Psychiatry · Year 2 · from Psychiatry
Case 2: Generalized Anxiety Disorder
Patient Presentation
Demographics: 47-year-old male
Chief Complaint: "I can't stop worrying. My mind never shuts off."
History of Present Illness: A 47-year-old small business owner presents with a chief complaint of constant worry that has worsened over the past year. He worries about multiple domains: his business finances (even though the business is profitable), his children's safety and futures (even though they are healthy and doing well), his health (despite normal checkups), and mundane daily matters like whether he locked the door or turned off the stove. He describes his worry as constant, shifting from topic to topic throughout the day. He experiences significant muscle tension, particularly in his shoulders and jaw (he grinds his teeth at night). He has difficulty concentrating at work because his mind is "always somewhere else worrying." He feels restless and on edge, snapping at his family. His sleep is poor - he lies awake ruminating. He reports fatigue despite sleeping 6-7 hours. He has used alcohol (2-3 drinks nightly) to "take the edge off" for the past 6 months, which provides temporary relief but worsens his anxiety the next morning.
Physical Examination:
- Vital signs: BP 134/88, HR 82
- General: Tense, fidgeting with hands
- MSK: Significant tension in trapezius muscles bilaterally
- Dental: Evidence of bruxism with tooth wear
Mental Status Examination:
- Appearance: Well-groomed, appears tense
- Behavior: Restless, frequently shifting position
- Speech: Rapid but organized
- Mood: "Worried, tense"
- Affect: Anxious, moderately constricted
- Thought process: Linear but ruminative
- Thought content: Multiple worry domains without obsessions
Workup:
- GAD-7: Score 17 (severe anxiety)
- PHQ-9: Score 9 (mild depression, likely secondary to anxiety)
- AUDIT: Score 12 (hazardous drinking)
- TSH: 1.8 mIU/L (normal)
- CMP: Normal
Diagnosis: Generalized Anxiety Disorder; Alcohol Use Disorder, mild
Treatment:
- Psychoeducation about GAD and the worry-anxiety cycle
- Discussed relationship between alcohol use and anxiety (short-term relief, long-term worsening)
- Started duloxetine 30 mg daily, increased to 60 mg after 1 week (chosen for comorbid muscle tension and pain)
- Night guard prescribed for bruxism
- Referral for CBT targeting:
- Worry exposure and tolerance of uncertainty
- Cognitive restructuring of probability overestimation
- Progressive muscle relaxation
- Brief intervention for alcohol use with goal of reduction/cessation
- Sleep hygiene education
- At 6-week follow-up: GAD-7 improved to 10, alcohol reduced to 2-3 drinks/week
- Added buspirone 10 mg TID for additional anxiolytic effect
- Continued CBT with good engagement
Clinical Pearl: GAD is characterized by excessive, difficult-to-control worry about multiple domains (not a single specific concern) for at least 6 months, with at least 3 associated symptoms (restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance). Alcohol is commonly used to self-medicate anxiety but worsens the condition over time. Duloxetine may be particularly helpful when anxiety is accompanied by significant muscle tension or pain complaints.