NUR 7632 Module 2 Generalized Anxiety Case: GAD-7, CBT and Comparing First-Line Medicines Example

Worry That Starts at 3 a.m.: A GAD-7 of 15, CBT and an Evidence-Based Medicine Choice for a 41-Year-Old Accountant

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7632: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Adult Population, Part A

Mentor Name

Month Day, Year

Worry That Starts at 3 a.m.: A GAD-7 of 15, CBT and an Evidence-Based Medicine Choice for a 41-Year-Old Accountant

Awake at Three

Priya is an invented patient, 41 years old and a senior accountant at a firm in Hoboken. For about two years she has worried most of the day about work deadlines, about her mother's heart failure, about money and about whether she locked the door. The worry is hard to switch off and wakes her at 3 a.m., after which she lies awake planning. She has tight shoulders, headaches, trouble concentrating in meetings and a racing heart that sent her to an urgent care center last month, where her electrocardiogram and troponin were normal. She has started to avoid driving on the turnpike and to call her mother several times a day.

She drinks three to four glasses of wine on weeknights to fall asleep, which she has not mentioned to anyone before. She has no panic attacks that come out of nowhere, no history of trauma and no periods of elevated mood. A friend gave her two alprazolam tablets last month, which helped, and she asks whether she could have a prescription.

Her job adds its own pressure. The firm's busy season runs from February to April, and last spring she worked most weekends and lost two pounds a week without trying. She worries that a diagnosis on her record could affect a promotion review, so the paper explains how her records are protected and that treatment details go to no one without her consent. Her husband has noticed that she checks the stove and the locks several times each night, which leads to brief screening questions for obsessive-compulsive disorder; her checking is driven by general worry rather than intrusive images or rituals she feels compelled to finish.

Measuring and Diagnosing

Spitzer et al. (2006) developed the seven-item Generalized Anxiety Disorder scale in 15 primary care clinics, testing it against interviews by mental health professionals in 965 of 2,740 patients. A cut point of 10 caught 89 percent of cases with 82 percent specificity, and each step up in score went with poorer functioning and more days lost to disability. Although anxiety and depression often occurred together, factor analysis showed they were separate dimensions. Priya scores 15, in the severe range.

The interview confirms the diagnosis: worry that runs beyond the facts, resists her efforts to stop it, touches work, family and money and has been present on more days than not for two years, with muscle tension, poor concentration, irritability and poor sleep. Her PHQ-9 of 8 shows mild low mood, short of a major depressive episode. Thyroid tests are ordered because hyperthyroidism can mimic anxiety, and her caffeine use, four large coffees a day, is noted.

The Wine at Night

Her drinking matters for diagnosis and for treatment. Alcohol helps her fall asleep but worsens sleep later in the night and can raise anxiety the next day as it wears off, feeding the cycle. Her AUDIT-C score suggests hazardous use. This is discussed without judgment, and she agrees to keep weeknights to a single glass while treatment begins. It is also the main reason a benzodiazepine is a poor choice for her, since combining the two raises the risk of oversedation and dependence.

Psychotherapy

Cuijpers et al. (2014) pooled 41 studies of psychological treatment for generalized anxiety disorder with 2,132 patients, most testing cognitive behavior therapy against a waiting list. The pooled effect of therapy against control conditions was large, and effects on depressive symptoms were also large. There were signs of publication bias, and too few head-to-head studies existed to say whether CBT beats medicine. Some evidence suggested CBT's benefit lasted at follow-up.

For Priya, CBT focuses on what keeps worry going: she learns to schedule a daily twenty-minute worry period instead of worrying all day, to notice when worry becomes problem solving and when it does not, to tolerate uncertainty about her mother's health without calling repeatedly, and to drive the turnpike again in steps. Progressive muscle relaxation addresses her tight shoulders.

Choosing a Medicine

Slee et al. (2019) compared 22 drugs and placebo across 89 trials with 25,441 adult outpatients. Four drugs, duloxetine, pregabalin, venlafaxine and escitalopram, lowered anxiety ratings beyond placebo while keeping dropout fairly low. Quetiapine led on raw effect yet lost many patients to side effects. Mirtazapine, sertraline, fluoxetine, buspirone and agomelatine also looked effective, but the evidence for them rested on smaller samples. Benzodiazepines were not a focus of the comparison.

Escitalopram is chosen because it is effective, generic, well tolerated and also treats the mild depressive symptoms. It starts at a low dose because people with anxiety often feel jittery in the first days, and it rises after one to two weeks.

Saying No to the Alprazolam

Priya's request is answered honestly. Benzodiazepines relieve anxiety quickly, but with daily use they bring tolerance, dependence and withdrawal, and her nightly wine makes them riskier. She is told that escitalopram and CBT take a few weeks but treat the disorder rather than masking it, and that a short supply of a non-habit-forming medicine such as hydroxyzine can help in the first weeks if needed.

Follow-Up

Visits fall at week two and week six, and each one rescores both scales and asks about the wine. The aim is a GAD-7 under 5. If she improves only partly after eight to twelve weeks at an adequate dose, the dose is raised or duloxetine is tried, with CBT continued.

Her own goals are written beside the scores: sleeping until her alarm on most weeknights, driving the turnpike to visit her mother without pulling over, and calling the cardiology office only on scheduled days. Each goal is checked at follow-up, and a simple wine log, kept on her phone, shows whether her weeknight drinking stays at the agreed level.

Conclusion

Priya has severe generalized anxiety disorder, measured with the GAD-7, with mild depressive symptoms and hazardous drinking at night. CBT, supported by large pooled effects, and escitalopram, chosen from a comparison of 89 trials for its balance of effect and tolerability, form her treatment. A benzodiazepine is declined for clear reasons, and her drinking is addressed directly as part of the plan.

References

Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Andersson, G. (2014). Psychological treatment of generalized anxiety disorder: A meta-analysis. Clinical Psychology Review, 34(2), 130-140. https://doi.org/10.1016/j.cpr.2014.01.002

Slee, A., Nazareth, I., Bondaronek, P., Liu, Y., Cheng, Z., & Freemantle, N. (2019). Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. The Lancet, 393(10173), 768-777. https://doi.org/10.1016/S0140-6736(18)31793-8

Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092-1097. https://doi.org/10.1001/archinte.166.10.1092