Ruby Pascal Case Study | Assignment

Running head:CASE STUDY
Ruby Pascal Case Study
Name of the Student
Name of the University
Author Note

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Introduction
The current case study concerns Ruby Pascal, who is a 43 year-old-women presented
in the emergency department for her increasing anxiety. She is currently admitted to the
medical ward for observation, and the registered nurse has identified some critical issues that
must be taken care of. These include her anxiety, her dependency, and probable overuse of
valium and her unhealthy lifestyle involving her food choices, which is flaring her diabetes.
This essay aims to highlight the interventions for those critical issues and the rationale behind
administering those interventions.
Discussion
The first critical issue that Ruby is facing has to do with her anxiety for which she
was brought to the ED and is kept under observation. She already suffers from Generalized
Anxiety Disorder, and thus her interventions should be targeted towards combating that. The
best intervention for GAD is Cognitive Behavioural Therapy (CBT) and Motivational
Interview (MI). CBT has been suggested for Ruby because she is already tensed for her
husband’s chemotherapy, her children, and a variety of topics and has trouble controlling her
anxiety. By CBT, her symptoms can be evaluated, and functional analysis can be suggested.
The functional analysis will determine the circumstances under which her anxiety is triggered
and the factors that influence her to lose control of her situation. This will be followed by
psychoeducation, behavioural, and cognitive therapy, which will be helpful for her to control
her anxiety. This will entail her to come to terms with her thoughts, accept them, and become
habituated (Borza, 2017). This will give her an idea of how to regulate her responses better
and thus face less troubling symptoms. She will be able to carry on with her daily activities
much better and control her anxiety. Motivational Interview is combined with CBT because it
has been seen that the combination of CBT and MI has been much more successful in GAD

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patients than CBT alone (Westra, Constantino & Antony, 2016). Multiple studies provide
CBT-MI success accounts rather than CBT in acute cases as well (Muir, 2019). MI is usually
employed as a health promotional tool (Lim et al., 2019). MI will help Ruby get more
focused on the goals of her life as she mentioned she is ‘all over the place.’
The second critical issue that she is facing is the overuse of Valium. She has conveyed
that she takes Valium whenever things get bad, and they usually dull her senses and help her
cope with whatever is going on. Even though she conveyed that she understands how much
should be taken, it has been proven that repeated use of valium causes a dependence majority
of the time (Cheng et al., 2018). The use of Valium requires regular monitoring of the patient,
due to ample side effects, which Ruby has not undergone (Dhaliwal & Saadabadi, 2019). It
has also been seen that repeated use of valium may cause the patient to grow tolerance
towards the medication, which results in the medication not working as well as the patient
having severe withdrawal symptoms when not taking the medication. This also includes
patients having a false sense of security with this medication (Tsao, 2018). The patients may
even have worsening anxiety (Accessdata.fda.gov., 2020). The intervention for this is to
switch the medication to a long-acting benzodiazepine and gradually reduce the dose of the
medication as the treatment progresses. This is important because Ruby has taken the drug
for a long time, and it can likely cause withdrawal symptoms if the drug is stopped too fast.
So, she should slowly stop taking it. This sort of maintenance and abstinence also requires
psychological therapy and encouragement for the patient. It has been seen that psychological
intervention accompanied by discontinuation has been proven superior to just gradually
withdrawing the medication alone. This is also important as Ruby may be apprehensive about
not taking her medication in fear of being helpless or not being able to control her anxiety.
For this, she requires therapy, which will enable her to address her problems psychologically.

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This will enable her to seriously consider giving up valium and believe that she can manage
to be stable without it (Brett & Murnion, 2015).
The final critical issue that Ruby is facing is her unhealthy lifestyle, her irregular
eating habits, and not taking care of herself. Her BMI is already above 35, which is way
higher than the average, and she is obese. She already has Diabetes Type II, which is ill-
managed. She already has medication prescribed for her diabetes. Her only problem is her
being unable to lead a proper routine in daily life. She eats cheap street food, and she rarely
exercises. She also gets stressed very often. The major intervention here must be holistic in
nature based on education and support, rather than medications. Ruby must be taught to
monitor her own blood glucose level and educated about the harm that is caused due to her
unhealthy lifestyle (Lee et al., 2016). The patient must be given an overview of what to eat,
how to exercise, and what might happen if they do not adhere to it. Here, Ruby already has
the motivation to adhere to the plan because she wants to take care of her husband after he
comes home. She just needs some guidance and support to make the right decisions and come
up with a proper routine. This includes healthier eating habits and a proper exercise routine
(National Institute of Diabetes and Digestive and Kidney Diseases., 2020). She must be
encouraged to do follow-ups and check in with the nurses from time to time.
Conclusion
In conclusion, if Ruby adheres to the interventions as planned for her, she will be able
to become healthier and take care of her husband and children like she wants to. For her
Generalized Anxiety Disorder, she has been suggested Cognitive Behavioural Therapy
combined with Motivational Interview, which should help her control her anxiety. For her
Valium dependence, she had been suggested reduction therapy, which should help her as
well. Finally, the nurse has opted to educate her on ways to follow a healthier routine, which

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will help her control her diabetes and BMI. All the interventions will be helpful for Ruby, for
short-term and in the long run.

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Reference
Accessdata.fda.gov. (2020). Retrieved 1 April 2020, from
https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/013263s094lbl.pdf.
Borza L. (2017). Cognitive-behavioral therapy for generalized anxiety. Dialogues in clinical
neuroscience, 19(2), 203–208.
Brett, J., & Murnion, B. (2015). Management of benzodiazepine misuse and
dependence. Australian prescriber, 38(5), 152.
Cheng, T., Wallace, D. M., Ponteri, B., & Tuli, M. (2018). Valium without dependence?
Individual GABAA receptor subtype contribution toward benzodiazepine addiction,
tolerance, and therapeutic effects. Neuropsychiatric disease and treatment, 14, 1351–
1361.
Dhaliwal, J. S., & Saadabadi, A. (2019). Diazepam. In StatPearls [Internet]. StatPearls
Publishing.
Lee, J. Y., Chan, C. K., Chua, S. S., Ng, C. J., Paraidathathu, T., Lee, K. K., & Lee, S. W.
(2016). Intervention for Diabetes with Education, Advancement and Support (IDEAS)
study: protocol for a cluster randomised controlled trial. BMC health services
research, 16(1), 524.
Lim, D., Schoo, A. M., Lawn, S., & Litt, J. (2019). A system approach to embed best practice
motivational interviewing in health care: a wicked problem?. In Asia Pacific Medical
Education Conference (APMEC 2019): Education for Health: Abstracts for Free and
Short Communications, 9-13 January 2019, Singapore (pp. 47-47).
Muir, H. (2019). Integrating Motivational Interviewing with CBT for Generalized Anxiety
Disorder: Direct and Indirect Effects on Interpersonal Outcomes.

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National Institute of Diabetes and Digestive and Kidney Diseases. (2020). Diabetes Diet,
Eating, & Physical Activity | NIDDK. Retrieved 1 April 2020, from
https://www.niddk.nih.gov/health-information/diabetes/overview/diet-eating-
physical-activity.
Tsao, J. (2018). Discouraging Use of Benzodiazepines for Anxiety and Insomnia.
Westra, H. A., Constantino, M. J., & Antony, M. M. (2016). Integrating motivational
interviewing with cognitive-behavioral therapy for severe generalized anxiety
disorder: An allegiance-controlled randomized clinical trial. Journal of Consulting
and Clinical Psychology, 84(9), 768.