Pearls

Patients who are treated with psychotropics may experience better recovery from their symptoms and improved quality of life when they receive targeted treatment with cognitive-behavioral therapy (CBT). Clinicians can use certain CBT techniques to “jump-start” recovery in patients before prescribed medications produce their intended therapeutic effects. When practitioners are familiar with their use, techniques such as behavioral activation and tools that enhance adherence can be employed during a brief medication management (“med check”) visit.

Take these steps to implement brief CBT interventions into your patient’s routine visits:

• develop a clear, formulation-driven treatment target
• design an intervention that can be explained during a brief visit
• have handouts and worksheets available for patients to use
• provide written explanations and reminders for patients to use in out-of-session practice.

We present a case report that illustrates incorporating brief CBT interventions in a patient with major depressive disorder (MDD).

CASE REPORT

Using CBT to help a patient with MDD

Mr. L, age 52, presents with moderate MDD, and is started on fluoxetine, 20 mg/d. Mr. L has significant anhedonia and poor energy, and has been avoiding going to work and seeing friends. The psychiatrist explains to him how individuals with depression often want to refrain from activity and “shut down,” but that doing so will not improve his quality of life, and his mood will worsen.

The psychiatrist asks Mr. L to identify a pleasurable or important activity to complete before his next appointment. Mr. L decides that he would like to call a friend, because he has been isolated and his friends have been calling him. The psychiatrist encourages him to call one of his golf buddies. She instructs Mr. L to set reminders, such as cell phone alarms and notes on the refrigerator, to prompt him to “Call Phil Saturday at 10 am.” She uses a prescription pad to write an “action prescription”¹ to remind Mr. L of the importance of engaging in this activity.

To increase the likelihood that Mr. L will make this call, he and his psychiatrist discuss anticipated obstacles and potential facilitators of this behavior. Mr. L says that he might not be able to reach his friend, or that his negative self-talk might prevent him from making the call. With his psychiatrist’s help, Mr. L selects a second friend to call if the first friend does not answer the phone. They create a coping card² with encouraging and factual statements (eg, “My friend will be happy to hear from me” and “This will make me feel good”) for Mr. L to refer to if his negative self-talk interferes with his desire to make the call.

The psychiatrist also encourages Mr. L to complete a Behavioral Activation Worksheet (for examples, see http://www.cci.health.wa.gov.au/docs/ACF3B92.pdf or https://www.therapistaid.com/worksheets/behavioral-activation.pdf) to track his depression, pleasure, and sense of achievement before and after completing this activity.

As illustrated by this case, collaborating with the patient is critical to developing a realistic treatment plan that incorporates CBT techniques. With your help and encouragement, patients can use these tools to reach their goals and target the symptoms of their illnesses.

Patients who are treated with psychotropics may experience better recovery from their symptoms and improved quality of life when they receive targeted treatment with cognitive-behavioral therapy (CBT). Clinicians can use certain CBT techniques to “jump-start” recovery in patients before prescribed medications produce their intended therapeutic effects. When practitioners are familiar with their use, techniques such as behavioral activation and tools that enhance adherence can be employed during a brief medication management (“med check”) visit.

Take these steps to implement brief CBT interventions into your patient’s routine visits:

• develop a clear, formulation-driven treatment target
• design an intervention that can be explained during a brief visit
• have handouts and worksheets available for patients to use
• provide written explanations and reminders for patients to use in out-of-session practice.

We present a case report that illustrates incorporating brief CBT interventions in a patient with major depressive disorder (MDD).

CASE REPORT

Using CBT to help a patient with MDD

Mr. L, age 52, presents with moderate MDD, and is started on fluoxetine, 20 mg/d. Mr. L has significant anhedonia and poor energy, and has been avoiding going to work and seeing friends. The psychiatrist explains to him how individuals with depression often want to refrain from activity and “shut down,” but that doing so will not improve his quality of life, and his mood will worsen.

The psychiatrist asks Mr. L to identify a pleasurable or important activity to complete before his next appointment. Mr. L decides that he would like to call a friend, because he has been isolated and his friends have been calling him. The psychiatrist encourages him to call one of his golf buddies. She instructs Mr. L to set reminders, such as cell phone alarms and notes on the refrigerator, to prompt him to “Call Phil Saturday at 10 am.” She uses a prescription pad to write an “action prescription”¹ to remind Mr. L of the importance of engaging in this activity.

To increase the likelihood that Mr. L will make this call, he and his psychiatrist discuss anticipated obstacles and potential facilitators of this behavior. Mr. L says that he might not be able to reach his friend, or that his negative self-talk might prevent him from making the call. With his psychiatrist’s help, Mr. L selects a second friend to call if the first friend does not answer the phone. They create a coping card² with encouraging and factual statements (eg, “My friend will be happy to hear from me” and “This will make me feel good”) for Mr. L to refer to if his negative self-talk interferes with his desire to make the call.

The psychiatrist also encourages Mr. L to complete a Behavioral Activation Worksheet (for examples, see http://www.cci.health.wa.gov.au/docs/ACF3B92.pdf or https://www.therapistaid.com/worksheets/behavioral-activation.pdf) to track his depression, pleasure, and sense of achievement before and after completing this activity.

As illustrated by this case, collaborating with the patient is critical to developing a realistic treatment plan that incorporates CBT techniques. With your help and encouragement, patients can use these tools to reach their goals and target the symptoms of their illnesses.

Patients who are treated with psychotropics may experience better recovery from their symptoms and improved quality of life when they receive targeted treatment with cognitive-behavioral therapy (CBT). Clinicians can use certain CBT techniques to “jump-start” recovery in patients before prescribed medications produce their intended therapeutic effects. When practitioners are familiar with their use, techniques such as behavioral activation and tools that enhance adherence can be employed during a brief medication management (“med check”) visit.

Take these steps to implement brief CBT interventions into your patient’s routine visits:

• develop a clear, formulation-driven treatment target
• design an intervention that can be explained during a brief visit
• have handouts and worksheets available for patients to use
• provide written explanations and reminders for patients to use in out-of-session practice.

We present a case report that illustrates incorporating brief CBT interventions in a patient with major depressive disorder (MDD).

CASE REPORT

Using CBT to help a patient with MDD

Mr. L, age 52, presents with moderate MDD, and is started on fluoxetine, 20 mg/d. Mr. L has significant anhedonia and poor energy, and has been avoiding going to work and seeing friends. The psychiatrist explains to him how individuals with depression often want to refrain from activity and “shut down,” but that doing so will not improve his quality of life, and his mood will worsen.

The psychiatrist asks Mr. L to identify a pleasurable or important activity to complete before his next appointment. Mr. L decides that he would like to call a friend, because he has been isolated and his friends have been calling him. The psychiatrist encourages him to call one of his golf buddies. She instructs Mr. L to set reminders, such as cell phone alarms and notes on the refrigerator, to prompt him to “Call Phil Saturday at 10 am.” She uses a prescription pad to write an “action prescription”¹ to remind Mr. L of the importance of engaging in this activity.

To increase the likelihood that Mr. L will make this call, he and his psychiatrist discuss anticipated obstacles and potential facilitators of this behavior. Mr. L says that he might not be able to reach his friend, or that his negative self-talk might prevent him from making the call. With his psychiatrist’s help, Mr. L selects a second friend to call if the first friend does not answer the phone. They create a coping card² with encouraging and factual statements (eg, “My friend will be happy to hear from me” and “This will make me feel good”) for Mr. L to refer to if his negative self-talk interferes with his desire to make the call.

The psychiatrist also encourages Mr. L to complete a Behavioral Activation Worksheet (for examples, see http://www.cci.health.wa.gov.au/docs/ACF3B92.pdf or https://www.therapistaid.com/worksheets/behavioral-activation.pdf) to track his depression, pleasure, and sense of achievement before and after completing this activity.

As illustrated by this case, collaborating with the patient is critical to developing a realistic treatment plan that incorporates CBT techniques. With your help and encouragement, patients can use these tools to reach their goals and target the symptoms of their illnesses.

Being a psychiatrist today often entails long hours immersed in charts or on computers, a lack of fresh air, and eating meals in a hurry. Being on call, facing deadline pressures, and juggling multiple responsibilities can lead to fatigue, frustration, and a lack of adequate socialization. These circumstances can take their toll on us in unpleasant and unhealthy ways, resulting in exhaustion, illness, and isolation. After spending many hours caring for our patients, yoga can help restore and revitalize our own bodies and minds. Preliminary research indicates that yoga can have beneficial effects on one’s mental state, and may help treat depression, anxiety, and other conditions, although many studies of yoga have been small or poorly designed.^1,2

What is yoga?

Yoga is an ancient practice that originated in India thousands of years ago. It was introduced to the West in the 19th century. Yoga is a holistic lifestyle of well-being that includes physical and meditative practices. Today, the most popular forms of yoga typically incorporate a combination of physical postures, controlled breathing, deep relaxation, and/or meditation.²

How to begin yoga practice

Start slow and simple. Watching a beginner’s video at home or taking a beginner’s class in a yoga studio can be extremely helpful. Take time to learn how to mindfully move in and out of postures to avoid injury or strain. Yoga postures often represent animals, nature, and heroes that suggest unity with life, evolution, and universality. These postures can be done in any quiet setting; practicing out in nature may be particularly enjoyable for some. Practicing yoga postures can help you:

• develop balance, endurance, strength, flexibility, and coordination
• release chronic muscular tension
• rejuvenate the body.

Explore different schools. Over time, numerous schools of yoga have evolved. They vary from gentle to strenuous, with an emphasis on postures, breath work, meditation, singing, or a combination of these skills. Choose what feels good and safe based on your personal preference and physical ability.

Be mindful. Focusing solely on the present moment calms the mind and increases awareness. Meditative practice can sharpen clarity and focus. Meditation can involve focusing your attention on sounds, images, or inspirational words or phrases. Each of our movements can invite self-respect and further awareness of the daily toll that modern life places on our minds and bodies. Active breath work is believed to cultivate vitality. Calm breath work and meditative practices help still the mind and decrease physiologic overarousal.

Stay consistent. Regardless of your physical ability or level of mobility, consistent yoga practice is necessary to realize its benefits. Therefore, a weekly class may be a good way to start. Eventually, a good goal is to practice twice a day, at dawn and dusk.

Appreciate the experience. Immerse yourself in each moment of yoga practice. There is no need to rush. Enjoy your journey!

Being a psychiatrist today often entails long hours immersed in charts or on computers, a lack of fresh air, and eating meals in a hurry. Being on call, facing deadline pressures, and juggling multiple responsibilities can lead to fatigue, frustration, and a lack of adequate socialization. These circumstances can take their toll on us in unpleasant and unhealthy ways, resulting in exhaustion, illness, and isolation. After spending many hours caring for our patients, yoga can help restore and revitalize our own bodies and minds. Preliminary research indicates that yoga can have beneficial effects on one’s mental state, and may help treat depression, anxiety, and other conditions, although many studies of yoga have been small or poorly designed.^1,2

What is yoga?

Yoga is an ancient practice that originated in India thousands of years ago. It was introduced to the West in the 19th century. Yoga is a holistic lifestyle of well-being that includes physical and meditative practices. Today, the most popular forms of yoga typically incorporate a combination of physical postures, controlled breathing, deep relaxation, and/or meditation.²

How to begin yoga practice

Start slow and simple. Watching a beginner’s video at home or taking a beginner’s class in a yoga studio can be extremely helpful. Take time to learn how to mindfully move in and out of postures to avoid injury or strain. Yoga postures often represent animals, nature, and heroes that suggest unity with life, evolution, and universality. These postures can be done in any quiet setting; practicing out in nature may be particularly enjoyable for some. Practicing yoga postures can help you:

• develop balance, endurance, strength, flexibility, and coordination
• release chronic muscular tension
• rejuvenate the body.

Explore different schools. Over time, numerous schools of yoga have evolved. They vary from gentle to strenuous, with an emphasis on postures, breath work, meditation, singing, or a combination of these skills. Choose what feels good and safe based on your personal preference and physical ability.

Be mindful. Focusing solely on the present moment calms the mind and increases awareness. Meditative practice can sharpen clarity and focus. Meditation can involve focusing your attention on sounds, images, or inspirational words or phrases. Each of our movements can invite self-respect and further awareness of the daily toll that modern life places on our minds and bodies. Active breath work is believed to cultivate vitality. Calm breath work and meditative practices help still the mind and decrease physiologic overarousal.

Stay consistent. Regardless of your physical ability or level of mobility, consistent yoga practice is necessary to realize its benefits. Therefore, a weekly class may be a good way to start. Eventually, a good goal is to practice twice a day, at dawn and dusk.

Appreciate the experience. Immerse yourself in each moment of yoga practice. There is no need to rush. Enjoy your journey!

Being a psychiatrist today often entails long hours immersed in charts or on computers, a lack of fresh air, and eating meals in a hurry. Being on call, facing deadline pressures, and juggling multiple responsibilities can lead to fatigue, frustration, and a lack of adequate socialization. These circumstances can take their toll on us in unpleasant and unhealthy ways, resulting in exhaustion, illness, and isolation. After spending many hours caring for our patients, yoga can help restore and revitalize our own bodies and minds. Preliminary research indicates that yoga can have beneficial effects on one’s mental state, and may help treat depression, anxiety, and other conditions, although many studies of yoga have been small or poorly designed.^1,2

What is yoga?

Yoga is an ancient practice that originated in India thousands of years ago. It was introduced to the West in the 19th century. Yoga is a holistic lifestyle of well-being that includes physical and meditative practices. Today, the most popular forms of yoga typically incorporate a combination of physical postures, controlled breathing, deep relaxation, and/or meditation.²

How to begin yoga practice

Start slow and simple. Watching a beginner’s video at home or taking a beginner’s class in a yoga studio can be extremely helpful. Take time to learn how to mindfully move in and out of postures to avoid injury or strain. Yoga postures often represent animals, nature, and heroes that suggest unity with life, evolution, and universality. These postures can be done in any quiet setting; practicing out in nature may be particularly enjoyable for some. Practicing yoga postures can help you:

• develop balance, endurance, strength, flexibility, and coordination
• release chronic muscular tension
• rejuvenate the body.

Explore different schools. Over time, numerous schools of yoga have evolved. They vary from gentle to strenuous, with an emphasis on postures, breath work, meditation, singing, or a combination of these skills. Choose what feels good and safe based on your personal preference and physical ability.

Be mindful. Focusing solely on the present moment calms the mind and increases awareness. Meditative practice can sharpen clarity and focus. Meditation can involve focusing your attention on sounds, images, or inspirational words or phrases. Each of our movements can invite self-respect and further awareness of the daily toll that modern life places on our minds and bodies. Active breath work is believed to cultivate vitality. Calm breath work and meditative practices help still the mind and decrease physiologic overarousal.

Stay consistent. Regardless of your physical ability or level of mobility, consistent yoga practice is necessary to realize its benefits. Therefore, a weekly class may be a good way to start. Eventually, a good goal is to practice twice a day, at dawn and dusk.

Appreciate the experience. Immerse yourself in each moment of yoga practice. There is no need to rush. Enjoy your journey!

Attention-deficit/hyperactivity disorder (ADHD) affects 5% of children and adolescents worldwide.¹ Children with ADHD commonly have trouble with attention, hyperactivity, impulsivity, organization, and emotional reactivity, and these difficulties can result in behaviors that frustrate, worry, and overwhelm parents, teachers, and other caregivers.

Extensive evidence supports stimulants as a first-line treatment. However, nonpharmacologic interventions are important, yet often overlooked, adjuncts that can be helpful for children who have a partial response to stimulants or are not prescribed medication. Teaching caregivers to use the following interventions will allow them to help children better navigate situations that require managing their symptoms, such as in a classroom setting.²

Attention. Children with ADHD typically find it challenging to prioritize what to focus on, sustain that focus, and switch between tasks. Shouting instructions often is unproductive. Therefore, encourage parents and teachers to use clear and concise instructions with supplementary visual tools to aid these children. When providing instructions in classrooms, teachers should look directly at the student and call him (her) by name. It also can be helpful to have the student repeat the instructions. Seating students with ADHD near the front of the classroom, close to the teacher and away from other distracting students, can improve their focus and allow the teacher to more easily give nonverbal cues, such as tapping on the student’s desk if his attention is waning.

Hyperactivity. Children with ADHD are prone to excessive talkativeness and continuous motor movement; therefore, sitting still for long periods can be exceptionally difficult. Teachers and caregivers should keep assignments short. For students whose primary manifestation of ADHD is hyperactivity, sitting near the back of the classroom will allow them to stand and stretch without disrupting the class. Occasionally giving these students a time-limited, acceptable outlet for their urge to move may be beneficial.

Impulsivity. Children who exhibit this symptom are more focused on the present and have difficulty weighing the consequences of their actions. Allowing these children to take frequent breaks (eg, more play time) will let their brains rest and recharge so that they can take a step back to evaluate the outcomes of their actions. Instruct parents and teachers to give children with ADHD regular verbal or written feedback to monitor and modify behaviors over time. Consequences for not following the rules should be immediate and consistent.

Organization. School assignments require sequencing, planning, and time management. Therefore, having daily visual reminders of prioritized assignments and schedules is helpful for children with ADHD, both at school and at home. Teachers and parents can help children stay organized by checking and reviewing the child’s agenda with him several times a day; this will allow him more time to think about what he needs to do to complete assignments.Emotional reactivity. Children with ADHD become frustrated easily and often are particularly sensitive to disappointment because of the continuous redirection they receive. Normalizing their mistakes by reinforcing that everyone makes mistakes and teaching them to learn from their mistakes can help reduce their embarrassment.

It also can be helpful to identify triggers for emotional reactivity. Parents and teachers should minimize the amount of talking when a child is unable to control his emotions. Helping children label their emotions, developing strategies for when they become upset, and outlining clear consequences for unacceptable behaviors can help modify their reactions.

Attention-deficit/hyperactivity disorder (ADHD) affects 5% of children and adolescents worldwide.¹ Children with ADHD commonly have trouble with attention, hyperactivity, impulsivity, organization, and emotional reactivity, and these difficulties can result in behaviors that frustrate, worry, and overwhelm parents, teachers, and other caregivers.

Extensive evidence supports stimulants as a first-line treatment. However, nonpharmacologic interventions are important, yet often overlooked, adjuncts that can be helpful for children who have a partial response to stimulants or are not prescribed medication. Teaching caregivers to use the following interventions will allow them to help children better navigate situations that require managing their symptoms, such as in a classroom setting.²

Attention. Children with ADHD typically find it challenging to prioritize what to focus on, sustain that focus, and switch between tasks. Shouting instructions often is unproductive. Therefore, encourage parents and teachers to use clear and concise instructions with supplementary visual tools to aid these children. When providing instructions in classrooms, teachers should look directly at the student and call him (her) by name. It also can be helpful to have the student repeat the instructions. Seating students with ADHD near the front of the classroom, close to the teacher and away from other distracting students, can improve their focus and allow the teacher to more easily give nonverbal cues, such as tapping on the student’s desk if his attention is waning.

Hyperactivity. Children with ADHD are prone to excessive talkativeness and continuous motor movement; therefore, sitting still for long periods can be exceptionally difficult. Teachers and caregivers should keep assignments short. For students whose primary manifestation of ADHD is hyperactivity, sitting near the back of the classroom will allow them to stand and stretch without disrupting the class. Occasionally giving these students a time-limited, acceptable outlet for their urge to move may be beneficial.

Impulsivity. Children who exhibit this symptom are more focused on the present and have difficulty weighing the consequences of their actions. Allowing these children to take frequent breaks (eg, more play time) will let their brains rest and recharge so that they can take a step back to evaluate the outcomes of their actions. Instruct parents and teachers to give children with ADHD regular verbal or written feedback to monitor and modify behaviors over time. Consequences for not following the rules should be immediate and consistent.

Organization. School assignments require sequencing, planning, and time management. Therefore, having daily visual reminders of prioritized assignments and schedules is helpful for children with ADHD, both at school and at home. Teachers and parents can help children stay organized by checking and reviewing the child’s agenda with him several times a day; this will allow him more time to think about what he needs to do to complete assignments.Emotional reactivity. Children with ADHD become frustrated easily and often are particularly sensitive to disappointment because of the continuous redirection they receive. Normalizing their mistakes by reinforcing that everyone makes mistakes and teaching them to learn from their mistakes can help reduce their embarrassment.

It also can be helpful to identify triggers for emotional reactivity. Parents and teachers should minimize the amount of talking when a child is unable to control his emotions. Helping children label their emotions, developing strategies for when they become upset, and outlining clear consequences for unacceptable behaviors can help modify their reactions.

Attention-deficit/hyperactivity disorder (ADHD) affects 5% of children and adolescents worldwide.¹ Children with ADHD commonly have trouble with attention, hyperactivity, impulsivity, organization, and emotional reactivity, and these difficulties can result in behaviors that frustrate, worry, and overwhelm parents, teachers, and other caregivers.

Extensive evidence supports stimulants as a first-line treatment. However, nonpharmacologic interventions are important, yet often overlooked, adjuncts that can be helpful for children who have a partial response to stimulants or are not prescribed medication. Teaching caregivers to use the following interventions will allow them to help children better navigate situations that require managing their symptoms, such as in a classroom setting.²

Attention. Children with ADHD typically find it challenging to prioritize what to focus on, sustain that focus, and switch between tasks. Shouting instructions often is unproductive. Therefore, encourage parents and teachers to use clear and concise instructions with supplementary visual tools to aid these children. When providing instructions in classrooms, teachers should look directly at the student and call him (her) by name. It also can be helpful to have the student repeat the instructions. Seating students with ADHD near the front of the classroom, close to the teacher and away from other distracting students, can improve their focus and allow the teacher to more easily give nonverbal cues, such as tapping on the student’s desk if his attention is waning.

Hyperactivity. Children with ADHD are prone to excessive talkativeness and continuous motor movement; therefore, sitting still for long periods can be exceptionally difficult. Teachers and caregivers should keep assignments short. For students whose primary manifestation of ADHD is hyperactivity, sitting near the back of the classroom will allow them to stand and stretch without disrupting the class. Occasionally giving these students a time-limited, acceptable outlet for their urge to move may be beneficial.

Impulsivity. Children who exhibit this symptom are more focused on the present and have difficulty weighing the consequences of their actions. Allowing these children to take frequent breaks (eg, more play time) will let their brains rest and recharge so that they can take a step back to evaluate the outcomes of their actions. Instruct parents and teachers to give children with ADHD regular verbal or written feedback to monitor and modify behaviors over time. Consequences for not following the rules should be immediate and consistent.

Organization. School assignments require sequencing, planning, and time management. Therefore, having daily visual reminders of prioritized assignments and schedules is helpful for children with ADHD, both at school and at home. Teachers and parents can help children stay organized by checking and reviewing the child’s agenda with him several times a day; this will allow him more time to think about what he needs to do to complete assignments.Emotional reactivity. Children with ADHD become frustrated easily and often are particularly sensitive to disappointment because of the continuous redirection they receive. Normalizing their mistakes by reinforcing that everyone makes mistakes and teaching them to learn from their mistakes can help reduce their embarrassment.

It also can be helpful to identify triggers for emotional reactivity. Parents and teachers should minimize the amount of talking when a child is unable to control his emotions. Helping children label their emotions, developing strategies for when they become upset, and outlining clear consequences for unacceptable behaviors can help modify their reactions.

Mindfulness is actively being aware of one’s inner and outer environments in the present moment. Core mindfulness skills include observation, description, participation, a nonjudgmental approach, focusing on 1 thing at a time, and effectiveness.¹

Psychotherapeutic interventions based on each of these skills have been developed to instill a mindful state in psychiatric patients. Evidence suggests these interventions can be helpful when treating borderline personality disorder, somatization, pain, depression, and anxiety, among other conditions.²

Elements of mindfulness can be integrated into brief interventions. The following 6 simple, practical exercises can be used to help patients develop these skills.

Observation involves noticing internal and external experiences, including thoughts and sensations, without applying words or labels. Guide your patient through the following exercise:

Focus your attention on the ground beneath your feet, feeling the pressure, temperature, and texture of this sensation. Do the same with your seat, your breath, and the sounds, sights, and smells of the room. Be aware of your thoughts and watch them come and go like fish in a fishbowl.

Description entails assigning purely descriptive words to one’s observations. To help your patient develop this skill, ask him (her) to describe the sensations he (she) observed in the previous exercise.

Participation entails immersive engagement in an activity. Ask your patient to listen to a song he has never heard before, and then play it again and dance or sing along. Instruct him to engage wholly, conscious of each step or note, without being judgmental or self-conscious. If he feels embarrassed or self-critical, tell him to observe these thoughts and emotions, put them aside, and return to the activity.

A nonjudgmental approach consists of separating out the facts and recognizing emotional responses without clinging to them. To practice this skill, ask your patient to play a song that he likes and one that he dislikes. The patient should listen to each, observing and describing the way they sound without judgment. Tell the patient that if judgmental words or phrases, such as “beautiful,” “ugly,” “I love…,” or “I hate…,” appear as thoughts, he should observe them, put them aside, and then return to nonjudgmental description and observation.

Focusing on 1 thing at a time means dedicating complete attention to a single task, activity, or thought. Give your patient a short paragraph or poem to read. Instruct him to try not to focus on recent personal events or what he will eat for dinner while reading. If he would like to switch to other tasks, then he should give his whole attention to this other task, and stop reading.

Effectiveness involves focusing on what works to attain one’s goals. For this exercise, set up a task for your patient by placing several items in a location that is neither immediately obvious nor readily accessible without an intermediate step. Instruct your patient to obtain these objects. Then guide them as follows:

What do you have to do to get them? Ask permission? Borrow a key? Recruit assistance? Determine the location? Brainstorm ways to obtain the items, and then complete the task.

Mindfulness is actively being aware of one’s inner and outer environments in the present moment. Core mindfulness skills include observation, description, participation, a nonjudgmental approach, focusing on 1 thing at a time, and effectiveness.¹

Psychotherapeutic interventions based on each of these skills have been developed to instill a mindful state in psychiatric patients. Evidence suggests these interventions can be helpful when treating borderline personality disorder, somatization, pain, depression, and anxiety, among other conditions.²

Elements of mindfulness can be integrated into brief interventions. The following 6 simple, practical exercises can be used to help patients develop these skills.

Observation involves noticing internal and external experiences, including thoughts and sensations, without applying words or labels. Guide your patient through the following exercise:

Focus your attention on the ground beneath your feet, feeling the pressure, temperature, and texture of this sensation. Do the same with your seat, your breath, and the sounds, sights, and smells of the room. Be aware of your thoughts and watch them come and go like fish in a fishbowl.

Description entails assigning purely descriptive words to one’s observations. To help your patient develop this skill, ask him (her) to describe the sensations he (she) observed in the previous exercise.

Participation entails immersive engagement in an activity. Ask your patient to listen to a song he has never heard before, and then play it again and dance or sing along. Instruct him to engage wholly, conscious of each step or note, without being judgmental or self-conscious. If he feels embarrassed or self-critical, tell him to observe these thoughts and emotions, put them aside, and return to the activity.

A nonjudgmental approach consists of separating out the facts and recognizing emotional responses without clinging to them. To practice this skill, ask your patient to play a song that he likes and one that he dislikes. The patient should listen to each, observing and describing the way they sound without judgment. Tell the patient that if judgmental words or phrases, such as “beautiful,” “ugly,” “I love…,” or “I hate…,” appear as thoughts, he should observe them, put them aside, and then return to nonjudgmental description and observation.

Focusing on 1 thing at a time means dedicating complete attention to a single task, activity, or thought. Give your patient a short paragraph or poem to read. Instruct him to try not to focus on recent personal events or what he will eat for dinner while reading. If he would like to switch to other tasks, then he should give his whole attention to this other task, and stop reading.

Effectiveness involves focusing on what works to attain one’s goals. For this exercise, set up a task for your patient by placing several items in a location that is neither immediately obvious nor readily accessible without an intermediate step. Instruct your patient to obtain these objects. Then guide them as follows:

What do you have to do to get them? Ask permission? Borrow a key? Recruit assistance? Determine the location? Brainstorm ways to obtain the items, and then complete the task.

Mindfulness is actively being aware of one’s inner and outer environments in the present moment. Core mindfulness skills include observation, description, participation, a nonjudgmental approach, focusing on 1 thing at a time, and effectiveness.¹

Psychotherapeutic interventions based on each of these skills have been developed to instill a mindful state in psychiatric patients. Evidence suggests these interventions can be helpful when treating borderline personality disorder, somatization, pain, depression, and anxiety, among other conditions.²

Elements of mindfulness can be integrated into brief interventions. The following 6 simple, practical exercises can be used to help patients develop these skills.

Observation involves noticing internal and external experiences, including thoughts and sensations, without applying words or labels. Guide your patient through the following exercise:

Focus your attention on the ground beneath your feet, feeling the pressure, temperature, and texture of this sensation. Do the same with your seat, your breath, and the sounds, sights, and smells of the room. Be aware of your thoughts and watch them come and go like fish in a fishbowl.

Description entails assigning purely descriptive words to one’s observations. To help your patient develop this skill, ask him (her) to describe the sensations he (she) observed in the previous exercise.

Participation entails immersive engagement in an activity. Ask your patient to listen to a song he has never heard before, and then play it again and dance or sing along. Instruct him to engage wholly, conscious of each step or note, without being judgmental or self-conscious. If he feels embarrassed or self-critical, tell him to observe these thoughts and emotions, put them aside, and return to the activity.

A nonjudgmental approach consists of separating out the facts and recognizing emotional responses without clinging to them. To practice this skill, ask your patient to play a song that he likes and one that he dislikes. The patient should listen to each, observing and describing the way they sound without judgment. Tell the patient that if judgmental words or phrases, such as “beautiful,” “ugly,” “I love…,” or “I hate…,” appear as thoughts, he should observe them, put them aside, and then return to nonjudgmental description and observation.

Focusing on 1 thing at a time means dedicating complete attention to a single task, activity, or thought. Give your patient a short paragraph or poem to read. Instruct him to try not to focus on recent personal events or what he will eat for dinner while reading. If he would like to switch to other tasks, then he should give his whole attention to this other task, and stop reading.

Effectiveness involves focusing on what works to attain one’s goals. For this exercise, set up a task for your patient by placing several items in a location that is neither immediately obvious nor readily accessible without an intermediate step. Instruct your patient to obtain these objects. Then guide them as follows:

What do you have to do to get them? Ask permission? Borrow a key? Recruit assistance? Determine the location? Brainstorm ways to obtain the items, and then complete the task.

Patients who are Muslim—followers of the religion of Islam—struggle with a political climate that has demonized them and the continued fallout of terrorist attacks perpetrated by individuals who identify themselves as Muslim. These patients may experience low self-esteem, bullying, depression, anxiety, or posttraumatic stress disorder.¹ Some have expressed feeling judged, labeled, attacked, and subjected to discrimination. Islamophobia and a spike in hate crimes have further marginalized this already vulnerable population.² Thus, understanding your Muslim patients is the first step to treating their mental illness.

How Muslim culture might affect care

Muslims are not a monolithic group; they vary widely in their religious adherence, cultural background, and acculturation. Some are American-born, including a significant African American Muslim population. Others are children of immigrants or have recently immigrated, including many who came to the United States because of the ongoing war in Syria. Many can trace their heritage to >50 predominantly Muslim countries. Many Muslim patients want to find a balance between their religious and American identities.

As clinicians, we should not make assumptions based on outward appearances or our preconceived notions of our patients, especially when it comes to gender roles. Our job is to ask how highly personal, individualized decisions, such as a woman’s choice to wear a hijab as an expression of her faith and a symbol of modesty, factor into our patients’ day-to-day lives. Doing so can help build the therapeutic alliance and improve the accuracy of the diagnosis and the appropriateness of treatment.

Mental health clinicians are well aware of the dangers of the social stigma that their patients may experience.³ These dangers are no different when it comes to Muslim patients, who often may face “double discrimination” for their religion and for having a mental illness. They may seek support from religious leaders, family, and friends before seeing a mental health provider. Some may view their mental illness as a weakness of faith, a punishment by God, or an affliction caused by a supernatural spirit, and therefore may feel that following religious doctrine will resolve their psychological distress.⁴ They may need additional encouragement to see a therapist or take psycho­tropics, and they may prefer specific treatments that reflect their cultural values, such as supplements.

Because some Muslim patients may be more comfortable presenting their psycho­logical concerns as somatic symptoms, they may first seek care from a primary care physician. Some patients may not be open or comfortable enough to address sensitive issues, such as substance use. Providing psychoeducation, comparing mental illness with medical illness, and emphasizing doctor–patient confidentiality may help these patients overcome the stigma that can act as a barrier to care.

Provide culturally competent care

Resources are available to help us provide the best possible care to our patients from various cultures and religions, including Muslim patients. A good starting point is the DSM-5’s Cultural Formulation Interview, which is a set of 16 questions psychiatrists can use to determine the impact of culture on a patient’s clinical presentation and care.⁵ Other resources include the American Psychiatric Association’s Assessment of Cultural Factors and the American Academy of Child and Adolescent Psychiatry’s Practice Parameter for Cultural Competence.⁶

When treating Muslim patients, remember to:

• Ask about what roles their culture and religion play
• Understand their explanation of their symptoms
• Work to overcome any stigma patients may perceive related to having a psychiatric disorder
• Engage your team to identify cultural and religious factors
• Connect to community resources, such as the patient’s family and friends.

Patients who are Muslim—followers of the religion of Islam—struggle with a political climate that has demonized them and the continued fallout of terrorist attacks perpetrated by individuals who identify themselves as Muslim. These patients may experience low self-esteem, bullying, depression, anxiety, or posttraumatic stress disorder.¹ Some have expressed feeling judged, labeled, attacked, and subjected to discrimination. Islamophobia and a spike in hate crimes have further marginalized this already vulnerable population.² Thus, understanding your Muslim patients is the first step to treating their mental illness.

How Muslim culture might affect care

Muslims are not a monolithic group; they vary widely in their religious adherence, cultural background, and acculturation. Some are American-born, including a significant African American Muslim population. Others are children of immigrants or have recently immigrated, including many who came to the United States because of the ongoing war in Syria. Many can trace their heritage to >50 predominantly Muslim countries. Many Muslim patients want to find a balance between their religious and American identities.

As clinicians, we should not make assumptions based on outward appearances or our preconceived notions of our patients, especially when it comes to gender roles. Our job is to ask how highly personal, individualized decisions, such as a woman’s choice to wear a hijab as an expression of her faith and a symbol of modesty, factor into our patients’ day-to-day lives. Doing so can help build the therapeutic alliance and improve the accuracy of the diagnosis and the appropriateness of treatment.

Mental health clinicians are well aware of the dangers of the social stigma that their patients may experience.³ These dangers are no different when it comes to Muslim patients, who often may face “double discrimination” for their religion and for having a mental illness. They may seek support from religious leaders, family, and friends before seeing a mental health provider. Some may view their mental illness as a weakness of faith, a punishment by God, or an affliction caused by a supernatural spirit, and therefore may feel that following religious doctrine will resolve their psychological distress.⁴ They may need additional encouragement to see a therapist or take psycho­tropics, and they may prefer specific treatments that reflect their cultural values, such as supplements.

Because some Muslim patients may be more comfortable presenting their psycho­logical concerns as somatic symptoms, they may first seek care from a primary care physician. Some patients may not be open or comfortable enough to address sensitive issues, such as substance use. Providing psychoeducation, comparing mental illness with medical illness, and emphasizing doctor–patient confidentiality may help these patients overcome the stigma that can act as a barrier to care.

Provide culturally competent care

Resources are available to help us provide the best possible care to our patients from various cultures and religions, including Muslim patients. A good starting point is the DSM-5’s Cultural Formulation Interview, which is a set of 16 questions psychiatrists can use to determine the impact of culture on a patient’s clinical presentation and care.⁵ Other resources include the American Psychiatric Association’s Assessment of Cultural Factors and the American Academy of Child and Adolescent Psychiatry’s Practice Parameter for Cultural Competence.⁶

When treating Muslim patients, remember to:

• Ask about what roles their culture and religion play
• Understand their explanation of their symptoms
• Work to overcome any stigma patients may perceive related to having a psychiatric disorder
• Engage your team to identify cultural and religious factors
• Connect to community resources, such as the patient’s family and friends.

Patients who are Muslim—followers of the religion of Islam—struggle with a political climate that has demonized them and the continued fallout of terrorist attacks perpetrated by individuals who identify themselves as Muslim. These patients may experience low self-esteem, bullying, depression, anxiety, or posttraumatic stress disorder.¹ Some have expressed feeling judged, labeled, attacked, and subjected to discrimination. Islamophobia and a spike in hate crimes have further marginalized this already vulnerable population.² Thus, understanding your Muslim patients is the first step to treating their mental illness.

How Muslim culture might affect care

Muslims are not a monolithic group; they vary widely in their religious adherence, cultural background, and acculturation. Some are American-born, including a significant African American Muslim population. Others are children of immigrants or have recently immigrated, including many who came to the United States because of the ongoing war in Syria. Many can trace their heritage to >50 predominantly Muslim countries. Many Muslim patients want to find a balance between their religious and American identities.

As clinicians, we should not make assumptions based on outward appearances or our preconceived notions of our patients, especially when it comes to gender roles. Our job is to ask how highly personal, individualized decisions, such as a woman’s choice to wear a hijab as an expression of her faith and a symbol of modesty, factor into our patients’ day-to-day lives. Doing so can help build the therapeutic alliance and improve the accuracy of the diagnosis and the appropriateness of treatment.

Mental health clinicians are well aware of the dangers of the social stigma that their patients may experience.³ These dangers are no different when it comes to Muslim patients, who often may face “double discrimination” for their religion and for having a mental illness. They may seek support from religious leaders, family, and friends before seeing a mental health provider. Some may view their mental illness as a weakness of faith, a punishment by God, or an affliction caused by a supernatural spirit, and therefore may feel that following religious doctrine will resolve their psychological distress.⁴ They may need additional encouragement to see a therapist or take psycho­tropics, and they may prefer specific treatments that reflect their cultural values, such as supplements.

Because some Muslim patients may be more comfortable presenting their psycho­logical concerns as somatic symptoms, they may first seek care from a primary care physician. Some patients may not be open or comfortable enough to address sensitive issues, such as substance use. Providing psychoeducation, comparing mental illness with medical illness, and emphasizing doctor–patient confidentiality may help these patients overcome the stigma that can act as a barrier to care.

Provide culturally competent care

Resources are available to help us provide the best possible care to our patients from various cultures and religions, including Muslim patients. A good starting point is the DSM-5’s Cultural Formulation Interview, which is a set of 16 questions psychiatrists can use to determine the impact of culture on a patient’s clinical presentation and care.⁵ Other resources include the American Psychiatric Association’s Assessment of Cultural Factors and the American Academy of Child and Adolescent Psychiatry’s Practice Parameter for Cultural Competence.⁶

When treating Muslim patients, remember to:

• Ask about what roles their culture and religion play
• Understand their explanation of their symptoms
• Work to overcome any stigma patients may perceive related to having a psychiatric disorder
• Engage your team to identify cultural and religious factors
• Connect to community resources, such as the patient’s family and friends.

Treating short-term or situational anxiety or anxiety attacks with benzodiazepines carries the risk of withdrawal and dependence. Other options include various antidepressants and buspirone. Although such medications decrease overall anxiety and can prevent anxiety from building, they are not effective for breakthrough anxiety. Other mainstays are antihistamines, antipsychotics, or newer antiepileptics such as gabapentin and pregabalin, but none of these have strong clinical literature support regarding their effectiveness for treating anxiety disorders.

PanX compounded medications are dual drug combinations of a beta blocker plus an antiemetic antimuscarinic agent.¹ They are designed and patented for as-needed treatment of anxiety disorders without using any controlled substances. Compounded medications are not FDA-approved, but are commercially available and subject to Section 503A of the Federal Food, Drug, and Cosmetics Act of 2013.²

In PanX medications, the beta blocker is intended to address the sympathetic cardiovascular symptoms of anxiety. Beta adrenergic receptor antagonists have been prescribed off-label for decades to treat social anxiety disorder, including performance anxiety. At least 7 beta blockers—atenolol, propranolol, pindolol, timolol, nadolol, betaxolol, and oxprenolol—have been reported to have anxiolytic effects, although these are limited to cardiovascular symptoms of anxiety.¹

However, there is a need to augment the limited effects of the beta blocker with another agent, such as an antimuscarinic agent, which is intended for parasympathetic noncardiovascular and CNS symptoms of anxiety. Scopolamine is a preferred antimuscarinic because it has been known for over a century to exhibit anxiolytic effects.³ Scopolamine’s mechanism of action is antagonism of acetylcholine binding to the M1 and/or M2 muscarinic receptors.⁴

We present a case of a patient who needed a nonbenzodiazepine treatment for acute anxiety. She received a compounded PanX combination of the beta-1 selective beta blocker atenolol, 25 mg, plus scopolamine hydrobromide, 0.2 mg, as needed for acute anxiety.

Case report

Acute anxiety, benzodiazepine abuse

Ms. L, age 30, with a family history of depression and anxiety, has had anxiety, depression, and posttraumatic stress disorder since she was in her mid-20s. She is evaluated in a 30-day rehabilitation program for alprazolam abuse. She is detoxed from alprazolam and stabilized with lurasidone, 60 mg once in the morning, gabapentin, 1,200 mg 4 times a day, and quetiapine, 125 mg as needed for sleep.

Ms. L improves significantly and is transferred to an intensive outpatient program. While there, she experiences increased periods of anxiety related to ruminative thoughts about relationship, occupational, and living stressors. She requests a medication for breakthrough anxiety and recognizes that, because of her history, a benzodiazepine is not medically indicated.

Ms. L signs a consent to a physician-sponsored trial of a PanX medication consisting of orally disintegrating tablets of atenolol, 25 mg, plus scopolamine hydrobromide, 0.2 mg, (in a polyglycol troche base plus mannitol, silica gel, and Steviol glycosides), which is prepared by a compounding pharmacy. Over 6 days, she takes the PanX combination 3 times. Immediately before she takes the medication, her symptoms are intense anxiety, nervousness, and agitation; feelings of panic; increased heart rate and palpitations; and shortness of breath. Ms. L says these symptoms developed approximately 20 minutes before she took the PanX combination. Approximately 30 minutes after taking the medication, she describes having a complete resolution of these symptoms that lasted for 4 hours. She says the medication “calmed [her] down” and had a “Klonopin or benzo-like effect.” She notes that her heart rate slowed quickly, followed by her breathing, and that she also was “more focused.” No information regarding her heart rate or blood pressure when she experienced the symptoms or after treatment is available. She denies experiencing dry mouth, dizziness, fatigue, sleepiness, blurred vision, or confusion.

Targets for future research

This case provides some preliminary clinical evidence of a rapid anxiolytic effect from a novel medication—a beta blocker plus scopolamine combination—that was beneficial in a situation where it may be likely that a benzodiazepine would have been utilized. This is our first case report documenting a trial of any PanX combination (ie, a combination of any beta blocker with any antimuscarinic agent) regarding anxiolytic efficacy and timing, tolerability, and adverse effects. With recognition that this is a report of 1 patient who took the medication 3 times, there is much that is not known.

Additional clinical studies are needed to evaluate the efficacy, tolerability, and adverse effects associated with using a beta blocker/antiemetic antimuscarinic combination to treat acute anxiety. Medication interactions also need to be considered. Whether this combination medication would be best for treating breakthrough anxiety or other acute anxiety episodes, and/or used as a regularly dosed medication is unknown. With documented risks of long-term benzodiazepine use, other novel therapeutics, such as the atenolol/scopolamine combination, may be welcome in treating acute anxiety.

Treating short-term or situational anxiety or anxiety attacks with benzodiazepines carries the risk of withdrawal and dependence. Other options include various antidepressants and buspirone. Although such medications decrease overall anxiety and can prevent anxiety from building, they are not effective for breakthrough anxiety. Other mainstays are antihistamines, antipsychotics, or newer antiepileptics such as gabapentin and pregabalin, but none of these have strong clinical literature support regarding their effectiveness for treating anxiety disorders.

PanX compounded medications are dual drug combinations of a beta blocker plus an antiemetic antimuscarinic agent.¹ They are designed and patented for as-needed treatment of anxiety disorders without using any controlled substances. Compounded medications are not FDA-approved, but are commercially available and subject to Section 503A of the Federal Food, Drug, and Cosmetics Act of 2013.²

In PanX medications, the beta blocker is intended to address the sympathetic cardiovascular symptoms of anxiety. Beta adrenergic receptor antagonists have been prescribed off-label for decades to treat social anxiety disorder, including performance anxiety. At least 7 beta blockers—atenolol, propranolol, pindolol, timolol, nadolol, betaxolol, and oxprenolol—have been reported to have anxiolytic effects, although these are limited to cardiovascular symptoms of anxiety.¹

However, there is a need to augment the limited effects of the beta blocker with another agent, such as an antimuscarinic agent, which is intended for parasympathetic noncardiovascular and CNS symptoms of anxiety. Scopolamine is a preferred antimuscarinic because it has been known for over a century to exhibit anxiolytic effects.³ Scopolamine’s mechanism of action is antagonism of acetylcholine binding to the M1 and/or M2 muscarinic receptors.⁴

We present a case of a patient who needed a nonbenzodiazepine treatment for acute anxiety. She received a compounded PanX combination of the beta-1 selective beta blocker atenolol, 25 mg, plus scopolamine hydrobromide, 0.2 mg, as needed for acute anxiety.

Case report

Acute anxiety, benzodiazepine abuse

Ms. L, age 30, with a family history of depression and anxiety, has had anxiety, depression, and posttraumatic stress disorder since she was in her mid-20s. She is evaluated in a 30-day rehabilitation program for alprazolam abuse. She is detoxed from alprazolam and stabilized with lurasidone, 60 mg once in the morning, gabapentin, 1,200 mg 4 times a day, and quetiapine, 125 mg as needed for sleep.

Ms. L improves significantly and is transferred to an intensive outpatient program. While there, she experiences increased periods of anxiety related to ruminative thoughts about relationship, occupational, and living stressors. She requests a medication for breakthrough anxiety and recognizes that, because of her history, a benzodiazepine is not medically indicated.

Ms. L signs a consent to a physician-sponsored trial of a PanX medication consisting of orally disintegrating tablets of atenolol, 25 mg, plus scopolamine hydrobromide, 0.2 mg, (in a polyglycol troche base plus mannitol, silica gel, and Steviol glycosides), which is prepared by a compounding pharmacy. Over 6 days, she takes the PanX combination 3 times. Immediately before she takes the medication, her symptoms are intense anxiety, nervousness, and agitation; feelings of panic; increased heart rate and palpitations; and shortness of breath. Ms. L says these symptoms developed approximately 20 minutes before she took the PanX combination. Approximately 30 minutes after taking the medication, she describes having a complete resolution of these symptoms that lasted for 4 hours. She says the medication “calmed [her] down” and had a “Klonopin or benzo-like effect.” She notes that her heart rate slowed quickly, followed by her breathing, and that she also was “more focused.” No information regarding her heart rate or blood pressure when she experienced the symptoms or after treatment is available. She denies experiencing dry mouth, dizziness, fatigue, sleepiness, blurred vision, or confusion.

Targets for future research

This case provides some preliminary clinical evidence of a rapid anxiolytic effect from a novel medication—a beta blocker plus scopolamine combination—that was beneficial in a situation where it may be likely that a benzodiazepine would have been utilized. This is our first case report documenting a trial of any PanX combination (ie, a combination of any beta blocker with any antimuscarinic agent) regarding anxiolytic efficacy and timing, tolerability, and adverse effects. With recognition that this is a report of 1 patient who took the medication 3 times, there is much that is not known.

Additional clinical studies are needed to evaluate the efficacy, tolerability, and adverse effects associated with using a beta blocker/antiemetic antimuscarinic combination to treat acute anxiety. Medication interactions also need to be considered. Whether this combination medication would be best for treating breakthrough anxiety or other acute anxiety episodes, and/or used as a regularly dosed medication is unknown. With documented risks of long-term benzodiazepine use, other novel therapeutics, such as the atenolol/scopolamine combination, may be welcome in treating acute anxiety.

Treating short-term or situational anxiety or anxiety attacks with benzodiazepines carries the risk of withdrawal and dependence. Other options include various antidepressants and buspirone. Although such medications decrease overall anxiety and can prevent anxiety from building, they are not effective for breakthrough anxiety. Other mainstays are antihistamines, antipsychotics, or newer antiepileptics such as gabapentin and pregabalin, but none of these have strong clinical literature support regarding their effectiveness for treating anxiety disorders.

PanX compounded medications are dual drug combinations of a beta blocker plus an antiemetic antimuscarinic agent.¹ They are designed and patented for as-needed treatment of anxiety disorders without using any controlled substances. Compounded medications are not FDA-approved, but are commercially available and subject to Section 503A of the Federal Food, Drug, and Cosmetics Act of 2013.²

In PanX medications, the beta blocker is intended to address the sympathetic cardiovascular symptoms of anxiety. Beta adrenergic receptor antagonists have been prescribed off-label for decades to treat social anxiety disorder, including performance anxiety. At least 7 beta blockers—atenolol, propranolol, pindolol, timolol, nadolol, betaxolol, and oxprenolol—have been reported to have anxiolytic effects, although these are limited to cardiovascular symptoms of anxiety.¹

However, there is a need to augment the limited effects of the beta blocker with another agent, such as an antimuscarinic agent, which is intended for parasympathetic noncardiovascular and CNS symptoms of anxiety. Scopolamine is a preferred antimuscarinic because it has been known for over a century to exhibit anxiolytic effects.³ Scopolamine’s mechanism of action is antagonism of acetylcholine binding to the M1 and/or M2 muscarinic receptors.⁴

We present a case of a patient who needed a nonbenzodiazepine treatment for acute anxiety. She received a compounded PanX combination of the beta-1 selective beta blocker atenolol, 25 mg, plus scopolamine hydrobromide, 0.2 mg, as needed for acute anxiety.

Case report

Acute anxiety, benzodiazepine abuse

Ms. L, age 30, with a family history of depression and anxiety, has had anxiety, depression, and posttraumatic stress disorder since she was in her mid-20s. She is evaluated in a 30-day rehabilitation program for alprazolam abuse. She is detoxed from alprazolam and stabilized with lurasidone, 60 mg once in the morning, gabapentin, 1,200 mg 4 times a day, and quetiapine, 125 mg as needed for sleep.

Ms. L improves significantly and is transferred to an intensive outpatient program. While there, she experiences increased periods of anxiety related to ruminative thoughts about relationship, occupational, and living stressors. She requests a medication for breakthrough anxiety and recognizes that, because of her history, a benzodiazepine is not medically indicated.

Ms. L signs a consent to a physician-sponsored trial of a PanX medication consisting of orally disintegrating tablets of atenolol, 25 mg, plus scopolamine hydrobromide, 0.2 mg, (in a polyglycol troche base plus mannitol, silica gel, and Steviol glycosides), which is prepared by a compounding pharmacy. Over 6 days, she takes the PanX combination 3 times. Immediately before she takes the medication, her symptoms are intense anxiety, nervousness, and agitation; feelings of panic; increased heart rate and palpitations; and shortness of breath. Ms. L says these symptoms developed approximately 20 minutes before she took the PanX combination. Approximately 30 minutes after taking the medication, she describes having a complete resolution of these symptoms that lasted for 4 hours. She says the medication “calmed [her] down” and had a “Klonopin or benzo-like effect.” She notes that her heart rate slowed quickly, followed by her breathing, and that she also was “more focused.” No information regarding her heart rate or blood pressure when she experienced the symptoms or after treatment is available. She denies experiencing dry mouth, dizziness, fatigue, sleepiness, blurred vision, or confusion.

Targets for future research

This case provides some preliminary clinical evidence of a rapid anxiolytic effect from a novel medication—a beta blocker plus scopolamine combination—that was beneficial in a situation where it may be likely that a benzodiazepine would have been utilized. This is our first case report documenting a trial of any PanX combination (ie, a combination of any beta blocker with any antimuscarinic agent) regarding anxiolytic efficacy and timing, tolerability, and adverse effects. With recognition that this is a report of 1 patient who took the medication 3 times, there is much that is not known.

Additional clinical studies are needed to evaluate the efficacy, tolerability, and adverse effects associated with using a beta blocker/antiemetic antimuscarinic combination to treat acute anxiety. Medication interactions also need to be considered. Whether this combination medication would be best for treating breakthrough anxiety or other acute anxiety episodes, and/or used as a regularly dosed medication is unknown. With documented risks of long-term benzodiazepine use, other novel therapeutics, such as the atenolol/scopolamine combination, may be welcome in treating acute anxiety.

Although the biological aspects of psychiatry are crucial, psychotherapy is an integral part of psychiatry. Unfortunately, the emphasis on psychotherapy training in psychiatry residency programs has declined compared with a decade or more ago. In an era of dwindling psychotherapy training and resources, the quality and type of psychotherapy training has become more variable. In addition to helping maintain the therapeutic alliance, nuanced psychotherapy by a trained professional can be transformational by helping patients to:

• process complex life events and emotions
• feel understood
• overcome psychological barriers to recovery
• enhance self-esteem.

For the therapist, effective psychotherapy usually involves warmth and empathy, active listening, an authentic and genuine positive regard for the patient and his (her) experiences. The therapist should also pay attention to her (his) own emotions and internal responses, as well as the patient’s, while having the perseverance to address and help the patient work through challenging aspects.

When providing psychotherapy for adult patients, consider these basic, but salient points that are often overlooked.

Refrain from making life decisions for patients, except in exceptional circumstances, such as in situations of abuse and other crises.¹ Telling an adult patient what to do about life decisions that he finds challenging fits more under life coaching than psychotherapy. Through therapy, patients should be helped in processing the pros and cons of certain decisions and in navigating the decision-making process to arrive at a decision that makes the most sense to them. Also, it’s not uncommon for thera­peutic relationships to rupture when therapists give advice such as suggesting that a patient divorce his spouse, date a certain individual, or have children.

There are many reasons why giving advice in psychotherapy is not recommended. Giving advice can be an impediment to the therapeutic process.² What is good advice for one patient may not be good for another. Therapists who give advice often do so from their own lens and perspective. This perspective may not only be different from the patient’s priorities and life circumstances, but the therapist also may have inadequate information about the patient’s situation,^1,2 which could lead to providing advice that could even harm the patient. In addition, providing advice might prevent a patient from gaining adequate agency or self-directedness while promoting an unhealthy dependence on the therapist and reinforcing the patient’s self-doubt or lack of confidence. In these cases, the patient may later resent the therapist for the advice.

Address the ‘here and now.’¹ Pay attention to immediate issues or themes that emerge, and address them with the patient gently and thoughtfully, as appropriate. Ignoring these may create risks of missing vital, underlying material that could reveal more of the patient’s inner world, as these themes can sometimes reflect other themes of the patient’s life outside of treatment.

Acknowledging and empathizing, when appropriate, are key initial steps that help decrease resistance and facilitate the therapeutic process.

Explore the affect. Paying attention to the patient’s emotional state is critical.³ This holds true for all types of psychotherapy. For example, if a patient suddenly becomes tearful when telling his story or describing recent events, this is usually a sign that the subject matter affects or holds value to the patient in a significant or meaningful way and should be further explored.

‘Meet the patient where they are.’ This doesn’t mean you should yield to the patient or give in to his demands. It implies that you should assess the patient’s readiness for a particular intervention and devise interventions from that standpoint, exploring the patient’s ambivalence, noticing resistance, and continuing to acknowledge and empathize with where the patient is in life or treatment. When utilized judiciously, this technique can help the therapist align with the patient, and help the patient move forward through resistance and ambivalence.

Be nonjudgmental and empathetic. Patients place trust in their therapists when they disclose thoughts or emotions that are sensitive, meaningful, or close to the heart. A nonjudgmental response helps the patient accept his experiences and emotions. Being empathetic requires putting oneself in another’s shoes; it does not mean agreeing with the patient. Of course, if you learn that your patient abused a child or an older adult, you are required to report it to the appropriate state agency. In addition, follow the duty to warn and protect in case of any other safety issues, as appropriate.

Do not assume. Open-ended questions and exploration are key. For example, a patient told her resident therapist that her father recently passed away. The therapist expressed to the patient how hard this must be for her. However, the patient said she was relieved by her father’s death, because he had been abusive to her for years. Because of the therapist’s comment, the patient doubted her own reaction and felt guilty for not being more upset about her father’s death.

Avoid over-identifying with your patient. If you find yourself over-identifying with a patient because you have a common background or life events, seek supervision. Over-identification not only can pose barriers to objectively identifying patterns and trends in the patient’s behavior or presentation but also can increase the risk of crossing boundaries or even minimizing the patient’s experience. Exercise caution if you find yourself wanting to be liked by your patient; this is a common mistake among beginning therapists.⁴

Seek supervision. If you are feeling angry, frustrated, indifferent, or overly attached toward a patient, recognize this countertransference and seek consultation or supervision from an experienced colleague or supervisor. These emotions can be valuable tools that shed light not only on the patient’s life and the session itself, but also help you identify any other factors, such as your own feelings or experiences, that might be contributing to these reactions.

Although the biological aspects of psychiatry are crucial, psychotherapy is an integral part of psychiatry. Unfortunately, the emphasis on psychotherapy training in psychiatry residency programs has declined compared with a decade or more ago. In an era of dwindling psychotherapy training and resources, the quality and type of psychotherapy training has become more variable. In addition to helping maintain the therapeutic alliance, nuanced psychotherapy by a trained professional can be transformational by helping patients to:

• process complex life events and emotions
• feel understood
• overcome psychological barriers to recovery
• enhance self-esteem.

For the therapist, effective psychotherapy usually involves warmth and empathy, active listening, an authentic and genuine positive regard for the patient and his (her) experiences. The therapist should also pay attention to her (his) own emotions and internal responses, as well as the patient’s, while having the perseverance to address and help the patient work through challenging aspects.

When providing psychotherapy for adult patients, consider these basic, but salient points that are often overlooked.

Refrain from making life decisions for patients, except in exceptional circumstances, such as in situations of abuse and other crises.¹ Telling an adult patient what to do about life decisions that he finds challenging fits more under life coaching than psychotherapy. Through therapy, patients should be helped in processing the pros and cons of certain decisions and in navigating the decision-making process to arrive at a decision that makes the most sense to them. Also, it’s not uncommon for thera­peutic relationships to rupture when therapists give advice such as suggesting that a patient divorce his spouse, date a certain individual, or have children.

There are many reasons why giving advice in psychotherapy is not recommended. Giving advice can be an impediment to the therapeutic process.² What is good advice for one patient may not be good for another. Therapists who give advice often do so from their own lens and perspective. This perspective may not only be different from the patient’s priorities and life circumstances, but the therapist also may have inadequate information about the patient’s situation,^1,2 which could lead to providing advice that could even harm the patient. In addition, providing advice might prevent a patient from gaining adequate agency or self-directedness while promoting an unhealthy dependence on the therapist and reinforcing the patient’s self-doubt or lack of confidence. In these cases, the patient may later resent the therapist for the advice.

Address the ‘here and now.’¹ Pay attention to immediate issues or themes that emerge, and address them with the patient gently and thoughtfully, as appropriate. Ignoring these may create risks of missing vital, underlying material that could reveal more of the patient’s inner world, as these themes can sometimes reflect other themes of the patient’s life outside of treatment.

Acknowledging and empathizing, when appropriate, are key initial steps that help decrease resistance and facilitate the therapeutic process.

Explore the affect. Paying attention to the patient’s emotional state is critical.³ This holds true for all types of psychotherapy. For example, if a patient suddenly becomes tearful when telling his story or describing recent events, this is usually a sign that the subject matter affects or holds value to the patient in a significant or meaningful way and should be further explored.

‘Meet the patient where they are.’ This doesn’t mean you should yield to the patient or give in to his demands. It implies that you should assess the patient’s readiness for a particular intervention and devise interventions from that standpoint, exploring the patient’s ambivalence, noticing resistance, and continuing to acknowledge and empathize with where the patient is in life or treatment. When utilized judiciously, this technique can help the therapist align with the patient, and help the patient move forward through resistance and ambivalence.

Be nonjudgmental and empathetic. Patients place trust in their therapists when they disclose thoughts or emotions that are sensitive, meaningful, or close to the heart. A nonjudgmental response helps the patient accept his experiences and emotions. Being empathetic requires putting oneself in another’s shoes; it does not mean agreeing with the patient. Of course, if you learn that your patient abused a child or an older adult, you are required to report it to the appropriate state agency. In addition, follow the duty to warn and protect in case of any other safety issues, as appropriate.

Do not assume. Open-ended questions and exploration are key. For example, a patient told her resident therapist that her father recently passed away. The therapist expressed to the patient how hard this must be for her. However, the patient said she was relieved by her father’s death, because he had been abusive to her for years. Because of the therapist’s comment, the patient doubted her own reaction and felt guilty for not being more upset about her father’s death.

Avoid over-identifying with your patient. If you find yourself over-identifying with a patient because you have a common background or life events, seek supervision. Over-identification not only can pose barriers to objectively identifying patterns and trends in the patient’s behavior or presentation but also can increase the risk of crossing boundaries or even minimizing the patient’s experience. Exercise caution if you find yourself wanting to be liked by your patient; this is a common mistake among beginning therapists.⁴

Seek supervision. If you are feeling angry, frustrated, indifferent, or overly attached toward a patient, recognize this countertransference and seek consultation or supervision from an experienced colleague or supervisor. These emotions can be valuable tools that shed light not only on the patient’s life and the session itself, but also help you identify any other factors, such as your own feelings or experiences, that might be contributing to these reactions.

Although the biological aspects of psychiatry are crucial, psychotherapy is an integral part of psychiatry. Unfortunately, the emphasis on psychotherapy training in psychiatry residency programs has declined compared with a decade or more ago. In an era of dwindling psychotherapy training and resources, the quality and type of psychotherapy training has become more variable. In addition to helping maintain the therapeutic alliance, nuanced psychotherapy by a trained professional can be transformational by helping patients to:

• process complex life events and emotions
• feel understood
• overcome psychological barriers to recovery
• enhance self-esteem.

For the therapist, effective psychotherapy usually involves warmth and empathy, active listening, an authentic and genuine positive regard for the patient and his (her) experiences. The therapist should also pay attention to her (his) own emotions and internal responses, as well as the patient’s, while having the perseverance to address and help the patient work through challenging aspects.

When providing psychotherapy for adult patients, consider these basic, but salient points that are often overlooked.

Refrain from making life decisions for patients, except in exceptional circumstances, such as in situations of abuse and other crises.¹ Telling an adult patient what to do about life decisions that he finds challenging fits more under life coaching than psychotherapy. Through therapy, patients should be helped in processing the pros and cons of certain decisions and in navigating the decision-making process to arrive at a decision that makes the most sense to them. Also, it’s not uncommon for thera­peutic relationships to rupture when therapists give advice such as suggesting that a patient divorce his spouse, date a certain individual, or have children.

There are many reasons why giving advice in psychotherapy is not recommended. Giving advice can be an impediment to the therapeutic process.² What is good advice for one patient may not be good for another. Therapists who give advice often do so from their own lens and perspective. This perspective may not only be different from the patient’s priorities and life circumstances, but the therapist also may have inadequate information about the patient’s situation,^1,2 which could lead to providing advice that could even harm the patient. In addition, providing advice might prevent a patient from gaining adequate agency or self-directedness while promoting an unhealthy dependence on the therapist and reinforcing the patient’s self-doubt or lack of confidence. In these cases, the patient may later resent the therapist for the advice.

Address the ‘here and now.’¹ Pay attention to immediate issues or themes that emerge, and address them with the patient gently and thoughtfully, as appropriate. Ignoring these may create risks of missing vital, underlying material that could reveal more of the patient’s inner world, as these themes can sometimes reflect other themes of the patient’s life outside of treatment.

Acknowledging and empathizing, when appropriate, are key initial steps that help decrease resistance and facilitate the therapeutic process.

Explore the affect. Paying attention to the patient’s emotional state is critical.³ This holds true for all types of psychotherapy. For example, if a patient suddenly becomes tearful when telling his story or describing recent events, this is usually a sign that the subject matter affects or holds value to the patient in a significant or meaningful way and should be further explored.

‘Meet the patient where they are.’ This doesn’t mean you should yield to the patient or give in to his demands. It implies that you should assess the patient’s readiness for a particular intervention and devise interventions from that standpoint, exploring the patient’s ambivalence, noticing resistance, and continuing to acknowledge and empathize with where the patient is in life or treatment. When utilized judiciously, this technique can help the therapist align with the patient, and help the patient move forward through resistance and ambivalence.

Be nonjudgmental and empathetic. Patients place trust in their therapists when they disclose thoughts or emotions that are sensitive, meaningful, or close to the heart. A nonjudgmental response helps the patient accept his experiences and emotions. Being empathetic requires putting oneself in another’s shoes; it does not mean agreeing with the patient. Of course, if you learn that your patient abused a child or an older adult, you are required to report it to the appropriate state agency. In addition, follow the duty to warn and protect in case of any other safety issues, as appropriate.

Do not assume. Open-ended questions and exploration are key. For example, a patient told her resident therapist that her father recently passed away. The therapist expressed to the patient how hard this must be for her. However, the patient said she was relieved by her father’s death, because he had been abusive to her for years. Because of the therapist’s comment, the patient doubted her own reaction and felt guilty for not being more upset about her father’s death.

Avoid over-identifying with your patient. If you find yourself over-identifying with a patient because you have a common background or life events, seek supervision. Over-identification not only can pose barriers to objectively identifying patterns and trends in the patient’s behavior or presentation but also can increase the risk of crossing boundaries or even minimizing the patient’s experience. Exercise caution if you find yourself wanting to be liked by your patient; this is a common mistake among beginning therapists.⁴

Seek supervision. If you are feeling angry, frustrated, indifferent, or overly attached toward a patient, recognize this countertransference and seek consultation or supervision from an experienced colleague or supervisor. These emotions can be valuable tools that shed light not only on the patient’s life and the session itself, but also help you identify any other factors, such as your own feelings or experiences, that might be contributing to these reactions.

Despite a lack of evidence, polypharmacy often is used to treat autism spectrum disorder (ASD),¹ while educational techniques are underutilized. Compared with the general population, children with ASD may be more prone to the adverse effects of the medications used to treat symptoms, such as antipsychotics and antidepressants.² Therefore, when addressing problem behaviors, such as tantrums, aggressiveness, or self-injury, in a patient with ASD, before prescribing a medication, consider the ABCs of these behaviors.³

Antecedents. What happened before the behavior occurred? Where and when did the behavior occur? Was the individual unable to get a desired tangible item, such as a preferred food, toy, or another object? Was the individual told complete a task that he (she) did not want to do? Did the individual see someone else getting attention?

Behaviors. What behavior(s) occurred after each antecedent?

Consequences. What happened after the behavior occurred? Did the caregiver give the individual the item he wanted? Was the individual able to get out of doing work that he did not want to do or become the center of attention?

Having parents document the ABCs is useful not only for finding out why a behavior occurred, but also for objectively determining if and how a medication is affecting the frequency of a behavior. Charts that parents can use to document ABC data are available online (eg, http://www.positively­autism.com/downloads/datasheet_abc.pdf). Once this data is collected, it can be used to implement appropriate interventions, which I describe as DEFG.

Differential reinforcement of other behaviors is a procedure that provides positive reinforcement for not engaging in a problem behavior or for staying on task. For example, use a token board to reward positive behaviors, with physical tokens or written marks. However, some patients require immediate reinforcement. I suggest that parents or caregivers carry small pieces of preferred food to give to the patient to reinforce positive behavior.

Exercise. A review of 18 studies reported that physical exercise, such as jogging, weight training, and bike riding, can help reduce problem behaviors in individuals with ASD.⁴ Among 64 participants with ASD, there was a decrease in aggression, stereotypy, off-task behavior, and elopement, and improvements in on-task and motor behavior such as playing catch.

Function. Refer to the ABCs to determine why a specific problem behavior is occurring. Each behavior can have 1 or multiple functions; therefore, develop a plan specific to the reason the patient engages in the behavior. For example, if the individual engages in a behavior to avoid a task, the parent or caregiver can give individual tokens that the individual can later exchange for a break, instead of engaging in the problem behavior to avoid the task. If a behavior appears to be done for attention, instruct the caregivers to provide frequent periods of attention when the individual engages in positive behaviors.

Go to the appropriate placement. By law, persons age ≤21 have the right to an education and to make meaningful progress. If a patient with ASD exhibits behaviors that interfere with learning, he is entitled to a placement that can provide intensive applied behavior analysis. If you feel that the child needs a different school, write an evaluation for the parent or guardian to submit to the school district and clearly outline the patient’s needs and requirements.

Despite a lack of evidence, polypharmacy often is used to treat autism spectrum disorder (ASD),¹ while educational techniques are underutilized. Compared with the general population, children with ASD may be more prone to the adverse effects of the medications used to treat symptoms, such as antipsychotics and antidepressants.² Therefore, when addressing problem behaviors, such as tantrums, aggressiveness, or self-injury, in a patient with ASD, before prescribing a medication, consider the ABCs of these behaviors.³

Antecedents. What happened before the behavior occurred? Where and when did the behavior occur? Was the individual unable to get a desired tangible item, such as a preferred food, toy, or another object? Was the individual told complete a task that he (she) did not want to do? Did the individual see someone else getting attention?

Behaviors. What behavior(s) occurred after each antecedent?

Consequences. What happened after the behavior occurred? Did the caregiver give the individual the item he wanted? Was the individual able to get out of doing work that he did not want to do or become the center of attention?

Having parents document the ABCs is useful not only for finding out why a behavior occurred, but also for objectively determining if and how a medication is affecting the frequency of a behavior. Charts that parents can use to document ABC data are available online (eg, http://www.positively­autism.com/downloads/datasheet_abc.pdf). Once this data is collected, it can be used to implement appropriate interventions, which I describe as DEFG.

Differential reinforcement of other behaviors is a procedure that provides positive reinforcement for not engaging in a problem behavior or for staying on task. For example, use a token board to reward positive behaviors, with physical tokens or written marks. However, some patients require immediate reinforcement. I suggest that parents or caregivers carry small pieces of preferred food to give to the patient to reinforce positive behavior.

Exercise. A review of 18 studies reported that physical exercise, such as jogging, weight training, and bike riding, can help reduce problem behaviors in individuals with ASD.⁴ Among 64 participants with ASD, there was a decrease in aggression, stereotypy, off-task behavior, and elopement, and improvements in on-task and motor behavior such as playing catch.

Function. Refer to the ABCs to determine why a specific problem behavior is occurring. Each behavior can have 1 or multiple functions; therefore, develop a plan specific to the reason the patient engages in the behavior. For example, if the individual engages in a behavior to avoid a task, the parent or caregiver can give individual tokens that the individual can later exchange for a break, instead of engaging in the problem behavior to avoid the task. If a behavior appears to be done for attention, instruct the caregivers to provide frequent periods of attention when the individual engages in positive behaviors.

Go to the appropriate placement. By law, persons age ≤21 have the right to an education and to make meaningful progress. If a patient with ASD exhibits behaviors that interfere with learning, he is entitled to a placement that can provide intensive applied behavior analysis. If you feel that the child needs a different school, write an evaluation for the parent or guardian to submit to the school district and clearly outline the patient’s needs and requirements.

Despite a lack of evidence, polypharmacy often is used to treat autism spectrum disorder (ASD),¹ while educational techniques are underutilized. Compared with the general population, children with ASD may be more prone to the adverse effects of the medications used to treat symptoms, such as antipsychotics and antidepressants.² Therefore, when addressing problem behaviors, such as tantrums, aggressiveness, or self-injury, in a patient with ASD, before prescribing a medication, consider the ABCs of these behaviors.³

Antecedents. What happened before the behavior occurred? Where and when did the behavior occur? Was the individual unable to get a desired tangible item, such as a preferred food, toy, or another object? Was the individual told complete a task that he (she) did not want to do? Did the individual see someone else getting attention?

Behaviors. What behavior(s) occurred after each antecedent?

Consequences. What happened after the behavior occurred? Did the caregiver give the individual the item he wanted? Was the individual able to get out of doing work that he did not want to do or become the center of attention?

Having parents document the ABCs is useful not only for finding out why a behavior occurred, but also for objectively determining if and how a medication is affecting the frequency of a behavior. Charts that parents can use to document ABC data are available online (eg, http://www.positively­autism.com/downloads/datasheet_abc.pdf). Once this data is collected, it can be used to implement appropriate interventions, which I describe as DEFG.

Differential reinforcement of other behaviors is a procedure that provides positive reinforcement for not engaging in a problem behavior or for staying on task. For example, use a token board to reward positive behaviors, with physical tokens or written marks. However, some patients require immediate reinforcement. I suggest that parents or caregivers carry small pieces of preferred food to give to the patient to reinforce positive behavior.

Exercise. A review of 18 studies reported that physical exercise, such as jogging, weight training, and bike riding, can help reduce problem behaviors in individuals with ASD.⁴ Among 64 participants with ASD, there was a decrease in aggression, stereotypy, off-task behavior, and elopement, and improvements in on-task and motor behavior such as playing catch.

Function. Refer to the ABCs to determine why a specific problem behavior is occurring. Each behavior can have 1 or multiple functions; therefore, develop a plan specific to the reason the patient engages in the behavior. For example, if the individual engages in a behavior to avoid a task, the parent or caregiver can give individual tokens that the individual can later exchange for a break, instead of engaging in the problem behavior to avoid the task. If a behavior appears to be done for attention, instruct the caregivers to provide frequent periods of attention when the individual engages in positive behaviors.

Go to the appropriate placement. By law, persons age ≤21 have the right to an education and to make meaningful progress. If a patient with ASD exhibits behaviors that interfere with learning, he is entitled to a placement that can provide intensive applied behavior analysis. If you feel that the child needs a different school, write an evaluation for the parent or guardian to submit to the school district and clearly outline the patient’s needs and requirements.