Fiona is a 29-year-old woman who works in a medical factory making medical equipment. She lives with her husband and in-laws. Over the last week, she has been more isolative, saying strange things to her husband, and not sleeping due to unidentified fearfulness. The only stressor that her husband can identify is that they started talking about having children. Fiona refuses to do her ADLs, eats very little, and appears intermittently in a trancelike state. The family was becoming more and more concerned and attempted to get Fiona to see their family doctor, but she was refusing. Finally, police were called due to worsening regressed behavior and Fiona was brought to the local emergency department (ED) for evaluation. The ED physician examined her and reported after labs and neuroimaging that she was medically stable. Although the patient reported no history of psychiatric illness, she did report that her maternal grandmother was in a state hospital for most of her life. The physician recommended psychiatric hospitalization for new onset of a psychotic illness.
Summarize the clinical case.
What is the DSM5 diagnosis? Identify the rationale for your diagnosis using the DSM5 diagnostic criteria.
According to the clinical guidelines, which one pharmacological treatment is most appropriate to prescribe? Include the medication name, dose, frequency and rationale for this treatment.
According to the clinical guidelines, which one non-pharmacological treatment would you prescribe? (exclude psychotherapy modalities) Include the risk and benefits of the chosen rationale for this treatment.
Include an assessment of medication\’s appropriateness, cost, effectiveness, safety, and potential for patient adherence.
Use a local pharmacy to research the cost of the medication. Use great detail when answering questions 3-5.
SOLUTION TO THE CASE STUDY
Chapter 8, Case 2 Question 1: Summary
The presented case describes a 29-year-old woman suffering from early onset of a psychotic illness. Fiona was brought to the emergency department by the police following worsening regressed behavior. Her husband reports that the patient started exhibiting symptoms after a discussion about having children. Over the last week, the patient has been isolative, saying strange things, and has had issues with sleeping due to unidentified fearfulness. Other symptoms exhibited include refusal to do activities of daily living, eating very little, and appearing to be in a trance-like state. The patient’s family history reveals that her maternal grandmother had a psychiatric illness and spent most of her time in the state hospital.
Question 2: DSM 5 Diagnosis
The DSM-5 diagnosis for Fiona is generalized anxiety disorder (GAD). This condition is characterized by chronic anxiety, exaggerated worry, and tension, even where there is nothing to provoke it (American Psychiatric Association, 2013). While it is usual for people to worry about things, people with GAD have exaggerated worry about life stressors when there may be little to worry about. The constant worry makes it difficult to perform activities of daily living and social isolation. The DSM-5 criteria for diagnosis of GAD include characteristics like excessive anxiety and worry about a number of events occurring more days than not for at least 6 months, difficulty controlling the worry, association of anxiety with other symptoms like sleep disturbance, irritability, and difficulty concentrating (American Psychiatric Association, 2013). Additionally, anxiety causes impairment in important areas of functioning and cannot be attributed to the psychological effects of substance or medical conditions.
Fiona presents with anxiety issues that cannot be attributed to a specific reason. She appears to have anxiety due to the stress of having children according to her husband and it has progressed to affect relationships and work. She has difficulties in performing ADLs, eats little, doesn’t sleep due to unidentified fearfulness, and appears intermittently in a trance-like situation. The labs and neuroimaging performed by the physician indicate that she does not have a medical condition to explain her behavior making GAD the most appropriate diagnosis.
Question 3: Pharmacological Treatment
Selective serotonin reuptake inhibitors are recognized as the first-line treatment of generalized anxiety disorder. I would prescribe escitalopram 10 mg PO once daily and later increase the dosage according to the patient’s response. Escitalopram is FDA approved for the management of generalized anxiety disorder and has an overall rating of 8.0 out of 10 in alleviating anxiety symptoms (Melaragno et al., 2021). This works by increasing overall serotogenic transmission in the brain by blocking the presynaptic transmission of serotonin. The goal of treatment is to make the patient feel better mentally and physically and increase engagement with people and other healthy habits. A few side effects that the patient may experience include nausea, headaches, sweating, and weakness making it easy for patients to adhere to treatment.
Question 4: Non-Pharmacological Treatment
The non-pharmacologic treatment approach I would recommend for the patient is hypnotherapy. Used as an adjunctive therapy, hypnosis works by allowing patients to feel relaxed, experience a growing sense of calm, and become more able to set concerns aside and enjoy life (Servant et al., 2019). The main advantage of hypnotherapy is that it heightens concentration and focused attention on the important things in life. It can help patients relax and forget their troubles. One of the disadvantages of this option is that it cannot fix anxiety issues on its own (Hasbi & Effendy, 2019). The patient ought to use medication or CBT to achieve results quickly.
Question 5: Cost of Medication
The current cost of escitalopram (Lexapro) in Florida ranges from $11.59 to $34.25. For example, 10 mg escitalopram (30 tablets) costs $12.49 in Rite Aid while the same drug costs $27.38 in Kroger pharmacy.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Hasbi, M., & Effendy, E. (2019). Hypnotherapy: A case of anxiety person who doesn’t want to use medication. Open access Macedonian Journal of Medical Sciences, 7(16), 2698–2700. https://doi.org/10.3889/oamjms.2019.820
Melaragno, A. J. (2021). Pharmacotherapy for anxiety disorders: From first-line options to treatment resistance. Focus, 19(2), 145-160. https://doi.org/10.1176/appi.focus.20200048
Servant D. (2019). Traitement non médicamenteux des troubles anxieux [Non-pharmacological treatment for anxiety disorders]. La Revue du praticien, 69(9), 985–987. https://pubmed.ncbi.nlm.nih.gov/32237617/
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