Running head: GENERALIZED ANXIETY DISORDER – SMITH
Evidenced Based Generalized Anxiety Disorder Case Study
Kelley E. Smith
NURS 5645 Management of Acute and Chronic Illnesses II
College of Nursing and Health Sciences
Texas A&M University – Corpus Christi
November 2014
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GENERALIZED ANXIETY DISORDER – SMITH
Abstract
This paper explores a patient case study involving a common primary care office complaint,
distractibility. In this case, the patient’s inability to focus can potentially be traced to a variety of
factors, namely anxiety, attention deficit hyperactivity disorder (ADHD) and depression. Key
subjective and objective data along with patient history are used to explore underlying causes,
cultural considerations, differential diagnoses, appropriate diagnostic tools, management,
complimentary therapy and follow-up care surrounding distractibility. Evidence-based practice is
utilized to guide comprehensive patient care regarding the primary diagnosis of anxiety. In
addition, Peplau’s theory of interpersonal relationships is applied in the case study to employ a
therapeutic, goal-directed, patient-nurse relationship. Due to the underlying issue of anxiety,
Peplau’s theory is of the utmost importance in order to establish patient rapport and ensure that
the plan of care incorporates the patient in the healthcare team. Finally, legal and ethical issues
are highlighted regarding the treatment of psychological disorders specifically with selective
serotonin reuptake inhibitors (SSRIs).
Keywords: anxiety, attention deficit hyperactivity disorder, depression, distractibility
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Introduction, Subjective & Objective Data
N.S. is a 25 year old African-American male who currently holds a full time job, works
as a delivery driver, has full medical benefits and lives with his older brother and sister-in-law.
N.S. presents to the clinic with the following chief complaint: “two to three times a week for
some reason I will decide I need to be finished with my deliveries by a certain time that I set
myself and then the rest of the day I feel pressured, irritable and have problems focusing. I will
get short with my customers if I feel like they are taking up too much of my time unnecessarily.”
(N.S., personal communication, October 2, 2014). N.S. is single, a high school graduate and has
taken some college courses. However, he wonders why all of his focusing problems began after
he graduated high school since he never had problems in school. N.S. denies smoking, using
drugs and has approximately two to three beers, three to four nights a week usually in social
settings. On one occasion over the last year, N.S admits to feeling so overwhelmed that he
experienced a brief one to two minute episode of shortness of breath with extreme anxiety that
resolved on its own with controlled breathing. About one year ago, N.S. was diagnosed with
ADHD.
Since his ADHD diagnosis, N.S. has tried Adderal, Vyvanse and Straterra all of which
he discontinued due to undesired side effects such as insomnia, nausea and/or were not helping
his ability to focus and make deliveries. N.S. stresses the importance of having a treatment plan
that will allow him to feel well rested for work, aid in focus, especially when he re-commits to
taking college courses, and will not affect his weight or sex drive.
N.S. denies taking any type of medication currently denies any past medical history other
than ADHD and denies any surgeries. The last medication he took was Strattera “a few months
ago” (N.S., personal communication, October 2, 2014). N.S. believes his mom is being treated
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GENERALIZED ANXIETY DISORDER – SMITH
for hypertension but cannot be sure and to his knowledge denies any known familial
psychological disorders, lung disease, heart disease or cancers.
N.S. reports the following in regard to his review of systems, specifically related to
ADHD and Anxiety: (a) organization: “good”, (b) appetite: “normal”, (c) mood: “up and down,
depends at work”, (d) sleep: “good”, (e) attention: “I have difficulty focusing, mostly at work”,
(f) hyperactivity: “no, I’m not really hyperactive”, (g) impulsivity: “nope”; stress level: “major, I
mean I live with my brother and his wife and I’m 25 , but I’m trying to save up for school and
what not”, (h) anxiety: “um, well I am right this second, but I don’t know how to gauge that”
(N.S., personal communication, October 2, 2014). In addition, N.S. denies any suicidal or
homicidal ideation, no significant change in weight (gain or loss), no fatigue, no visual/auditory
hallucinations, no delusions, no headaches, no dizziness, no loss of consciousness, no apathy , no
chest pain, no palpitations, no shortness of breath, no nausea, no vomiting, no diarrhea, no
constipation, no cold or heat intolerance, no change in voice and no excessive sweating or dry
skin (N.S., personal communication, October 2, 2014).
N.S.’s objective findings on physical exam include: (a) psychological: patient appears,
anxious, fidgety well-spoken, pleasant with appropriate affect, well-groomed and a reliable
historian , (b) neurological: alert, oriented to person, place, time, event with clear speech and
smooth and steady gait, (c) neck/thyroid: neck supple, trachea midline, full range of motion with
and without resistance, no masses, non-tender, no cervical LAD, (d) lungs: clear to auscultation
in all five lobes both anteriorly and posteriorly, regular rate, no wheezing, crackles, rhonchi or
adventitious sounds noted, (e) cardiovascular: S1 & S2 noted, regular rate and rhythm, no
murmurs, rubs or gallops, (f) abdomen: active bowel sounds in all 4 quadrants, soft, non-tender,
no masses, irregularities or hepatosplenomegaly, (g) endocrine: hair black, shiny evenly
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GENERALIZED ANXIETY DISORDER – SMITH
distributed, (h) vital signs: blood pressure 130/78, heart rate 60, temp 98.7, RR 18, pulse
oximetry 98 percent on room air.
One of the greatest cultural considerations for N.S. is a new phenomenon called the
“emerging adult” or “extended adolescence” stage of life (Gallo & Gallo, 2011). Gallo & Gallo
(2011) report that this new stage of life is occurring in 18 to 26 year olds who desire the benefits
of adulthood, but struggle with the cost of achieving successful role performances. This stage is
comprised of five features: identity exploration, instability, self-focus, feeling in-between and the
age of possibility (Bigham, 2012). Moreover, some people in this stage face problems unveiling
their true identity due to external forces such as inability to focus in N.S.’s case; this
phenomenon of external forces is often referred to as foreclosing one’s true identity prematurely
(Gallo & Gallo, 2013).
Assessment
When evaluating and treating a patient with ADHD, is it is important to rule out other
closely related disorders such as mood disorders. Common differential diagnosis for ADHD
include: anxiety, depression and substance abuse (Bukstein, 2014). In addition, anxiety disorders
can be diverted by the patient’s focus of the disorder, which at times can present similarity to the
distractibility seen in ADHD (Bukstein, 2014).
Although the patient was diagnosed with ADHD one year ago, N.S. scored an 11 out of
21 on the he generalized anxiety disorder seven-item scale (GAD-7) scale indicting a moderate
level of anxiety during his visit. The patient also demonstrated the possibility of a depression
syndrome and symptoms of ADHD on the other two diagnostic scales performed during the
patient’s visit which is discussed below. The mutually agreed upon primary working diagnosis
decided by N.S. and the provider for the visit was generalized anxiety disorder (GAD).
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GENERALIZED ANXIETY DISORDER – SMITH
In addition to depression & ADHD as secondary diagnoses, the provider could have
considered adjustment disorder as the patient expressed he felt “major stress” about living with
his brother. However, the lack of information gathered regarding the time frame N.S. has lived
with his brother is a weakness for this particular diagnosis (Baldwin, 2014). Lastly, a thyroid
disorder was ruled out at the patient’s last visit in June 2014 via blood work, history and exam.
The patient also had a negative urine drug screen in June 2014 and denies any substance abuse
problems so this differential is unlikely at the current time.
Management
Taking into account N.S.’s cultural considerations and stage of life, treatment
interventions should be aimed at creating an environment where the patient can focus, promote
positive identity exploration, generate opportunity and initiate and obtain goals while being
mindful of cost both literally and emotionally; N.S. and the provider plan on these goals being
achieved with proper control of N.S.’s anxiety
First-line medication treatment for GAD includes SSRIs and serotonin-norepinephrine
reuptake inhibitors (SNRIs). “In cases of co-occurring GAD and depression, a common
comorbidity, SSRIs can provide effective treatment for both GAD and major depression”
(Bystritsky, 2014, p.1). In addition, the use of cognitive-behavior therapy (CBT) in tandem with
medication was discussed, but N.S. stated he was not at all interested in “therapy” at this time
(Bystritsky, 2014); mostly due to N.S.’s perceived lack of time and stigma associated with
therapy. Craske (2013) also noted that CBT tends to be less effective in African American
cultures as their core values are directed at harmony, family and spirituality whereas Northern
Americans benefit more often with principles of an individual’s capacity for change, open selfdisclosure, independence and autonomy. Agreeing that therapy was not the best approach, the
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GENERALIZED ANXIETY DISORDER – SMITH
provider reviewed common side effects of SSRIs such as weight gain, sexual dysfunction,
drowsiness, dizziness, headache and dry mouth (Kristin Gilbert, personal communication,
October 2, 2014 & Hirsch & Birnbaum, 2014).
Although the provider originally suggested paroxetine, sertraline and citalopram which
are efficacious, cheap, SSRIs for GAD in study trials, N.S. was most concerned with minimizing
side effects (especially decreased libido). N.S. was inquisitive about what medication the
provider had seen the best outcomes for anxiety and minimal side effects with her other patients.
The provider discussed with N.S. that she had the best patient success with Viibryd in relation to
minimal side effects , but stressed that this medication was newer, expensive, had no generic
alternative, and other SSRIs were available at a cheaper cost and potentially just as effective.
Furthermore, the provider reviewed that the most common complaints about Viibryd from
patients which included nausea, vomiting, diarrhea and trouble sleeping (Viibryd: drug
information, 2014 & Kristin Gilbert, personal communication, October 2, 2014).
With much consideration, N.S. decided he wanted to try the samples of Viibryd. The
provider reassured N.S. that selecting the best medication was like trying on a pair of shoes;
what works for one person, may take another person a couple different times before finding the
right fit. N.S. was educated that the initial dose of Viibryd should start at 10mg once daily the
first week and then increase to 20mg once daily the second week; then, the patient should return
for a follow up visit at the end of the two week period for re-evaluation (Kristin Gilbert, personal
communication, October 2, 2014). Additional follow up instructions included that a trial period
of four to eight weeks may be necessary to determine the desired response or if the medication
needs to be changed (Buttaro, Trybulski, Bailer, & Sandberg-Cook, 2013). Next, N.S. was
educated about the black box warning regarding all SSRIs ability to cause suicidal ideation and
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to call or go to the hospital immediately if any of these thoughts occurred (Vildaodone: drug
information, 2014).
Finally, N.S. was educated that alternative methods such as acupuncture and routine
physical activity have demonstrated some benefits for the treatment of anxiety, but other herbal
remedies such as Kava are not recommended for general use; thus, the patient was to call with
any questions or concerns that may arise before taking new medications or supplements (Buttaro,
Trybulski, Bailer & Sandberg-Cook, 2013).
Theory
As a team, N.S. and the provider utilized Peplau’s theory of interpersonal relationships to
identify N.S.’s goals and build a mutually agreed upon plan of care. Peplau’s theory is defined as
“a therapeutic, goal-directed, interpersonal process between the nurse and the patient. The theory
is an educative process that promotes growth of personality towards health and constructive
functioning” (Jones, 1996, p.877-888).
The initial portion of the office visit consisted of the orientation phase where the provider
listened to the patient and aimed to present herself as a resource. During this phase, the patient
defined problems, conveyed needs, shared past experiences and soon began to work with the
provider to identify emerging goals; the identification phase was quickly in full swing
unmasking hidden problems (Jones, 1996). N.S. stated his frustrations with the three previous
failed treatment plans and that he never had a problem focusing in high school, but that he was
willing to try just about anything. The provider noted to N.S. that at times symptoms of ADHD,
such as inability to focus, can mirror an underlying disorder like anxiety and discussed whether
or not the patient felt this could be plausible in his case. N.S. admitted to feeling somewhat
anxious in the office and thought it would be beneficial to take the quick anxiety, depression and
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ADHD scales to explore alternative factors. N.S wanted to discuss his treatment options once the
three diagnostic scales noted a moderate level of anxiety, the possibility of depression syndrome
and possible symptoms of ADHD. From there, the exploitation phase took place as the patient
and provider actively discussed different treatment options for generalized anxiety disorder,
depression and ADHD symptoms while taking into consideration N.S.’s busy work schedule and
concern for unwanted side effects discussed above.
The last phase of Peplau’s theory is the Resolution phase, but this phase has not yet been
initiated. The Resolution phase begins when the patient’s goals have been successfully met and
therefore termination of the professional relationship occurs (Jones, 1996).
Cost-effectiveness of Diagnostics and Plan of Care
In addition to gaining patient rapport and key subjective and objective data through
Peplau’s theory of interpersonal relationships, the patient and provider chose to investigate
underlying causes for N.S’s chief complaint utilizing three different scales: the GAD-7 for
anxiety, the Center for Epidemiology Studies Depression Revised (CESD-R) scale for depression
and the Adult ADHD Self-report Scale (ASRS). The primary diagnostic tool, the GAD-7, had a
sensitivity of 89 percent and specificity of 82 percent (GAD-7, 2013). All three scales were free,
patient self-reported, quick (N.S took all three quizzes in approximately 15 minutes) and
produced instant test results (K, Gilbert, personal communication, October 2, 2014).
In contrast to the effective, low-cost, quick screening scales, N.S’s medication of choice
was more expensive than other options, but he made that decision well informed. N.S was told
paroxetine is approximately $4 dollars at Walmart while Vibriid is approximately $25 at
Walmart with the Viibryd Coupon (K. Gilbert, personal communication, October 2, 2014).
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GENERALIZED ANXIETY DISORDER – SMITH
Legal and Ethical Issues
Before prescribing any medication, but specifically with SSRIs, information about how
the medication will affect the patient should always be discussed at length. Items like side
effects, abrupt cessation of the medication, medication response time and interactions with other
drugs should be addressed. It is important that the patient be made aware that the desired
response from the medication could take several weeks to present or potentially may require
trying a different option. SSRIs can also precipitate dangerous interactions with other drugs such
as monoamine oxidase inhibitors, which can be fatal so a comprehensive drug interaction
assessment should be performed with the patient’s current medication list (Hirsch & Birnbaum,
2014). The patient should also be advised to speak with the provider before taking any additional
medication, herbs, and supplement or over the counter therapy.
Lastly, a discussion with the patient should occur regarding the fact that antidepressants
have been found to increase the risk of suicidal thinking in children, adolescents and young
adults in short-term studies aimed around major depressive disorder and other psychiatric
disorders (Vilazodone: drug information, 2014). For this reason, the clinician should stress the
urgency for the patient to immediately report any worsening of symptoms or suicidal ideation.
Conclusion
Through the positive therapeutic process outlined by Paplau’s theory, the foundation for a
strong patient-provider relationship was built with an open line of communication; this line of
communication paved the way for N.S and the provider to explore differential diagnoses, costeffective diagnostic tools and treatment options. Furthermore, N.S. and the provider discovered
an underlying cause of N.S.’s distractibility, anxiety. If the opportunity presented itself, the
author would choose to have this case study printed in the Annual Review of Clinical
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Psychology Journal (ARCP). The ARCP’s content encompasses research, theory and application
of psychological principles while addressing broader issues such as diagnosis, treatment, social
policies, cross-cultural considerations and legal issues of many psychological disorders including
anxiety (Journal Home, n.d).
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References
Baldwin, D. (2014). Generalized anxiety disorder: Epidemiology, pathogenesis, clinical
manifestations, course, assessment, and diagnosis. UpToDate. Retrieved from
http://www.uptodate.com.manowar.tamucc.edu/contents/generalized-anxiety-disorderepidemiology-pathogenesis-clinical-manifestations-course-assessment-anddiagnosis?source=machineLearning&search=general+anxiety+disorder&selectedTitle=2
~150&sectionRank=1&anchor=H448541462#H448541462
Bigham, D. S. (2012). Emerging adulthood in sociolinguistics. Language & Linguistics
Compass, 6(8), 533-544. doi:10.1002/lnc3.350
Bukstein, O. (2014). Adult attention deficit hyperactivity disorder in adults:
Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis.
UpToDate. Retrieved from uptodate.com.manowar.tamucc.edu/contents/adultattention-deficit-hyperactivity-disorder-in-adults-epidemiology-pathogenesisclinical-features-course-assessment-anddiagnosis?source=machineLearning&search=adhd&selectedTitle=2~150&secti
onRank=2&anchor=H1647059649#H1647059649
Buttaro, T., Trybulski, J., Bailer, P.l., & Sandberg-Cook, J. (2013) Primary care: A
collaborative practice (4thEd). St. Louis, MO: Mosby- Elsevier. ISBN 978-0-32307501-5
Bystritsky, A. (2014). Pharmacotherapy for generalized anxiety disorder. UpToDate. Retrieved
from http://www.uptodate.com.manowar.tamucc.edu/contents/pharmacotherapy-forgeneralized-anxiety
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disorder?source=machineLearning&search=anxiety&selectedTitle=1~150&sectionRank
=1&anchor=H1639259#H1639259
Craske, M. (2013). Psychotherapy for generalized anxiety disorder. UpToDate. Retrieved from
http://www.uptodate.com.manowar.tamucc.edu/contents/psychotherapy-for-generalizedanxietydisorder?source=machineLearning&search=generalized+anxiety&selectedTitle=4
~150& sectionRank=1&anchor=H15673212#H15673212
GAD-7. (2013). Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/clinicalscales-gad-7/clinical-scales-gad-7/gad-7
Gallo, E. & Gallo, J. (2011). How 18 became 26: The changing concept of adulthood. I
Retrieved from https://www.naepc.org/journal/issue08b.pdf
Hirsch, M. & Birnbaum, R. (2014). Selective serotonin reuptake inhibitors: Pharmacology,
administration, and side effects. UpToDate. Retrieved from
http://www.uptodate.com.manowar.tamucc.edu/contents/selective-serotonin-reuptakeinhibitors-pharmacology-administration-and-sideeffects?source=machineLearning&search=ssri&selectedTitle=1~150&sectionRank=1&a
nchor=H399779802#H399779802
Jones, A. (1996). Education and debate. The value of Peplau's theory for mental health nursing.
British Journal of Nursing, 5(14), 877-881.
Journal Home. (n.d). Annual Review of Clinical Psychology. Retrieved from
http://www.annualreviews.org/journal/clinpsy
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Vilazodone: drug information. (2014). UpToDate. Retrieved from
http://www.uptodate.com.manowar.tamucc.edu/contents/vilazodone-druginformation?source=search_result&search=viibryd+adult&selectedTitle=1~9
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15
Grading Criteria
Criteria
Clinical problem clearly identified, including
 Topic is relevant to the assignment (2)
 Subjective information (Patient’s
historical data is complete and relevant
to the topic; plus cultural beliefs, risk
factors, past medical history, etc.
identified as appropriate). (10)
 Relevant objective information (10)
Assessment:
 Appropriate differential diagnoses/
hypotheses identified, based on patient
information presented (5)
 One diagnosis is followed throughout (5)
Management plan consistent with literature
cited, flows from clinical case and includes:
 Diagnostics and treatment thresholds ( 8)
 Therapeutic management including
education and follow-up (6)
 Research based guidelines/ literature (8)
 Cultural considerations of treatment (4)
 Follow-up recommendations (4)
Theory
 Appropriate theory with rationale (8)
 Application to case study (7)
Cost-effectiveness of diagnostic tests and
treatment plans addressed
Legal and ethical issues identified
Professional journal identified for publishing the
paper
Writing style
 Flows logically and clearly from the
guidelines, and indicates in the
conclusion what the reader should
appreciate from the case study. (3)
 Appropriate at the graduate level (2)
 Proper use of APA format (including
cover sheet, abstract, reference page) (3)
 Appropriate references (3)
Total
Possible
Points
22
10
30
15
5
5
2
11
100
Points
Earned
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