5 anxiety disorders

PUTTING IT ALL TOGETHER 33Diagnose√ PsychotherapyInitiate Treatment√ PathophysiologyAssess ResponseContinue Augment ChangeFigure 2.1. An approach to treatment. The first step in initiating treatment is to determinethe disorder(s) that is producing distress. Treatment is initiated, and at the appropriatetimes, a determination of efficacy is made. Depending on this assessment,treatment is continued, something is added, or a change is made. Failure to achieve thedesired outcome in a timely fashion should raise issues about (1) the pathophysiology ofthe disease state and the mechanism of action of the drugs being prescribed, (2) thepresence or absence of appropriate psychotherapy, and (3) a determination that theoriginal diagnosis is, in fact, the correct diagnosis.treatment. A general approach to treatment is shown in Figure 2.1. The diagnosis ismade, treatment is initiated, and, at the appropriate time, an assessment of treatmentresponse is made. The timing of assessment can vary widely not only between differentillnesses but also within an individual patient at different times. Dependingon the results of the assessment, we either continue the treatment, change the treatment,or add to the treatment. Let’s review a couple of illustrative examples.Clinical VignetteJim is a 24-year-old male with a 3 year history of bipolar disorder (previouslytermed manic depression), who had been stable with medication but stoppedtaking his mood stabilizer 3 weeks ago because he said it made him feel tooslowed down. He has had no sleep for the last 48 hours and upon presentationat his therapist’s office is disheveled, with pressured speech, grandiosity,and some paranoid ideation. What are the time points for assessment here?First, Jim needs to get some sleep, be less agitated, and not represent adanger to himself or others. Commonly, benzodiazepines such as lorazepam(Ativan) and an antipsychotic would be used. Since sleep deprivation cantrigger manic episodes, it is important to reverse his current pattern. So, thefirst assessment of medication effect is shortly after his admission to theemergency room. The next major assessment time will be days to a week ortwo to ensure that mood stabilization is taking place. Finally, later on wewill want to assess the long-term tolerability of the treatment to maximizethe likelihood that Jim remains adherent with treatment in the future.