Anxiety Case Study

Keywords:

Generalized anxiety disorder, treatment, therapy, symptoms


Authors:


Dana Moorer, SPT & Kaelin Hocker, SPT

Abstract:


The exact cause of Generalized Anxiety Disorder is not fully understood. The current hypothesis is that neurotransmitters including serotonin, dopamine, and norepinephrine levels fluctuate, causing patients psychological state to change. The patient in the case study reported many clinical symptoms that can be misinterpreted for musculoskeletal deficits. Physical therapy cannot directly cure anxiety, since it is thought to be caused by neurotransmitters within the brain. However, physical therapists can help those who suffer from GAD be aware of their anxiety. The purpose of this case report is to report how physical therapy can’t cure GAD; however it can help reduce physical signs and symptoms associated with GAD.
Introduction:


Generalized Anxiety Disorder affects 3.1% of the U.S population. GAD is characterized by constant and excessive worrying, for at least six months or more. GAD can be considered a primary or secondary disorder, depending on the time of onset. Diagnosis at a young age is considered a primary disorder, and secondary is normally diagnosed later in life and is associated with other disorders. GAD is most often associated with other disorders that involve anxiety and depression and can lead to or worsen pre-existing conditions. Many of the bodies systems can be affected by GAD, including: Cardiopulmonary, Musculoskeletal, Gastrointestinal and Neurological systems. This disorder can manifest in several ways, incorporating physical, behavioral, and cognitive characteristics.

Case Presentation:


A 28 year-old Caucasian female presents to the clinic with complaints of joint pain (arthralgia) and intermittent low back pain. Patient cannot recall any mechanism of injury. She reports she has trouble falling asleep at night and is unable to get a good night’s rest. She often feels "restless" or "on edge", which she associates with not sleeping. She states she constantly worries about her performance in school, her family, and her mother’s health, who has recently been diagnosed with Stage IV Small Cell Carcinoma. Patient also states she wakes up at night with throbbing headaches that last for a couple hours. She feels tense the majority of the day, causing her to feel stiff. She also has difficulty paying attention in class and finishing her homework.

Subjective:

Joint pain, low back pain, headache, muscle stiffness, difficulty sleeping and paying attention for approximately a year. Previously diagnosed with PTSD and treated with CBT.
Demographic Information: Second Year Graduate Student, female, 28
Medical diagnosis if applicable: Diagnosed with PTSD in February of 2000.

Co-morbidities:

Hypertension, drinks 10+ alcoholic beverages per week (possible substance abuse), Depression
Previous care or treatment: PTSD treated with Cognitive Behavioral Therapy by Clinical Psychologist following car crash in 2000.

Self-Report Outcome Measures:

GAD-7 = 16/21, Penn State Worry Questionnaire (PSWQ) = 64/80, McGill Pain Questionnaire = 42/78

Physical Performance Measures:Oswestry Disability Index (ODI) = 38%

Objective:

Vitals: HR= 98 bpm (tachycardia), BP: 146/92 mmHg (hypertension), RR= 24 bpm. Palpable muscle tightness in upper trapezius, forward flexed head along with increased kyphosis. Patient appears to be profusely sweating and hands are cold and clammy to touch.


• Cervical AROM= limited extension and bilateral rotation
• Shoulder AROM= bilateral shoulder flexion decreased.
• All other shoulder AROM WFL.
• Myotomes= C1/C2, C2/C3 and C3/C4 weakness
• UE sensation intact
• LE AROM= limited trunk flexion/extension, along with knee flexion and ankle dorsiflexion deficits.
• Myotomes= L4/L5, L5/S1 weakness
• LE sensation intact


Clinical Impression:


¬ Hypertension
¬ Tachycardia
¬ Increased respiratory rate
¬ Red Flags:
Patient used phrases such as “restless and on edge” to describe her current state.
Patient has a significant medical history and suffered from PTSD and possible substance abuse, along with the stress of school and her mother’s health.
¬ Outcome Measures: Patient scored significantly high on the GAD-7, Penn State Worry Questionnaire & the McGill Pain Questionnaire.


¬ Limited AROM:

Cervical extension, cervical rotation, shoulder elevation, trunk flexion/extension, knee flexion and ankle dorsiflexion


¬ Myotome weakness: C1/C2, C2/C3, C3/C4, L4/L5, L5/S1

Intervention:


The scores from the outcomes measures revealed that the patient has signs and symptoms that are consistent with a moderately severe form of GAD. Therapist recommended that the patient follows up with her primary care physician to discuss the results of the outcome measures and see what approaches her physician recommends would be best for her since she has a significant medical history.
The therapist explained to the patient that physical therapy can not cure her possible GAD; however therapists can treat the symptoms through education because there is no specific physical therapy intervention to treat GAD.
Therapist provided educational information pertaining to anxiety management that the patient can utilize outside of therapy. Stress management techniques such as: mediation, deep breathing, progressive muscle relaxation techniques, exercise and modifying her diet. Therapist also discussed patient’s alcohol consumption and education on alcoholism and the effects it has on the mind and the body.

Outcomes:
After being diagnosed with GAD from her primary care physician, patient was referred back to PT for treatment of the musculoskeletal deficits secondary to GAD. Her primary care prescribed her Paxil to increase her levels of serotonin, which greatly improved her motivation for therapy. Within 2-3 weeks her AROM improved and the scores on her outcome measures decreased significantly.

GAD-7 = 10/21
Penn State Worry Questionnaire = 48/80
McGill Pain Questionnaire = 31/78

Discussion:


There is limited research on physical therapy interventions to directly treat GAD. However, physical therapy can be very effective when treating musculoskeletal impairments that are secondary to GAD. An important role physical therapists can take is patient education. By educating patients about sticking to an adherent medical regimen (medication schedule) that can help improve patient compliance and can educate the patient on the complexity of their condition. Also, teaching the patient relaxation techniques, such as deep breathing exercises and massage techniques can help to decrease muscle tension. Exercise is another way that physical therapists can aid in reducing anxiety and significantly improve cardiovascular health. Physical therapy when combined with other interventions such as cognitive behavioral therapy and holistic approaches can significantly improve the overall quality of life in patients suffering from GAD.

Related Pages:


http://www.physio-pedia.com/Generalized_Anxiety_Disorder

References:

1. Goodman CC and Snyder TK. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th edition. St. Louis, Missouri: Saunders Elsevier, 2007.
2. Katzman M. Current Considerations in the Treatment of Generalized Anxiety Disorder. CNS Drugs. 2009; 23: 103-120. Available from: ProQuest Medical Library. Accessed March 23, 2017, Document ID: 1658393961.
3. Kavan M., Elsasser G., Barone E. Generalized Anxiety Disorder: Practical Assessment and Management. American Family Physician. 2009; 79:785-791, 9-10.
4. Medical Foundation for Medical Education and Research. Mayo Clinic: Depression and anxiety: Exercise eases symptoms. http://www.mayoclinic.com/health/depression-and-exercise/MH00043. Updated October 10, 2014. Accessed March 27, 2017.
5. Medical Foundation for Medical Education and Research. Mayo Clinic: Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs). http://www.mayoclinic.com/health/antidepressants/MH00067. Updated December 10, 2008. Accessed March 24, 2017.

Anxiety Disorder and OCD Case Study

M.S.
18 y/o male
OCD, Anxiety Disorder

M.S. was an eighteen-year-old male with a severe degree of OCD along with an anxiety disorder. Before starting the REI Custom Program his therapists described that often it took M.S. 25 minutes to get from the front door of the facility to her office - a total of 15 feet. He had to touch specific items in a particular order repeatedly. He also picked at his clothing and skin until he bled and rocked his body back and forth repeatedly. This compulsivity also extended to his eating habits. He was also highly anxious and was often unable to sit still or to attend to a task. Other times he was lethargic and preferred to lie around.

After two weeks listening to the REI Custom Program CD#1 he was able to enter his therapists center and get to his therapist’s office within just a couple of minutes - he didn't need to engage in the elaborate rituals he did in the past. He was picking at his skin less and was much more able sit and focus on a task. He was also rocking less frequently.

After 10 weeks of the REI Custom Program, M.S. was much less compulsive which was demonstrated each week by his ability to go straight to his therapist’s office without engaging in ritualistic behaviors. He rarely picked at his skin and would stop if asked to do so. He no longer felt the need to rock and preferred listening to the REI Custom Program CD when he was anxious. His ability to focus and sit still had improved considerably - he was able to focus at a near age appropriate level.

He is continuing to see gains from the CDs and is still listening to them everyday.

Anxiety and Sleep Disturbance Case Study

Subject detail: K. C.
32 y/o female
Anxiety/sleep disorder.

Before beginning the program K.C.’s sleep was poor. She would often fall sleep within an hour of going to bed but she generally woke several times a night and had trouble getting back to sleep because she worried about things. She also experienced anxious thoughts throughout the day. The worst times being when she drove in her car. This anxiety often resulted in her getting disoriented and feeling lost even when on familiar roads. She also wouldn’t travel on a plane. In addition K.C. was disorganized and often missed appointments.

After about 3 weeks using the REI Custom Program, K.C. began sleeping through the night. In the rare ocassions where she did wkae up at night, she found that she could turn CD#1 on and her anxious thoughts would quickly dissipate.

At the 8 week point of listening, she was consistently sleeping through the night with only the occasional night where she woke up. Again, turning on CD#1 would help her get back to sleep within 20 minutes (the length of the CD). She found that she was more energetic during the day and was more organized. She also began implementing a organizational system to help to keep on top of things. As a result she hadn’t missed any appointments in six weeks. Her anxiety during the day had reduced significantly - she was able to drive to and from work without getting anxious, though she still didn’t feel comfortable driving anywhere new.

After 16 weeks, K.C. was still sleeping well - only woke occasionally at night but would be able to get back to sleep quickly by playing her CD. She continued to improve in her ability to manage her anxious thoughts. She took a plane to a conference for the first time.

After 5 years, she reported that her sleep was still good and her overall anxiety level was still very low even though she hadn’t heard CD in three years.

Anxiety and Fatigue case study

G.B.
27 y/o female
Fatigue and anxiety

When G.B. began the REI Custom Program she was experiencing severe fatigue in the afternoons, which required her to go home from work at lunch to take nap in order to have the energy necessary to finish her day. As well, she described having feelings of anxiety for which she was seeing a therapist. She chose to try to REI Custom Program after using Calming Rhythms for her nap and noticing that she had more energy after listening to it.

After 1 1/2 weeks of using her REI Custom Program CD#1, she described that she had much more energy and didn’t feel the need to go home at lunch to take a nap. Instead she played her CD while she ate lunch. As well, so found that she spontaneously left her apartment one evening to go on a walk. Prior to this occasion she would need to get in her car from the basement garage and drive a few blocks in order to take a walk due to her anxiety over leaving the front door of her apartment building. She had been working on this issue in therapy for several years with no improvement ntil beginning the REI Custom Program CDs.

After 8 weeks on the REI Custom Program, G.B. has much more energy and didn’t experience the afternoon fatigue that she had in the past. She also fond herself no longer having anxiety about leaving her apartment building on foot and took her daily walk without needing to drive her car from her building. She was continuing to listen daily to CD#2 during her lunch break.

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