Psychiatry · Year 3 · from Psychiatry

Case 1: Generalized Anxiety Disorder

Patient Demographics

  • Age: 34 years old
  • Sex: Female
  • Occupation: Financial analyst

Chief Complaint

"I can't stop worrying about everything. My mind won't turn off."

History of Present Illness

The patient presents to her primary care physician with chronic, persistent anxiety that has worsened over the past year. She describes constant worry about multiple areas of her life, including work performance, finances (despite being financially stable), her children's health and safety, her marriage, and world events. She states she has always been a "worrier" but the worry has become uncontrollable and is affecting her ability to function. She reports difficulty falling asleep due to racing worried thoughts, often lying awake for hours reviewing potential problems. She experiences chronic muscle tension, particularly in her neck and shoulders, leading to frequent headaches. She feels restless and "on edge" throughout the day and has become increasingly irritable, snapping at her husband and children. She has difficulty concentrating at work and has had to re-read reports multiple times. She denies panic attacks, specific phobias, or obsessive-compulsive symptoms. She denies depressed mood but acknowledges feeling exhausted from constant worrying.

Mental Status Examination

Appearance: Well-groomed professional woman, tense posture, fidgeting with hands

Behavior: Restless, frequently shifts position, picks at cuticles, cooperative but anxious

Speech: Normal rate (slightly pressured at times), normal volume, coherent

Mood: "Anxious" and "exhausted"

Affect: Anxious, worried, tense, appropriate

Thought Process: Linear, goal-directed, slightly circumstantial when discussing worries

Thought Content: Preoccupied with multiple worry themes (work, family, health, future), no suicidal or homicidal ideation, no delusions or obsessions

Perceptions: No hallucinations

Cognition: Alert, oriented x4, attention mildly impaired by distractibility related to worry

Insight: Good - recognizes worry is excessive and seeks help

Judgment: Good

Psychiatric Workup

Screening Tools:

  • GAD-7: 18/21 (severe anxiety)
  • Feeling nervous/anxious: 3
  • Unable to stop worrying: 3
  • Worrying too much: 3
  • Trouble relaxing: 3
  • Restlessness: 2
  • Irritability: 2
  • Feeling afraid: 2
  • PHQ-9: 8 (mild depression, likely secondary to anxiety)
  • Penn State Worry Questionnaire: 72 (clinical range)

Laboratory Studies:

  • TSH: 1.8 mIU/L (normal)
  • CBC, CMP: Normal
  • Caffeine intake: 4 cups coffee daily

Diagnosis

Generalized Anxiety Disorder (F41.1)

DSM-5 Criteria:

  • Excessive anxiety and worry occurring more days than not for at least 6 months (present >1 year)
  • About multiple events or activities (work, family, finances, health, world events)
  • Difficulty controlling the worry (present)
  • Three or more of the following (in adults):
  • Restlessness/feeling on edge - present
  • Being easily fatigued - present
  • Difficulty concentrating - present
  • Irritability - present
  • Muscle tension - present
  • Sleep disturbance - present
  • Causes clinically significant distress or functional impairment (present)
  • Not attributable to substance or medical condition
  • Not better explained by another mental disorder

Treatment Plan

Pharmacotherapy:

  • Start sertraline 50 mg daily (SSRI first-line for GAD)
  • Titrate to 100-150 mg as tolerated over 4-6 weeks
  • Discussed 4-6 week onset for full effect
  • Consider buspirone 7.5 mg BID as adjunct if insufficient response

Short-term anxiolytic (if needed):

  • Hydroxyzine 25 mg TID PRN (non-habit forming)
  • Avoid benzodiazepines as first-line given chronic nature of GAD

Psychotherapy:

  • Cognitive Behavioral Therapy (CBT) - first-line for GAD
  • Focus areas:
  • Cognitive restructuring of worry thoughts
  • Worry exposure (scheduled worry time)
  • Relaxation training (progressive muscle relaxation)
  • Mindfulness techniques

Lifestyle Modifications:

  • Reduce caffeine intake (taper to 1-2 cups, then decaf)
  • Regular aerobic exercise (30 min, 5x/week)
  • Sleep hygiene education
  • Limit news/social media consumption

Follow-up:

  • Return in 4 weeks for medication check
  • GAD-7 at each visit for monitoring

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