Treatment of Refractory Anxiety

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Hello Professor and class,
Treatment of anxiety can be complex. Psychiatric mental health nurse practitioners (PMHNPs) may provide care to clients with treatment-refractory anxiety.
Emotionally healthy people have control over their thoughts, feelings, and behaviors. They feel good about themselves and have good relationships with other people. In addition, they can put problems in perspective and have ways of coping with stress and problems.
Stress and problems with family, work, or school can cause mental illness to become worse. Mental illness also often has a physical cause such as a chemical imbalance in the brain.
Define treatment refractory anxiety.
In refractory or resistant depression, the response to antidepressants is poor, although the pharmacological strategy is adequate. Most patients have a response but not a remission, that is, they manifest symptoms despite experiencing some improvement (Ansara, 2020).
Describe two common comorbidities of treatment refractory anxiety.
When we are in the presence of anxiety refractory to treatment, it is important to rethink the diagnosis and redo the clinical exercise, carefully analyzing the symptoms and signs as well as the risk factors of our patient. Well, an initial misdiagnosis can lead to failure in the indicated therapy. Within the comorbidities associated with anxiety refractory to treatment we can mention hyperthyroidism and substance abuse disorder (Roy-Byrne, 2022).
It is known that thyroid disease can cause secondary psychiatric manifestations that can be corrected by reestablishing proper thyroid function. A range of neuropsychiatric symptoms have been documented including not only anxiety but also depression, mania, psychosis and dementia symbolizing their importance in psychiatric clinical practice. People with hyperthyroidism may experience anxiety, hyperactivity, distractibility, irritability, hypersensitivity to noise, feelings of internal tension, impatience, emotional lability, insomnia, unstable moods, insomnia, and lack of appetite. In extreme cases they can present delusions and hallucinations (Nazli Gülsoy, et al, 2020).
Today the consumption of certain psychotropic or narcotic substances is widespread in society, especially among the youngest. However, it is difficult to determine how each substance affects the anxiety disorder and how it affects the appearance, maintenance or worsening of this disease. On the one hand, the abuse of some substances such as stimulants can favor the appearance of an anxiety disorder but, on the other hand, some people with anxiety disorders tend to resort to drugs as a way to reduce some symptoms, such as nervousness or irritability. When a person continuously abuses drugs, this can cause the appearance of some symptoms related to anxiety, and it is even possible for the subject to experience psychological alterations. When anxiety has been induced in some way by drug use, its symptoms are considered to be related to the abuse of some legal or illegal substance, whether by occasional use, abuse or dependence (Hellberg, Russell, & Robinson, 2019).
Discuss two possible approaches to treatment for treatment refractory anxiety.
The use of atypical antipsychotics such as quetiapine, risperidone and olanzapine, aripiprazole have improved response in several studies in non-responders to SSRIs. Their effect on anxiety and irritability has made them popular in the treatment of refractory agitation and insomnia. It is a subject that is still in controversy but beneficial outcomes have definitely been found in the management of anxiety refractory to treatment (Ansara, 2020).
The literature review indicates several potential drug classes and individual agents that can be used as augmentation strategies to treat residual symptoms when guideline-recommended therapy fails. Ketamine was originally approved by the US Food and Drug Administration (FDA) as an anesthetic, but is increasingly used to treat mood disorders such as treatment-resistant depression, anxiety disorders, and mood disorders. Post-traumatic stress disorder (PTSD). Several studies have also found it to be effective in treating suicidal ideation. A growing body of evidence points to the role of glutamate, a widely distributed excitatory neurotransmitter, in mediating the stress response and the formation of traumatic memories. Ketamine is an ionotropic glutamatergic north-methyl-d-aspartate (NMDA) receptor antagonist. Its antidepressant and anxiolytic effects are presumed to occur through activation of synaptic plasticity by increasing translation and secretion of brain-derived neutrophilic factor and also by inhibiting glycogen synthase kinase-3 and activating the mammalian target of rapamycin signaling (Tully, Dahlén, Haggarty, Schiöth, & Brooks, 2022).
Identify the most appropriate response to a client who states that they use marijuana to manage their anxiety. Discuss the education the PMHNP should provide.
I would tell the patient that the relationship between marijuana use and anxiety disorders is not yet definitively established, and that it is still a controversial topic. Several studies have associated marijuana use with an increased risk of psychiatric disorders, including psychosis (schizophrenia), depression, anxiety, and drug use disorders, but it is not always easy to determine whether use is indeed the cause of these disorders or to what extent it causes them. It has been found that the amount of drug used, the age at which it is used for the first time and the genetic vulnerability of the person are all factors that influence this relationship. The strongest evidence so far points to a connection between marijuana use and drug use disorders, and between marijuana use and psychiatric disorders in people who have a pre-existing vulnerability, genetic or otherwise. Even with careful dosing, there are still risks associated with using marijuana to treat anxiety disorders. The risks are especially high for those under the age of 25 and those with little or no experience with cannabis. One possibility is experiencing a “bad trip,” but you can reduce this risk by forgoing marijuana edibles in favor of topical, or by using CBD in isolation (Gold, 2020).
Identify the most appropriate response to a client who states that they use Silexan to manage their anxiety. Discuss the education the PMHNP should provide?
There are studies to investigate the anxiolytic efficacy of Silexan, a new oral preparation of lavender oil capsules, compared to placebo in primary care units. The Lavender oil preparation had a significant positive influence on sleep quality and duration and improved general mental and physical health without causing unwanted sedation or other drug-specific effects. Silexan Lavender oil preparation is effective and safe for the relief of Anxiety Disorder Not Otherwise Specified. Has a clinically significant anxiolytic effect and relieves anxiety-related sleep disturbances (Kasper et al, 2018).
References,
Ansara, E.D. (2020). Management of treatment-resistant generalized anxiety disorder. Mental Health Clinician. 10 (6); p.326–334. doi: https://doi(dot)org/10.9740/mhc.2020.11.326 (Links to an external site.)
Gold, M. (2020). Medicinal Marijuana, Stress, Anxiety, and Depression: Primum non nocere. Missouri medicine, 117(5), 406–411.
Hellberg, S.N., Russell, T.I. & Robinson, M.J.F. (2019). Cued for risk: Evidence for an incentive sensitization framework to explain the interplay between stress and anxiety, substance abuse, and reward uncertainty in disordered gambling behavior. Cogn Affect Behav Neurosci. 19; pg. 737–758 (2019). https://doi(dot)org/10.3758/s13415-018-00662-3 (Links to an external site.)
Kasper, S., Müller, W. E., Volz, H. P., Möller, H. J., Koch, E., & Dienel, A. (2018). Silexan in anxiety disorders: Clinical data and pharmacological background. The world journal of biological psychiatry, 19(6), 412-420.
Nazli Gülsoy, K., Özlem Turhan, I., Yusuf, B., Şerife Mehlika, I., Cüneyd, A., & et al. (2020). The effect of iatrogenic subclinical hyperthyroidism on anxiety, depression and quality of life in differentiated thyroid carcinoma. Turkish Journal of Medical Sciences. 50(4). Doi:10.3906/sag-1902-176
Roy-Byrne, P. (2022). Treatment-refractory anxiety; definition, risk factors, and treatment challenges. Dialogues in clinical neuroscience. https://doi(dot)org/10.31887/DCNS.2015.17.2/proybyrne (Links to an external site.)
Tully, J.L., Dahlén,A.D., Haggarty,C. J., Schiöth, H.B., and Brooks, S. (2022). Ketamine treatment for refractory anxiety: A systematic review. https://doi(dot)org/10.1111/bcp.15374 (Links to an external site.)
Whittaker, E., Dadabayev, A. R., Joshi, S. A., & Glue, P. (2021). Systematic review and meta-analysis of randomized controlled trials of ketamine in the treatment of refractory anxiety spectrum disorders. Therapeutic Advances in Psychopharmacology. https://doi(dot)org/10.1177/20451253211056743