NUR 676 Module 3 Milestone One Example

Milestone One: Diagnosing and Treating Generalized Anxiety Disorder in a 28-Year-Old in Primary Care

[Student Name]

Southern New Hampshire University

NUR 676: Primary Care for Mental Health

Module Three Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone One: Diagnosing and Treating Generalized Anxiety Disorder in a 28-Year-Old in Primary Care

Anxiety disorders are among the most common mental health conditions, yet they often go unrecognized in primary care because patients present with headaches, stomach upset, fatigue or insomnia rather than naming worry as the problem. When anxiety is recognized, treatment is sometimes limited to reassurance or a benzodiazepine, neither of which addresses the disorder well. Priya is a 28-year-old accountant seen at a composite community clinic for headaches and poor sleep. This milestone documents how her anxiety was identified, confirmed and treated. It argues that screening with a validated tool, confirming criteria, ruling out medical and substance causes and offering first-line psychological and medication treatment with measured follow-up gives patients with generalized anxiety disorder effective care in primary care.

Screening

The USPSTF recommends screening for anxiety disorders in adults younger than 65, including pregnant and postpartum persons, based on evidence that screening tools identify anxiety accurately and that treatment is effective (Barry et al., 2023). For people 65 and over, it made no recommendation because the studies were too limited. Priya's clinic had added the GAD-7 to annual visits after the recommendation.

Spitzer et al. (2006) developed the GAD-7, a seven-item self-report scale asking how often over the past two weeks the patient has been bothered by nervousness, inability to stop worrying, excessive worry about different things, trouble relaxing, restlessness, irritability and fear that something awful might happen. In a large primary care sample, a score of 10 or more identified generalized anxiety disorder with good sensitivity and specificity, and scores of 5, 10 and 15 marked mild, moderate and severe anxiety. The scale also performed reasonably well for panic, social anxiety and post-traumatic stress disorders. Priya scored 15.

History and Examination

Priya reports that for more than a year she has worried most days about deadlines, finances, her parents' health and whether she locked the door, and that she cannot turn the worry off even when she tries. She feels keyed up and tired, has trouble concentrating, is irritable with her partner, has tight shoulders and tension headaches most afternoons and lies awake for an hour or more before falling asleep. She has no discrete attacks of sudden intense fear with palpitations and a sense of doom. Her mood is not persistently low, and she still enjoys time with friends, although she cancels plans when stressed. Her coffee intake runs to three or four cups daily, takes no stimulants or supplements and drinks alcohol rarely. There is no family history of thyroid disease. Her mother has anxiety.

Examination: pulse 88, blood pressure 118/74, no tremor, no thyroid enlargement or eye signs. Tender trapezius muscles. PHQ-9 score 7. Thyroid-stimulating hormone normal.

Assessment

Generalized anxiety disorder, moderate to severe. Her picture fits the diagnosis: worry that spans several parts of life, that she cannot rein in and that has been present on most days for well over six months, together with all six of the physical and mental companions the criteria list, from feeling keyed up and tired to poor focus, irritability, tight muscles and broken sleep, and it is interfering with her work and relationships. Differential diagnoses considered: hyperthyroidism, excluded by a normal thyroid-stimulating hormone and examination; caffeine-induced anxiety, possible as a contributor but unlikely to explain a year of pervasive worry; panic disorder, unlikely without discrete attacks; and major depression, not present, although her PHQ-9 of 7 reflects mild depressive symptoms that often accompany anxiety.

Treatment Choice

First-line treatments for generalized anxiety disorder include cognitive behavioral therapy and certain antidepressants. Pooling randomized drug trials for generalized anxiety in one network analysis, Slee et al. (2019) found that several drugs, including duloxetine, pregabalin, venlafaxine and escitalopram, were more effective than placebo, with escitalopram and sertraline among the options with relatively good acceptability. The analysis also highlighted the limited long-term data. Benzodiazepines relieve symptoms quickly but carry risks of dependence, sedation and cognitive effects, and they do not treat co-occurring depression, so they are not appropriate as first-line maintenance treatment for a young woman with a chronic condition.

Priya preferred to try therapy but was open to medication given the severity of her symptoms. The plan combines both: weekly sessions with the in-house therapist using a worry-focused CBT protocol with relaxation training, and escitalopram 5 mg daily for one week, increasing to 10 mg, starting low because people with anxiety are often sensitive to early side effects such as jitteriness.

Plan and Follow-Up

She was advised to reduce coffee to one cup in the morning, to practice a daily ten-minute relaxation exercise from an app the therapist recommends and to keep a regular sleep schedule. She was told that escitalopram takes two to four weeks to begin working, that early jitteriness usually fades and that she should not stop suddenly. In two weeks the care manager will phone her, ask how the medicine is sitting and have her redo the GAD-7. At six weeks, if the score has fallen by less than half, the dose will be increased or the plan reviewed. The goal is a GAD-7 score below 5. She was told to call immediately for any thoughts of self-harm, which she denied today.

Addressing Her Concerns About Treatment

Priya worried that taking medication meant she was weak and that she might need it forever. These concerns were discussed directly. She was told that generalized anxiety disorder is a common medical condition with biological and psychological components, that medication and therapy work together and that many people stop medication after six to twelve months of feeling well, with a gradual taper planned with the clinician. She also worried that therapy would take too much time from work. The therapist offered early morning video sessions, and she agreed to eight weekly sessions with homework practice. Her partner was invited to one session so he could understand how to respond when she seeks reassurance, which can unintentionally feed worry. Addressing these concerns at the start makes it more likely that she will stay with treatment long enough for it to work.

Conclusion

Priya's headaches and insomnia were the visible edge of generalized anxiety disorder. Screening with the GAD-7, as the USPSTF recommends for adults her age, led to a confirmed diagnosis once medical and substance causes and other anxiety disorders were considered. Cognitive behavioral therapy and escitalopram, chosen with evidence from a network meta-analysis and her own preferences, with measured follow-up, give her a strong chance of recovery without the risks of long-term benzodiazepines.

References

Barry, M. J., Nicholson, W. K., Silverstein, M., Coker, T. R., Davidson, K. W., Davis, E. M., Donahue, K. E., Jaén, C. R., Li, L., Ogedegbe, G., Pbert, L., Rao, G., Ruiz, J. M., Stevermer, J., Tsevat, J., Underwood, S. M., & Wong, J. B. (2023). Screening for anxiety disorders in adults: US Preventive Services Task Force recommendation statement. JAMA, 329(24), 2163-2170. https://doi.org/10.1001/jama.2023.9301

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., & Löwe, 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