What if the treatment plan had not been successful?

If Jennifer had not seen a reduction in her anxiety, a change to her treatment plan would be necessary. A number of options could be available including referring on to specialist mental health services. Many, but not all, Scottish Stroke MCNs have access to stroke-specialist clinical neuropsychology services and it may be appropriate to refer Jennifer to them or at least to consult with them in more detail over Jennifer’s treatment. Alternatively referring Jennifer to Older Adult Mental Health services that include psychiatrists, psychiatric nurses, clinical psychologists, and mental health OTs would be appropriate.

These professionals would work with Jennifer in more depth looking at factors that maintain and exacerbate her anxiety. Jennifer has already tried to increase her activity using a behavioural approach (i.e., looking to gradually increase her ability to go outside). If this had not been successful then specialist mental health professionals may focus more on her cognitions (e.g., her thoughts) surrounding her concerns about her physical ability, the likelihood of having another fall, and her health beliefs about having another stroke. They are likely to use cognitive behavioural therapy and focus on a here-and-now, problem-solving, goal-orientated approach looking to intervene at some of the stages shown in the diagram below that outlines what might be going on for Jennifer.

A diagram showing the effects of anxiety

Diagram adapted from Powell, T. (2001). The Mental Health Handbook. Oxon: Speechmark Practical Photocopy Resource.

There is some (non Randomised Controlled Trials) evidence that psychological management can have a beneficial impact on fear of falling. Child, L., & Kneebone, I. (2002). Falls, fear of falling and psychological management. British Journal of Therapy and Rehabilitation, 9, 225-231.

Stress and anxiety cycle flowchart:

  1. Stress [leads to 2]
  2. Anxiety [leads to 3, 4, and 5]
  3. Physical symptoms (e.g. sweating, trembling, heart palpitations, dizziness, and muscle tension) [leads to 4]
  4. Mental symptoms (e.g. worrying thoughts: will I ever get better? Will I fall? Am I having another stroke?) [leads to 3 and 5]
  5. Behavioural changes (Avoiding going out, stopping pleasant activities, and avoiding socialising) [leads to 3, 4, and 6]
  6. Loss of confidence (When life becomes restricted due to anxiety, loss of confidence often results.) [leads to 7 and possibly 1]
  7. Feeling demoralised, depressed, and hopeless [leads possibly to 1]

Page last reviewed: 26 Feb 2020