5 Point Plan
Diagnostics: The anxiety screening I would perform is the SIAS (Social Interaction and Anxiety Scale)- A 19-item questionnaire which assesses cognitive, affective, or behavioral reaction to a social interaction in dyads or groups (Reddy, Sudhir, Manjula, Arumugham and Narayanaswamy, 2020). I would also have the patient fill out a PHQ-9 screening test. Laboratory Tests I would include is an EKG due to the complaint of palpitations (Schub, 2018).
Medications: Wean off Lexapro and discontinue. Wean down the use of Xanax. Benzodiazepines should only be used for breakthrough anxiety treatment short term (MayoClinic, 2019).
Selective serotonin reuptake inhibitors (SSRIs) are the first type of drug tried for persistent symptoms of social anxiety according to the MayoClinic (2018) with Paxil being the most effective SSRI for social anxiety disorder (Schub, 2018).
Paxil 25 mg
1 tablet by mouth daily
Disp #30 (thirty)
Refill #1 (one)
Dx: Depression and Social anxiety
Xanax 1 mg
Take 1 tablet BID as needed for severe anxiety attack
Disp #30 (thirty)
Refill #1 (one)
Dx: Anxiety disorder
Education: I would be able to monitor the SSRI and Benzo administration to this patient. It would be very important and the NP to provide self with this patient. Some main roles would be to assess the patient’s anxiety level and coping ability; educate and encourage discussion about the benefits of long-term treatment with psychological therapy and medication, risks and benefits of medication, joining a support group, and individualized prognosis (Schub, 2018). Assisting with relaxation techniques such as deep breathing, meditation, physical activities can also provide decreased anxiety levels (Schub, 2018).
Referral: Mental Health Clinician for counseling and CBT
Follow Up: I would like to follow up within 1 week to verify the patient is compliant with the medication change and treatment provided by psychiatry. Plus, this allows the patient a chance to talk about anything regarding the current therapies. It will take time for this patient.
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Studies have shown that by use of a functional magnetic resonance imaging (fMRI) found most significant areas of activation during emotional vs. neutral stimuli in individuals with social anxiety disorder included bilateral amygdala, anterior cingulate, and Globus pallidus (Stein, 2015). Other studies have shown increased activation in temporoparietal regions, including posterior superior temporal sulcus and supramarginal gyrus /temporo-parietal junction, which are consistent with increased bodily self-consciousness (Stein, 2015). For neurochemistry, social anxiety disorder is characterized by alterations in both the dopaminergic and serotonergic (Stein, 2015). Neuropeptides such as oxytocin are important in mediating social anxiety (Stein, 2015).
Medications tested through RCT’s showing improvement of symptoms include: SSRIs, SNRIs, MAOIs, benzodiazepines and anticonvulsants (Stein, 2017).However, studies have proven that the SSRIs were the only medication proving effective in reducing relapse based on moderate‐quality evidence (Stein, 2017).
Additional analysis of the case: This includes national guidelines that were or should have been used to make diagnosis or treatment and review how they applied or how care was unique but based in guidelines.
According to the National Institute for Health and Care Excellence (2020) guidelines would include When assessing an adult with possible social anxiety disorder: conducting an assessment that considers fear, avoidance, distress and functional impairment and monitoring for comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis and autism. Guidelines all suggest offering adults with social anxiety disorder individual cognitive behavioral therapy (CBT) that has been specifically developed to treat social anxiety disorder, do not routinely offer group CBT in preference to individual CBT. Evidence shows that group CBT is more effective than most other interventions, it is less clinically and cost effective than individual CBT, If the person wishes to proceed with a pharmacological intervention, offer a selective serotonin reuptake inhibitor (SSRI) (escitalopram or sertraline). Monitor the person carefully for adverse reactions
I would like to set up referral for about 2 weeks. This gives the patient time to transition from the Lexapro to the Paxil and to offer ample time for the patient to start her cognitive therapy provided by psychiatry who the patient will be referred too.
Diagnosis would be different for each patient depending on their medical history and symptoms. Getting a more detailed history of my patients’ childhood could help to benefit further treatment or for assisting with a support system.
CPT codes include EKG (93000), PHQ-9 screening (96127), SIAS screening (96111), Outpatient services (99213). ICD 10 codes would include: F40.11 (SAD), R00.2 (Palpitations), F33.2 (Moderate Depression).
- Mayo Clinic (2019). Social anxiety disorder (Social phobia). Retrieved from https://www.mayoclinic.org/diseases-conditions/social-anxiety-disorder/diagnosis-treatment/drc-20353567
- NICE. (2020). Social Anxiety Disorder: recognition, assessment, and treatment. Retrieved from https://www.nice.org.uk/guidance/cg159/chapter/1-Recommendations#interventions-for-adults-with-social-anxiety-disorder-2
- Schub, T. (Mar. 2018). Social Phobia (Social Anxiety Disorder). Retrieved from https://eds-a-ebscohost-com.chamberlainuniversity.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=1&sid=0aa03bef-6a87-410f-b527-0cfd0f34f913%40sessionmgr4006
- Stein, D.J. (Sept. 23, 2015). Social Anxiety Disorder and the psychobiology of Self-Consciousness. Frontiers in Human Neuroscience. https://doi.org/10.3389/fnhum.2015.00489
- Stein, D.J. (Oct. 19, 2017). Pharmacotherapy for social anxiety disorder (SAnD). Cochrane Library. https://doi.org/10.1002/14651858.CD001206.pub3
- Truschel, J. (2020). Social Anxiety Disorder: Symptoms, Causes and Treatment. Retrieved from https://www.psycom.net/social-anxiety-disorder-overview
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