuptake inhibitors (SSRIs) are recommended as a first-line treatment for anxiety disorders (Bandelow et al., 2017). They increase serotonin levels by blocking the serotonin transporter (SERT) which helps to reduce anxiety (Stahl & Muntner, 2021). These drugs can be used long-term due to better tolerability, less sedation, and less chance of abuse or withdrawal (Bandelow et al., 2017). A study that was conducted by Jakubovski et al (2018), also reported that serotonin-norepinephrine reuptake inhibitors (SNRIs) are also the first-line pharmacological treatment for anxiety disorders, but higher doses of these medications are not needed to relieve anxiety. Therefore, the pharmacotherapeutic treatment is somewhat a matter of professional expertise and what the provider is comfortable with prescribing.

What therapy would be indicated for someone with anxiety?

Cognitive behavior therapy (CBT) can be indicated for someone with anxiety. It can be used to examine negative thoughts that contribute to anxiety symptoms and replace those thoughts with more positive realistic thoughts. This type of therapy approach is to help clients identify irrational thoughts and help them analyze their negative beliefs. Furthermore, the use of an SSRI with CBT can reduce the activity in the amygdala and insula which is responsible for pain and emotional perception, and addictive behaviors (Gorka et al., 2019).

What do you need to assess before prescribing a benzodiazepine? What special considerations should be given and discussed with the patient?

Benzodiazepines may be used in the management of diseases such as insomnia or anxiety. However, the use of benzodiazepines can result in respiratory depression due to its effects on the central nervous system hence patients should be educated on its use and contraindications. Benzodiazepines are recommended for short-term pharmacotherapeutic treatment use due to the significant risk of dependence. Long-term benzodiazepines should be avoided if possible due to the risk of dependence, possible abuse, and cognitive decline (Stahl, 2017). Moreover, patients should be tapered off long-term use if they can tolerate the discontinuation without severe withdrawal. According to Takaesu et al (2019), patients taking benzodiazepines are at increased risk of cognitive function decline, falls, as well as dependence, and tolerance. That being said, benzodiazepines should not be considered first-line due to their high potential for abuse.

Last Name: I-N

Body Dysmorphic Disorder (F45.22)

How would you define the disorder?

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) (2013), defines body dysmorphic disorder (BDD) as a preoccupation with one or more flaws in physical appearance that others do not see that causes social anxiety and avoidance. Individuals who have BDD excessively look at themselves in the mirror, and they are always grooming themselves. These types of behaviors cause a significant amount of distress which affects one’s everyday functioning. The person with BDD cannot control these behaviors and therefore has a high level of anxiety. They are always concerned about their appearance and try to compare themselves with others. Their preoccupation is not related to their weight or body fat therefore they do not have an eating disorder (American Psychiatric Association, 2013). Some individuals with this disorder have beliefs that their body is built too thin with insufficient muscles. Additionally, individuals have compulsions and obsessions that are mainly focused on their physical appearance, and they are usually time-consuming as well as difficult to control (American Psychiatric Association, 2013). According to Nicewicz and Boutrouille (2021), BDD was first recognized as an atypical somatoform disorder.

What signs/symptoms would one see in the patient that demonstrate the disorder?

The signs and symptoms that one would see that demonstrate body dysmorphic disorder are individuals engaging in repetitive behaviors, such as excessive mirror checking, compulsive skin picking, camouflaging, participating in excessive grooming, excessive weightlifting, or pervasive mental acts that involve them comparing themselves to other people (Field, 2018). These perceived physical flaws most commonly occur on the skin, hair, or nose, but any body part can be involved. An individual is hyper-focused on his/her appearance which makes them believe that they are ugly and unattractive. They are usually concerned about their eyes, teeth, lips, breasts, stomach, genitals, and legs among others (American Psychiatric Association, 2013). They compare themselves with other people, they think other people are taking note of their negative appearance and they might repeatedly apply makeup to try to cover flaws. Some individuals end up seeking medical procedures, excessively tanning their skin, and changing their clothes excessively (American Psychiatric Association, 2013). They also tend to seek reassurance from others about how they look and sometimes avoid social situations due to fear of being judged or maybe people will notice their imperfections.

What are the main DSM-5 criteria for this disorder?

According to the DSM 5, body dysmorphic disorder is classified under obsessive-compulsive and related disorders. An individual exhibits the four of the following features to meet the diagnostic criteria:

Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable by others or others slightly notices them (American Psychiatric Association, 2013, p.242).

The person performs repetitive behaviors such as checking mirrors, excessive grooming, skin picking, reassurance-seeking, or mental acts that are concerning to their appearance (American Psychiatric Association, 2013, p.242).

The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. (American Psychiatric Association, 2013, p.242).

The appearance preoccupation is not explained by concerns with body fat or weight that one meets the criteria for an eating disorder. (American Psychiatric Association, 2013, p.242).

What is the top 3 differential diagnosis for this disorder from the DSM-5?

The three top differential diagnoses from the DSM-5 include Obsessive-compulsive disorder whereby there are preoccupations and repetitive behaviors. However, in BDD they are more focused on their appearance hence the skin picking to improve how they look. The second is an eating disorder this can be comorbid. Thirdly is anxiety disorders which are common in body dysmorphic disorder. However, in BDD the anxiety is appearance-related and not social or avoidance (American Psychiatric Association, 2013).

What medications would you use? Why? Black box warnings?

Before prescribing any medications, I would first obtain consent for treatment. It is important to explain to the patient all the risks versus benefits of the medication. The medication class that is preferred for patients with BDD is selective serotonin reuptake inhibitors (SSRIs). According to Nicewicz and Boutrouille (2021), Fluoxetine is the recommended drug to treat BDD. The dosage will be 20mg daily as it is important to start low and see how the patient might tolerate the drug. The goal will be to reduce the symptoms. The onset of action is usually delayed 2-4 weeks and if it is not working within 6-8 but the patient is tolerating the drug then it should be increased. The side effects that need to be discussed with the patient include nausea, diarrhea, headache, drowsiness or activation, sexual dysfunction, or desire. Serious adverse effects include suicidal thoughts and/or behaviors, mania, and seizures (Stahl, 2021). While waiting on the therapeutic effects to take effect, the patient can also be started on a small dose of benzodiazepine short-term to give some relief to the distressing symptoms.

What type of therapy would you recommend for this patient?

The types of therapy that have shown to be beneficial for patients with BDD include cognitive-behavioral therapy (CBT) and metacognitive therapy (Phillipou et al., 2016). CBT is the recommended first line of treatment for BDD. These types of therapy will help the patient to work on his/her self-confidence. Also, help in identifying the behaviors and triggers that cause these feelings. 

What do you see as the possible outcomes for this patient?

Clinicians need to communicate realistic expectations to patients who are diagnosed with BDD at the beginning of treatment and explain that their disorder might not be cured but the goal is a reduction of symptoms. The outcome for the patient would be to continue taking fluoxetine until the symptoms of BDD have resolved or have been significantly reduced. Also, for the patient to participate in cognitive behavioral therapy to manage negative thoughts and modify behaviors.

What are the 5 components of a suicide risk assessment that the patient needs to be asked?

The five components of the suicide risk assessment that the patient needs to be asked are do you have current thoughts of killing yourself, what are your intentions, do you have a plan, have you ever tried to kill yourself in the past, what is keeping you alive, or what might decrease the chances of you trying to kill yourself as suicidality is high within individuals with body dysmorphic disorder. Furthermore, 80% of individuals with body dysmorphic disorder think about suicide while approximately 26% of those individuals have attempted suicide (Koenig et al., 2021).

In addition to the suicide risk assessment questions, the clinical can conduct a physical assessment of an individual who has body dysmorphic disorder, he or she might notice some skin lesions secondary to skin picking. Most patients with BDD have a history of self-inflicted injuries. Although clients might not want to share with the clinicians about their disorders, it is important to ask them questions about any cosmetic procedures, or surgical interventions. Also find out how they feel about their appearance, how much time they spend worrying about their appearance, and ask whether their condition affects their quality of life. Find out if the patient has other dermatologic issues. Find out the onset and duration of symptoms. Ask if the patient has mental health history in his or her family or if he/she is experiencing any significant life changes or stressors. It is also imperative for the clinician to assess and rule out disorders and other comorbidities like social anxiety disorder and obsessive-compulsive disorder (American Psychiatric Association 2013). 

Student 2: Klaus

What medications are considered first line best practice for treating anxiety? How long can they expect these medications to take full effect? Alternative to use?

To treat social anxiety disorder, health care providers may prescribe medications. This disorder can be effectively treated with a variety of medications, including selected serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are antidepressants (SNRIs); this class of medications may take several weeks to reach their effect usually four to six weeks; alternatively, benzodiazepines can also be utilized and these usually take a shorter time to take effect but long term use is contradicted as it can be addictive (Mayo Foundation for medical Education and Research, 2021).

What therapy would be indicated for someone with anxiety?

Most patients with social anxiety disorder benefit from psychotherapy. In therapy, you will learn how to recognize and modify negative beliefs about yourself as well as build skills to help you achieve social confidence; CBT (cognitive behavioral therapy) is the most successful type of psychotherapy for anxiety, and it can be used either individually or in groups (Mayo Foundation for medical Education and Research, 2021).

What do you need to assess before prescribing a benzodiazepine? What special considerations should be given and discussed with the patient?

Examine the patient for signs of addiction and abuse. Benzodiazepines should not be used by patients who have a history of substance abuse, particularly prescriiption drug abuse; If the patient has other risk factors, use cautious, such as: a background of chronic pain, a history of substance abuse and behavioral addictions in the family (Mayo Foundation for medical Education and Research, 2021).

Social Anxiety Disorder

How would you define the disorder?

In situations where they may be inspected, assessed, or judged by others, such as speaking in public, meeting new people, answering a question in class, or having to chat to a cashier in a store, a person with social anxiety disorder experiences anxiety or terror; commonplace activities such as eating or drinking in front of people or using a public lavatory, might generate anxiety or dread of being embarrassed, judged, or rejected (Mayo Foundation for medical Education and Research, 2021).

What signs/symptoms would one see in the patient that demonstrate the disorder?

Unlike ordinary uneasiness, social anxiety disorder include fear, anxiety, and avoidance that interfere with relationships, daily routines, job, school, or other activities (Mayo Foundation for medical Education and Research, 2021).

What are the main DSM-5 criteria for this disorder?

Several criteria are involved when diagnosing someone with social anxiety disorder (DSM-5 definition of social anxiety disorder, n.d).

persistent anxiety of being exposed to unfamiliar people or being scrutinized by others in one or more social or performance circumstances. The person is afraid that he or she may do something embarrassing and humiliating (or show anxiety symptoms).

Being exposed to the feared situation nearly always causes worry, which can manifest as a situationally bound or predisposed Panic Attack.

The individual recognizes that his or her fear is irrational or excessive.

Fearful circumstances are avoided or endured with a great deal of anxiety and distress.

The avoidance, nervous anticipation, or distress in the dreaded social or performance situation(s) severely interferes with the person's usual routine, occupational (academic) functioning, social activities, or relationships, or the person feels distressed by having the phobia.

The fear, worry, or avoidance is long-term, usually lasting six months or more.

4.

What are the top 3 differential diagnosis for this disorder from the DSM-5?

panic disorder

agoraphobia

atypical depression

5.

What medications would you use? Why? Black box warnings?

Though there are a variety of drugs available, selective serotonin reuptake inhibitors (SSRIs) are frequently used to treat chronic social anxiety symptoms. Sertraline or paroxetine (Paxil) may be prescribed by your doctor (Zoloft); Venlafaxine (Effexor XR), a serotonin and norepinephrine reuptake inhibitor (SNRI), may also be used to treat social anxiety disorder (Mayo Foundation for medical Education and Research, 2021).

What type of therapy would you recommend for this patient?

Most patients with social anxiety disorder benefit from psychotherapy. In therapy, you will learn how to recognize and modify negative beliefs about yourself as well as build skills to help you achieve social confidence; CBT (cognitive behavioral therapy) is the most successful type of psychotherapy for anxiety, and it can be used either individually or in groups (Mayo Foundation for medical Education and Research, 2021).

What do you see as the possible outcomes for this patient?

Combination of an appropriate therapy and medications as last resort should be helpful to this patient to a high degree and go a long way in increasing the prognosis

What are the 5 components of a suicide risk assessment (From the PowerPoint/Kaltura in Week1) that the patient needs to be asked?

I’ll as if the patient has any plans of killing themselves

Ask what the plan is

Seek to know if they has any access to the plan

Seek to know their intention

Seek to find out what is keeping them from executing the plan so far