Client Description

John is a 35-year-old, college-educated, Caucasian married male with two young children, who is referred by his psychotherapist for evaluation and medication for “severe anxiety.” John resumed psychotherapy after a 6-year hiatus. John’s therapist states that his current symptoms are similar but more severe than in the past, making it difficult for him to gain traction in psychotherapy. John has not wanted to consider medications in the past, but he now states, “I’m open to anything that you think may help. I just want to feel better.”

History of Presenting Symptoms

John states that he and his wife purchased a local business to allow him to leave his technology job which required a long commute. He states that he had been feeling quite well, with only mild occasional anxiety, until about 3 months ago when he experienced a panic attack after an argument with his wife. John states that business-related setbacks and financial stressors are weighing on the couple, and they have been arguing more lately, something that he states is unusual for them. He describes experiencing panic attacks at increasing frequency. Despite resuming psychotherapy over a month ago, his level of distress has increased to the point that he has been having difficulty falling and staying asleep. He lies awake for hours “worrying about money, my mom, my sister, my kids . . . everything.” He finally falls asleep in the early morning hours, an hour or so before he must get up to start his day. Although keeping busy had been helpful in distracting him from his anxious thoughts, he has grown increasingly exhausted. He has used exercise as a coping skill in the past; however, his long workdays, coupled with low energy, have prevented him from resuming a workout routine. His concentration now waxes and wanes, and he recently made a mistake in an important work order. He describes his appetite as poor, often feeling “as though I have a fist in my stomach,” and he has lost close to 10 pounds. He denies feeling overtly sad. He denies having suicidal ideation. He states that he feels guilty “for letting my family down.”

Past Mental Health Issues

John recalls his parents arguing a lot. He recalls feeling highly anxious during his parents’ arguments and worrying about his mother’s safety when dad would become enraged while drinking. He, his sister, and his mother went to family therapy for a brief period after his parents’ divorce. He reports that he has worried about his mom’s well-being since he was a child. Although he did well in school, he chose to attend a local college so that he could “be there” for his mother and sister. He began individual psychotherapy, prompted by experiencing a panic attack after graduating from college, related to “feeling anxious and guilty” for moving away from home. He briefly attended an Adult Children of Alcoholics group but stopped when he felt the group took up too much time. John denies ever having experienced symptoms consistent with a major depressive episode. He states he has never experienced suicidal ideation.

Pertinent Medical History

John has “always been thin” but now weighs 156 lbs, and he is 6’ tall. John’s general health is otherwise good. John does not take any prescription medications. He takes a multivitamin and vitamin D3 supplement.

He does not drink alcohol, use cannabis, or take illicit drugs. He does not use any tobacco products. He has been drinking “a lot more coffee lately to get through my day.”

Family History

John is the oldest in a sib-ship of two. His parents divorced when he and his sister were in elementary school. John’s father has a long history of alcohol abuse and John and his sister have not had much of a relationship with him since the divorce. John’s paternal grandparents both abuse alcohol. John’s mother suffers from panic disorder and has taken “lots of anxiety medications over the years.” John’s mother was adopted, and she does not have information about her biological parents. John’s sister also struggles with anxiety symptoms. Both John and his sister worry about their mother’s use of anxiety medications, which has impacted their willingness to consider medications for their own anxiety issues.

DSM-5 Diagnosis

● Panic Disorder

● John completed a Beck Anxiety Inventory (BAI); score = 52

Risk Formulation

Low. John denies a recent or remote history of suicidal ideation. He does not abuse alcohol or other substances that might contribute to impulsive behaviors. There is no evidence of a thought disorder.

Possible Explanation

John’s family business has recently faced setbacks. His family of origin history is significant for John’s father’s alcohol abuse and his rage when drinking. John recalls being highly anxious during these times, often worrying about his mother’s safety. John’s experience of recent panic attacks began after he and his wife had an argument. He has experienced a sense of responsibility to “be there” for his mom and sister since he was a child and, in fact, he first experienced a panic attack as he planned to move away from home after graduating from college. He now feels guilty for what he perceives as letting his wife and children down.

Strengths

John has completed college. He is in a supportive relationship. He is motivated to once again participate in psychotherapy and has benefitted from this treatment in the past. He is open to considering medication.

Treatment Plan

SRI to address panic symptoms. Short-term medication to address severe insomnia. Ongoing collaboration with client’s psychotherapist to obtain corroborative information and to support psychotherapeutic work.

Stage of Treatment: Acute Orientation

Weeks 1–4

John’s concerns about “anxiety medication” and dependency were addressed. After considering various treatment options, mirtazapine 15 mg was started at bedtime along with fluoxetine 10 mg each morning with a plan to increase to 20 mg after 1 week. Potential risks and benefits of both medications, potential interactions, and the expected time to therapeutic effect were discussed. A release of information was obtained to allow collaboration with his psychotherapist. The impact of caffeine on both sleep and anxiety was discussed, and John agreed to taper off caffeine. He identified resuming exercise as a nonmedication coping skill and committed to exercising on a regular basis. John’s ability to sleep and eat improved quickly with mirtazapine. He tolerated both medications well.

Stage of Treatment: Stabilization

Weeks 5–8

After 6 weeks on fluoxetine 20 mg, John reported a decrease in frequency of panic attacks but anxiety remained high (BAI = 45). Concentration was still impaired, making work difficult. John’s therapist noted that although he was better able to engage in psychotherapy, progress was slow. Fluoxetine was increased to 40 mg. John committed to increase his exercise to 30 minutes, 5 to 7 days/week and reported feeling a reduction in anxiety after doing so.

Stage of Treatment: Maintenance

Summary of Treatment

One month after increasing fluoxetine to 40 mg, John reported he no longer experienced panic attacks and his overall anxiety was much improved (BAI = 12, indicating a low level of anxiety). His concentration had improved, and he was better able to work. John’s weight gradually increased back to his baseline weight and remained stable. He elected to taper off mirtazapine at week 12 and continued to sleep well. John was once again able to make use of psychotherapy,

and he and his therapist addressed how childhood trauma issues continued to impact his adult life. His wife and he have also met with the therapist on several occasions to explore how these issues may be playing out in their marriage.

Two months after increasing fluoxetine to 40 mg (week 16), John reported that he was feeling well. By prioritizing exercise and other self-care measures, he was better able to tolerate work stressors. He continued to explore long-standing cognitive distortions which have led him to thinking he has let people down. Medication treatment going forward was discussed and John elected to remain on escitalopram 20 mg for the time being, with a plan to reevaluate in 6 weeks. If John continues to do well, it may be reasonable to begin to taper off fluoxetine at that time.

                           CASE STUDY DISCUSSION QUESTIONS

1. What open-ended client-centered questions would you want to ask John to complete a thorough assessment?
2. What biological, psychological, social, and structural factors may be playing a positive or negative role in John’s symptoms?
3. As you get to know this client over time he may present with additional symptoms. What differential diagnoses would you continue to monitor for in John and why?