In clinical practice, there are many patients who may have several health problems and require special assessment and treatment. As a rule, there is one main health problem and several co-morbid conditions which may influence the development of the primary disease and the effects of a chosen treatment. In this case formulation problem, the case of a patient who is diagnosed with generalized anxiety disorder (GAD) and gastroesophageal reflux disease (GERD) will be discussed in terms of both diseases’ etiology, epidemiology, neurobiology, culture, signs and symptoms, diagnoses, socio-economic factors, and treatment plans.
It is normal for people of various ages to be anxious about something. Some patients may face a single incident of depression or anxiety and deal with its symptoms for several days. However, there are also people who have to live with disorders such as GAD for a long time. This case study concerns a patient with evident symptoms of GAD and the need to receive the required amount of medical help and psychiatric care. The development of this disease depends on a number of personal and environmental factors. The chosen patient started suffering GAD three months ago because of certain changes in life and work. At the same time, another disease, GERD, significantly influences the patient’s health. The patient suffers from regular acid reflux that irritates the esophagus. The results of this physical condition include constant heartburn and regurgitation that lead to the inability to breathe properly and a loss of control over daily activities.
Each of these diseases has its own symptoms and causes, and it is necessary to investigate both health problems in order to understand their possible combined outcomes for a patient and develop an effective treatment plan.
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is a psychiatric condition that is usually characterized by the presence of excessive worrying without any particular circumstances (Stolerman & Price, 2015). Though cases of anxiety are frequent among Americans due to various stresses and unexpected changes, excessive anxiety is not easy to control. This inability leads to the development of a mental disorder. As a rule, doctors advise their patients to have a physical examination as well as oral and blood tests. GAD was introduced in the DSM at the beginning of the 1980s (Cuijpers et al., 2014). According to the American Psychiatric Association (2013) and its DSM-5, the diagnostic criteria for this disorder are found under number 300.03 (F41.1) and include such signs and symptoms as excessive anxiety and worry that last more than one day but not more than six months, an inability to control them, restlessness, fatigue, irritability, muscle tension, poor concentration, and sleep problems.
The etiology of GAD includes a related family history, exposure to stressful situations, a frequent use of caffeine or tobacco, or child abuse. Epidemiological studies show that this disorder is usually observed among 2.9% of adults and 0.9% of adolescents in the United States (American Psychiatric Association, 2013). Females are twice as likely as males to experience GAD.
From the genetic point of view, genes may contribute about 50% to the development of GAD (Patriquin & Mathew, 2017). Environmental factors play the same role in GAD’s growth, contributing through various epigenetic mechanisms, e.g. DNA methylation of the glucocorticoid receptor gene (Patriquin & Mathew, 2017). Other neurobiological factors may include disrupted brain activities, problematic frontolimbic areas, and reduced resting-state functional connectivity between the amygdala and prefrontal cortex (Patriquin & Mathew, 2017). When people start worrying, their nervous system activities undergo considerable change, and it is hard to predict what kind of change may occur in a patient.
In general, a doctor may base a diagnosis of GAD on the information given by the patient, the results of a mental health screening, and the evaluation of the symptoms and defined risk factors. At the same time, a doctor has to determine if there is a possibility of other abuse problems that may cause similar symptoms. For example, a disorder such as GAD may be linked to GERD, also known as gastroesophageal reflux disease.
Gastroesophageal Reflux Disease
Gastroesophageal reflux disease (GERD) is a health problem that is usually characterized by the presence of reflux in the stomach (Yang, Jiang, Hou, & Song, 2015). Patients with this disease may suffer from a burning chest sensation or chest pain after eating. There are also cases when patients have difficulty swallowing because the amounts of gastric juice exceed the norm and cause certain mucosal injuries. The main symptoms of GERD are heartburn and regurgitation (Sugerman, 2014). In addition, patients may have a sore throat and a cough. To diagnose patients, doctors use endoscopy or esophagogastroduodenoscopy and evaluate the results of manometry. The level of pH has to be identified to prove the presence of certain gastroesophageal problems.
In the United States, GERD is observed in 10-20% of the population, with most prevalence among patients aged 50 years and older (Bashashati, Sarosiek, & McCallum, 2016). Aging is one of the risk factors of GERD. Cases of GERD increased considerably in the mid 1990s in the United States. Patients faced high expenses to be diagnosed with GERD and then to be properly treated. The lifestyles of patients and their dietary habits may be serious risk factors that contribute to the growth of GERD. Such food as chocolate or fast food, or drinks like coffee or some alcoholic beverages, may cause stomach reflux. A lack of physical activity and the inability to exercise regularly put people under at risk of having this physical problem. Obesity, as a result of poor diet and lifestyle choices, increases the risk of having GERD. Smoking is another important risk factor that cannot be neglected in discussing the causes of GERD in patients of different ages.
In the case under consideration, the patient has certain symptoms of GAD, including anxiety, sleep problems, constant fatigue, the inability to relax, and GERD, including chest pain and regurgitation. Despite intentions to make lifestyle changes and quit bad habits, the patient has failed to achieve these goals and has been forced to approach a doctor. The first step that has to be taken is the choice of an appropriate diagnostic tool. In addition to general blood and urine tests and a number of psychological questions, the patient has to be prepared for endoscopy, which will make it possible to examine the stomach and esophagus. Physical and psychological problems cannot be completely diagnosed with the help of a single test or tool. Therefore, the patient in this case has to undergo at least one psychological test and one physical examination. Sweating and trembling are associated with muscle tension that is the result of GAD (American Psychiatric Association, 2013). It is suggested to check the patient’s temperature and determine the nature of any physical changes.
The essential feature of GAD is worry and anxiety (American Psychiatric Association, 2013). Doctors have to pay attention to such factors as the intensity of the anxiety, its duration, and its frequency. According to the assessment criteria developed by the American Psychiatric Association (2013), GAD should not last more than six months, and the patient’s worries have to be pervasive and distressing. For example, attention must be paid to life circumstances that can make a person worry, including recent changes at work, financial challenges, or the necessity to care for a child. Finally, it is expected that the patient will report any subjective distress arising from challenges in occupational, social, and personal areas. It may be that a person cannot follow a healthy lifestyle or an appropriate diet because of low income and the necessity to work days and nights in an office with no opportunity for physical activity. As a result, patients with GAD are easily fatigued, cannot eat properly, and suffer from pain in the chest and other parts of the body.
The common signs of GAD and GERD include disturbed sleep and fatigue that cannot be explained by one single factor. Health promotion for the patients who have GAD and GERD symptoms has to be based on lifestyle changes. These changes may touch upon dietary improvements, an increase in physical exercise, and new daily activities. Some people find it enough to avoid eating products that contain chocolate, tomato, and peppermint (Sugerman, 2014) in order to reduce the risks of developing GERD. GAD and any type of anxiety can be reduced when patients try to promote changes in their daily lives, think about new behaviors, and look at their worries from a realistic and less pessimistic point of view. Anxiety is also a possible cause of depression, which may cause some gastrointestinal changes. The close connection between anxiety and depression should be given due attention in order to promote health and protect the population against the negative outcomes of anxiety or stomach problems.
In this paper, several risk factors have already been mentioned in regards to GAD and GERD separately. However, it is also necessary to understand that if a person has both diseases at the same time, the risk factors have to be properly recognized and explained. GAD is a chronic disorder, meaning that it can be repeated episodically (Stolerman & Price, 2015). GERD is a local disease that has its particular causes, outcomes, and risks. Doctors cannot protect every patient and make sure that they are able to avoid complications. Though health promotion is possible, certain risk factors have to be taken into consideration. Negative personal experiences make people anxious and lead them to choose unhealthy habits. For example, personal stress is a reason for anxiety and also a cause for some people to start smoking. Personal stress may also be caused by pregnancy and the necessity to adapt to a new style of life, new demands, and a high level of responsibility. Pregnancy is a risk factor of GERD as well. Regarding the connection between the risk factors of GAD and GERD, doctors have to be very careful with giving differential diagnoses and developing treatment plans.
Acute gastritis is a disease of the gastric mucosa that may be caused by different inflammatory changes. In addition to chest pain and nausea, patients suffer from insomnia and fatigue. Stress is one of the possible reasons for gastritis. In this case, the patient has depression based on personal and work changes. The inability to eat properly and follow a daily routine causes all these changes in the patient’s body.
Post-traumatic stress disorder is another diagnosis that may be given to patients who are struggling with past experience, dealing with the necessity to survive changes, or experiencing flashbacks. Insomnia, shortness of breath, and a lack of energy or enthusiasm to be involved in activities are characteristic features of this condition.
Obsessive-compulsive disorder is another form of mental disorder that has to be taken into consideration when encountering the patient’s symptoms and the problems observed in their behavior. This disorder includes the presence of unreasonable thoughts and fears which are intrusive by their nature (American Psychiatric Association, 2013). Patients with obsessive-compulsive disorders cannot relax and sleep normally because of their inability to stop thinking about the dangers around them.
As soon as the patient approaches a doctor with such complaints as constant anxiety, problems with sleep, chest pain, and rare cases of shortness of breath, it is necessary to develop an appropriate treatment plan in response to the results of the tests and examinations previously conducted.
Pharmacological interventions include the use of medications that help to stabilize a patient’s psychological condition and improve the work of the stomach after reflux has influenced the functioning of the esophagus. GERD can be treated with the help of H2-blockers in order to reduce acid production (Yang et al., 2015). Medications for GAD include an SNRI antidepressant to improve the symptoms of anxiety. If no allergies are observed during the first six hours after taking a medication, the same interventions are suggested during the next seven days.
Psychotherapy is a well-known method of treatment that can be offered to patients with anxiety and depression. This type of therapy is based on working with a therapist and enabling discussion of the symptoms and causes of anxiety. Such therapy need not last very long. Sometimes, 3-5 meetings with a therapist are sufficient for the patient to understand how to avoid worries and promote important lifestyle changes.
Nowadays, there are many treatment plans which are based on alternative medicine. Anxiety disorders can be treated using different herbal supplements. However, not all patients are able to respond to herbal treatment. Therefore, if the patient does not find herbal help effective, it may be necessary to consult another specialist and focus on the improvements that are important for that person.
During the treatment process, the patient has to take blood and urine tests regularly so that nurses can detect any change in the body and evaluate the effectiveness of medications offered. At the end of the treatment process, doctors have to check the condition of the stomach using endoscopy. Finally, it is expected that the patient’s pH level is normal.
In the case study under analysis, referrals play an important role because not all therapists and nurses are able to explain all causes of anxiety, or be confident that similar sources are not repeated. In addition to a general therapist, it is suggested to address such experts as a psychologist, a psychiatrist, a gastroenterologist, and a diagnostician whose goal is to provide a correct diagnosis that takes into account all available symptoms.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
Bashashati, M., Sarosiek, I., & McCallum, R.W. (2016). Epidemiology and mechanisms of gastroesophageal reflux disease in the elderly: A perspective. Annals of the New York Academy of Sciences, 1380(1), 230-234.
Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Andersson, G. (2014). Psychological treatment of generalized anxiety disorder: A meta-analysis. Clinical Psychology Review, 34(2014), 130-140.
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Yang, X.J., Jiang, H.M., Hou, X.H., & Song, J. (2015). Anxiety and depression in patients with gastroesophageal reflux diseas and their effect on quality of life. World of Journal of Gastroenterology, 21(14), 4302-4309. Web.