SSRIs and SNRIs are first-line treatments for anxiety disorders. They can take 4-6 weeks to take full effect. Benzodiazepines provide faster relief but carry risks of dependence and abuse with long-term use. Cognitive behavioral therapy is an effective psychotherapy for treating anxiety by helping patients identify and modify negative thoughts. Benzodiazepines should only be prescribed short-term after assessing for risk of addiction or substance abuse. Side effects, risks of dependence, and need for gradual tapering should be discussed with patients.

1. Student 1: Judy
What medications are considered first-line best practices for
treating anxiety? How long can they expect these medications to
take full effect? Alternative to use?
Selective serotonin reuptake inhibitors (SSRIs) are
recommended as a first-line treatment for anxiety disorders
(Bandelow et al., 2017). They increase serotonin levels by
blocking the serotonin transporter (SERT) which helps to reduce
anxiety (Stahl & Muntner, 2021). These drugs can be used long-
term due to better tolerability, less sedation, and less chance of
abuse or withdrawal (Bandelow et al., 2017). A study that was
conducted by Jakubovski et al (2018), also reported that
serotonin-norepinephrine reuptake inhibitors (SNRIs) are also
the first-line
pharmacological
treatment for anxiety disorders, but higher doses of these
medications are not needed to relieve anxiety. Therefore, the
pharmacotherapeutic treatment is somewhat a matter of
professional expertise and what the provider is comfortable with
prescribing.
What therapy would be indicated for someone with anxiety?
Cognitive behavior therapy (CBT) can be indicated for someone
with anxiety. It can be used to examine negative thoughts that
contribute to anxiety symptoms and replace those thoughts with
more positive realistic thoughts. This type of therapy approach
is to help clients identify irrational thoughts and help them
analyze their negative beliefs. Furthermore, the use of an SSRI
with CBT can reduce the activity in the amygdala and insula
which is responsible for pain and emotional perception, and

2. addictive behaviors (Gorka et al., 2019).
What do you need to assess before prescribing a
benzodiazepine? What special considerations should be gi ven
and discussed with the patient?
Benzodiazepines may be used in the management of diseases
such as insomnia or anxiety. However, the use of
benzodiazepines can result in respiratory depression due to its
effects on the central nervous system hence patients should be
educated on its use and contraindications. Benzodiazepines are
recommended for short-term pharmacotherapeutic treatment use
due to the significant risk of dependence. Long-term
benzodiazepines should be avoided if possible due to the risk of
dependence, possible abuse, and cognitive decline (Stahl, 2017).
Moreover, patients should be tapered off long-term use if they
can tolerate the discontinuation without severe withdrawal.
According to Takaesu et al (2019), patients taking
benzodiazepines are at increased risk of cognitive function
decline, falls, as well as dependence, and tolerance. That being
said, benzodiazepines should not be considered first-line due to
their high potential for abuse.
Last Name: I-N
Body Dysmorphic Disorder (F45.22)
How would you define the disorder?
Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM 5) (2013), defines body dysmorphic disorder
(BDD) as a preoccupation with one or more flaws in physical
appearance that others do not see that causes social anxiety and
avoidance. Individuals who have BDD excessively look at
themselves in the mirror, and they are always grooming
themselves. These types of behaviors cause a significant amount

3. of distress which affects one’s everyday functioning. The
person with BDD cannot control these behaviors and therefore
has a high level of anxiety. They are always concerned about
their appearance and try to compare themselves with others.
Their preoccupation is not related to their weight or body fat
therefore they do not have an eating disorder (American
Psychiatric Association, 2013). Some individuals with this
disorder have beliefs that their body is built too thin with
insufficient muscles. Additionally, individuals have
compulsions and obsessions that are mainly focused on their
physical appearance, and they are usually time-consuming as
well as difficult to control (American Psychiatric Association,
2013). According to Nicewicz and Boutrouille (2021), BDD was
first recognized as an atypical somatoform disorder.
What signs/symptoms would one see in the patient that
demonstrate the disorder?
The signs and symptoms that one would see that demonstrate
body dysmorphic disorder are individuals engaging in repetitive
behaviors, such as excessive mirror checking, compulsive skin
picking, camouflaging, participating in excessive grooming,
excessive weightlifting, or pervasive mental acts that involve
them comparing themselves to other people (Field, 2018). These
perceived physical flaws most commonly occur on the skin,
hair, or nose, but any body part can be involved. An individual
is hyper-focused on his/her appearance which makes them
believe that they are ugly and unattractive. They are usually
concerned about their eyes, teeth, lips, breasts, stomach,
genitals, and legs among others (American Psychiatric
Association, 2013). They compare themselves with other
people, they think other people are taking note of their negative
appearance and they might repeatedly apply makeup to try to
cover flaws. Some individuals end up seeking medical
procedures, excessively tanning their skin, and changing their
clothes excessively (American Psychiatric Association, 2013).

4. They also tend to seek reassurance from others about how they
look and sometimes avoid social situations due to fear of being
judged or maybe people will notice their imperfections.
What are the main DSM-5 criteria for this disorder?
According to the DSM 5, body dysmorphic disorder is classified
under obsessive-compulsive and related disorders. An
individual exhibits the four of the following features to meet the
diagnostic criteria:
Preoccupation with one or more perceived defects or flaws in
physical appearance that are not observable by others or others
slightly notices them (American Psychiatric Association, 2013,
p.242).
The person performs repetitive behaviors such as checking
mirrors, excessive grooming, skin picking, reassurance-seeking,
or mental acts that are concerning to their appearance
(American Psychiatric Association, 2013, p.242).
The preoccupation causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning. (American Psychiatric Association, 2013, p.242).
The appearance preoccupation is not explained by concerns with
body fat or weight that one meets the criteria for an eating
disorder
. (American Psychiatric Association, 2013, p.242).
What is the top 3 differential diagnosis for this disorder from
the DSM-5?
The three top differential diagnoses from the DSM-5 include
Obsessive-compulsive disorder whereby there are
preoccupations and repetitive behaviors. However, in BDD they

5. are more focused on their appearance hence the skin picking to
improve how they look. The second is an eating disorder this
can be comorbid. Thirdly is anxiety disorders which are
common in body dysmorphic disorder. However, in BDD the
anxiety is appearance-related and not social or avoidance
(American Psychiatric Association, 2013).
What medications would you use? Why? Black box warnings?
Before prescribing any medications, I would first obtain consent
for treatment. It is important to explain to the patient all the
risks versus benefits of the medication. The medication class
that is preferred for patients with BDD is selective serotonin
reuptake inhibitors (SSRIs). According to Nicewicz and
Boutrouille (2021), Fluoxetine is the recommended drug to treat
BDD. The dosage will be 20mg daily as it is important to start
low and see how the patient might tolerate the drug. The goal
will be to reduce the symptoms. The onset of action is usually
delayed 2-4 weeks and if it is not working within 6-8 but the
patient is tolerating the drug then it should be increased. The
side effects that need to be discussed with the patient include
nausea, diarrhea, headache, drowsiness or activation, sexual
dysfunction, or desire. Serious adverse effects include suicidal
thoughts and/or behaviors, mania, and seizures (Stahl, 2021).
While waiting on the therapeutic effects to take effect, the
patient can also be started on a small dose of benzodiazepine
short-term to give some relief to the distressing symptoms.
What type of therapy would you recommend for this patient?
The types of therapy that have shown to be beneficial for
patients with BDD include cognitive-behavioral therapy (CBT)
and metacognitive therapy (Phillipou et al., 2016). CBT is the
recommended first line of treatment for BDD. These types of
therapy will help the patient to work on his/her self-confidence.
Also, help in identifying the behaviors and triggers that cause

6. these feelings.
What do you see as the possible outcomes for this patient?
Clinicians need to communicate realistic expectations to
patients who are diagnosed with BDD at the beginning of
treatment and explain that their disorder might not be cured but
the goal is a reduction of symptoms. The outcome for the
patient would be to continue taking fluoxetine until the
symptoms of BDD have resolved or have been significantly
reduced. Also, for the patient to participate in cognitive
behavioral therapy to manage negative thoughts and modify
behaviors.
What are the 5 components of a suicide risk assessment that the
patient needs to be asked?
The five components of the suicide risk assessment that the
patient needs to be asked are do you have current thoughts of
killing yourself, what are your intentions, do you have a plan,
have you ever tried to kill yourself in the past, what is keeping
you alive, or what might decrease the chances of you trying to
kill yourself as suicidality is high within individuals with body
dysmorphic disorder. Furthermore, 80% of individuals with
body dysmorphic disorder think about suicide while
approximately 26% of those individuals have attempted suicide
(Koenig et al., 2021).
In addition to the suicide risk assessment questions, the clinical
can conduct a physical assessment of an individual who has
body dysmorphic disorder, he or she might notice some skin
lesions secondary to skin picking. Most patients with BDD have
a history of self-inflicted injuries. Although clients might not
want to share with the clinicians about their disorders, it is
important to ask them questions about any cosmetic procedures,
or surgical interventions. Also find out how they feel about

7. their appearance, how much time they spend worrying about
their appearance, and ask whether their condition affects their
quality of life. Find out if the patient has other dermatologic
issues. Find out the onset and duration of symptoms. Ask if the
patient has mental health history in his or her family or if
he/she is experiencing any significant life changes or stressors.
It is also imperative for the clinician to assess and rule out
disorders and other comorbidities like social anxiety disorder
and obsessive-compulsive disorder (American Psychiatric
Association 2013).
Student 2: Klaus
What medications are considered first line best practice for
treating anxiety? How long can they expect these medications to
take full effect? Alternative to use?
To treat social anxiety disorder, health care providers may
prescribe medications. This disorder can be effectively treated
with a variety of medications, including selected serotonin
reuptake inhibitors (SSRIs) and serotonin-norepinephrine
reuptake inhibitors (SNRIs) are antidepressants (SNRIs); this
class of medications may take several weeks to reach their
effect usually four to six weeks; alternatively, benzodiazepines
can also be utilized and these usually take a shorter time to take
effect but long term use is contradicted as it can be addictive
(Mayo Foundation for medical Education and Research, 2021).
What therapy would be indicated for someone with anxiety?
Most patients with social anxiety disorder benefit from
psychotherapy. In therapy, you will learn how to recognize and
modify negative beliefs about yourself as well as build skills to
help you achieve social confidence; CBT (cognitive behavioral
therapy) is the most successful type of psychotherapy for
anxiety, and it can be used either individually or in groups

8. (Mayo Foundation for medical Education and Research, 2021).
What do you need to assess before prescribing a
benzodiazepine? What special considerations should be given
and discussed with the patient?
Examine the patient for signs of addiction and abuse.
Benzodiazepines should not be used by patients who have a
history of substance abuse, particularly prescriiption drug
abuse; If the patient has other risk factors, use cautious, such
as: a background of chronic pain, a history of substance abuse
and behavioral addictions in the family (Mayo Foundation for
medical Education and Research, 2021).
Social Anxiety Disorder
How would you define the disorder?
In situations where they may be inspected, assessed, or judged
by others, such as speaking in public, meeting new people,
answering a question in class, or having to chat to a cashier in a
store, a person with social anxiety disorder experiences anxiety
or terror; commonplace activities such as eating or drinking in
front of people or using a public lavatory, might generate
anxiety or dread of being embarrassed, judged, or rejected
(Mayo Foundation for medical Education and Research, 2021).
What signs/symptoms would one see in the patient that
demonstrate the disorder?
Unlike ordinary uneasiness, social anxiety disorder include fear,
anxiety, and avoidance that interfere with relationships, daily
routines, job, school, or other activities (Mayo Foundation for
medical Education and Research, 2021).
What are the main DSM-5 criteria for this disorder?

9. Several criteria are involved when diagnosing someone with
social anxiety disorder (DSM-5 definition of social anxiety
disorder, n.d).
persistent anxiety of being exposed to unfamiliar people or
being scrutinized by others in one or more social or
performance circumstances. The person is afraid that he or she
may do something embarrassing and humiliating (or show
anxiety symptoms).
Being exposed to the feared situation nearly always causes
worry, which can manifest as a situationally bound or
predisposed Panic Attack.
The individual recognizes that his or her fear is irrational or
excessive.
Fearful circumstances are avoided or endured with a great deal
of anxiety and distress.
The avoidance, nervous anticipation, or distress in the dreaded
social or performance situation(s) severely interferes with the
person's usual routine, occupational (academic) functioning,
social activities, or relationships, or the person feels distressed
by having the phobia.
The fear, worry, or avoidance is long-term, usually lasting six
months or more.
4.
What are the top 3 differential diagnosis for this disorder from
the DSM-5?
panic disorder

10. agoraphobia
atypical depression
5.
What medications would you use? Why? Black box warnings?
Though there are a variety of drugs available, selective
serotonin reuptake inhibitors (SSRIs) are frequently used to
treat chronic social anxiety symptoms. Sertraline or paroxetine
(Paxil) may be prescribed by your doctor (Zoloft); Venlafaxine
(Effexor XR), a serotonin and norepinephrine reuptake inhibitor
(SNRI), may also be used to treat social anxiety disorder (Mayo
Foundation for medical Education and Research, 2021).
What type of therapy would you recommend for this patient?
Most patients with social anxiety disorder benefit from
psychotherapy. In therapy, you will learn how to recognize and
modify negative beliefs about yourself as well as build skills to
help you achieve social confidence; CBT (cognitive
behavioral
therapy) is the most successful type of psychotherapy for
anxiety, and it can be used either individually or in groups
(Mayo Foundation for medical Education and Research, 2021).
What do you see as the possible outcomes for this patient?
Combination of an appropriate therapy and medications as last
resort should be helpful to this patient to a high degree and go a
long way in increasing the prognosis
What are the 5 components of a suicide risk assessment (From
the PowerPoint/Kaltura in Week1) that the patient needs to be

11. asked?
I’ll as if the patient has any plans of killing themselves
Ask what the plan is
Seek to know if they has any access to the plan
Seek to know their intention
Seek to find out what is keeping them from executing the plan
so far