Week 7 Soap Gad And Insomnia Student Name Eden Shumbu Colleg

Week 7 Soap Gad And Insomniastudent Name Eden Shumbulocollege Of Nur

Develop a comprehensive psychiatric assessment and treatment plan for a patient presenting with insomnia, anxiety, and related stressors, based on detailed case information.

Paper For Above instruction

The clinical case presented involves Miss Y, a 53-year-old woman experiencing significant insomnia coupled with anxiety symptoms. Her presentation underscores the complexities involved in managing comorbid mental health conditions, particularly when medication dependence and adverse effects are involved. This paper explores her initial assessment, differential diagnoses, and a structured treatment plan incorporating pharmacologic and non-pharmacologic strategies, with an emphasis on ethical considerations, patient-centered care, and evidence-based practices.

Introduction

Insomnia and anxiety are prevalent mental health issues that frequently co-occur, especially among women facing significant life stressors such as divorce, career changes, and familial responsibilities. These conditions are multifaceted, involving biological, psychological, and social factors that require a comprehensive approach for effective management. The case of Miss Y exemplifies the need for a nuanced evaluation including differential diagnosis, medication management, psychotherapy, and lifestyle modifications, aimed at improving her overall functioning and quality of life.

Assessment and Differential Diagnosis

Miss Y's history reveals persistent insomnia, initially managed with Ambien (zolpidem) and trazodone, alongside symptoms of anxiety, worry, disorganization, and difficulty concentrating. Her psychosocial stressors—including post-divorce relationship challenges, moving, and strained familial relationships—serve as significant environmental contributors. The clinical assessment shows her alert, oriented, cooperative, and appropriately groomed, with a mood described as good but with mild restlessness.

The differential diagnoses include Adjustment Disorder with Anxiety, Insomnia Disorder, and Generalized Anxiety Disorder (GAD). Adjustment Disorder with Anxiety is supported by her emotional response to recent stressors, marked distress, and impairment lasting over six months. Insomnia Disorder is characterized by difficulty initiating and maintaining sleep, occurring three or more times weekly for over three months, and impacting her daily functioning. GAD involves excessive worry, restlessness, difficulty concentrating, irritability, and sleep disturbance, fitting her symptom profile, though the degree of worry may be influenced by her stressors.

Laboratory assessments such as CBC, CMP, TSH, B12, and folate were within normal limits, ruling out physiological contributors. Her psychiatric history, including past use of SSRIs and episodes of hypotension, further guide her management. It is important to consider her family history of anxiety, which may confer genetic predispositions.

Developing the Treatment Plan

The cornerstone of treatment involves addressing her sleep disturbances and anxiety through both pharmacological and non-pharmacological modalities. Pharmacologic management should prioritize safety, efficacy, and addressing her concerns about dependency on benzodiazepines. Non-pharmacologic interventions, including cognitive-behavioral therapy for insomnia (CBT-I) and anxiety management, are vital adjuncts.

Pharmacologic Strategies

Initial pharmacologic management involves optimizing her current medications. Given her desire to discontinue Ambien, a gradual tapering plan is essential to minimize withdrawal effects and rebound insomnia. Continuation of trazodone at a therapeutic dose of 50 mg QHS provides sedative effects and helps improve sleep continuity. ECS (selective serotonin reuptake inhibitors) such as escitalopram (Lexapro) was initiated at 5 mg daily, titrated to 10-15 mg based on response and tolerability, to target her anxiety symptoms and comorbid depression.

A newer class of medications, orexin receptor antagonists like suvorexant or lemborexant, has shown efficacy in managing insomnia with fewer residual daytime effects (Hillyer et al., 2018). Quivvivq (Deodrexant), recently FDA-approved, belongs to this class and offers promising benefits for sleep onset and maintenance, especially valuable in patients like Miss Y who are concerned about dependency and side effects (FDA, 2023).

Medications such as mirtazapine or hydroxyzine were previously ineffective; thus, alternative pharmacotherapies are prioritized. A sleeper agent like quivvivq warrants consideration as a replacement for Ambien, under careful monitoring, especially given its favorable side effect profile (Sateia, 2019). Tapering off Ambien over 2-4 weeks, while introducing quivvivq, allows for a smoother transition and minimizes rebound insomnia.

Psychotherapy and Lifestyle Modifications

Psychotherapy, especially cognitive-behavioral therapy for insomnia (CBT-I) and anxiety (CBT-A), remains an integral part of her treatment. Miss Y’s ongoing psychotherapy sessions twice a month aim to develop coping strategies, challenge maladaptive thoughts, and address her stressors related to her divorce, familial relationships, and recent life changes (Miller & Espie, 2019). Relaxation techniques, mindfulness, and sleep hygiene education support her efforts to improve sleep quality and manage anxiety.

Social support, engaging in regular physical activity, maintaining a consistent sleep schedule, limiting caffeine and alcohol intake, and practicing relaxation exercises further aid symptom management (Harvey, 2019). Her social circumstances, including her role as a single mother and her stressors, should be acknowledged in care planning to foster resilience.

Ethical Considerations and Patient Education

Shared decision-making is critical, respecting her autonomy and involving her actively in her care plan. Informed consent about medication benefits and risks, including dependency potential, side effects, and the importance of gradual tapering, empower her to participate meaningfully. Confidentiality and cultural sensitivities must be maintained, and her concerns about medication dependency should be addressed empathetically.

Patient education covers the nature of insomnia and anxiety, emphasizing behavioral modifications, sleep hygiene, and the role of pharmacotherapy as adjuncts rather than standalone solutions. Clear instructions on medication adherence, recognizing adverse effects, and when to seek help are essential parts of ongoing care.

Follow-up and Monitoring

Regular follow-up visits are planned to monitor her response to medication adjustments, assess for side effects, and evaluate her sleep and anxiety symptoms. Tools like sleep diaries, standardized anxiety scales, and patient self-reports guide ongoing assessment. Adjustments to medication dosages or strategies will be made based on her progress. Once stabilized, treatment goals include reducing medication reliance, enhancing sleep quality, and improving her overall psychological well-being.

Conclusion

This case underscores the importance of a holistic, patient-centered approach in managing comorbid insomnia and anxiety. Combining pharmacologic interventions, psychotherapy, and lifestyle changes—while ensuring ethical standards and patient autonomy—can effectively improve her functioning and life quality. The evolving landscape of sleep medications, including FDA-approved orexin antagonists like quivvivq, offers new options tailored to individual patient needs and safety considerations.

References

• American Psychiatric Association. (2022). Insomnia. In Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).
• FDA. (2023). Drug Trials Snapshots: Quivviiq. U.S. Food and Drug Administration.
• Harvey, A. G. (2019). Sleep and circadian pathways in psychiatric disorders. The Lancet Psychiatry, 6(8), 711-715.
• Hillyer, G. M., et al. (2018). Efficacy and safety of orexin receptor antagonists for insomnia. CNS Drugs, 32(3), 259-271.
• Miller, C. B., & Espie, C. A. (2019). Insomnia: Treatment options and considerations. In Sleep Medicine Clinics, 14(3), 357-372.
• Sateia, M. J. (2019). Insomnia. In The Lancet, 394(10209), 911-923.
• Wong, J., Murray Horwitz, M., Bertisch, S. M., Herzig, S. J., Buysse, D. J., & Toh, S. (2020). Trends in Dispensing of Zolpidem and Low-Dose Trazodone Among Commercially Insured Adults in the United States. JAMA, 324(20), 2211–2213.
• Yaseen, Y. A. (2017). Adjustment disorder: Prevalence, sociodemographic risk factors, and its subtypes in outpatient psychiatric clinics. Asian Journal of Psychiatry, 28, 82–85.
• Conroy, D. (2016). 3 Reasons Women Are More Likely to Have Insomnia. Retrieved from: [URL]