# Clinical Cases: Anxiety Disorders ## Case 1: Panic Disorder with Agoraphobia ### Patient Presentation **Demographics:** 32-year-old female **Chief Complaint:** "I'm having heart attacks, but the doctors say there's nothing wrong with my heart." **History of Present Illness:** A 32-year-old marketing executive presents to the psychiatry clinic after being referred by cardiology following her third emergency department visit in 2 months for "chest pain and heart racing." Each episode was characterized by sudden onset of palpitations, chest tightness, shortness of breath, dizziness, sweating, and an overwhelming sense of impending doom. The first attack occurred 3 months ago while grocery shopping; she became convinced she was having a heart attack and called 911. Extensive cardiac workup including ECG, troponins, echocardiogram, and stress test were all normal. Since the first attack, she has become increasingly fearful of having another one. She now avoids grocery stores, shopping malls, and driving on highways. She will only go to restaurants if seated near the exit. She has called in sick to work multiple times to avoid the commute. She worries constantly about when the next attack will occur and what it means for her health. She denies caffeine, stimulant, or illicit drug use. **Physical Examination:** - Vital signs: BP 118/76, HR 88, RR 16 - General: Anxious-appearing female, fidgeting - Cardiac: Regular rate and rhythm, no murmurs - Pulmonary: Clear to auscultation **Mental Status Examination:** - Appearance: Well-groomed, age-appropriate - Behavior: Restless, frequently checking pulse - Mood: "Anxious, scared" - Affect: Anxious, congruent - Thought content: Preoccupied with health concerns, catastrophic thoughts about panic attacks - Insight: Partial - acknowledges cardiac workup was normal but still fears heart disease **Workup:** - **Panic Disorder Severity Scale:** 18 (severe) - **Mobility Inventory for Agoraphobia:** Significant avoidance across multiple domains - **TSH:** 2.1 mIU/L (normal) - **CBC, CMP:** Within normal limits - **Urine drug screen:** Negative - Review of cardiac workup confirms no pathology **Diagnosis:** Panic Disorder with Agoraphobia **Treatment:** - Psychoeducation about panic attacks as false alarm response - not dangerous - Started sertraline 25 mg daily (low initial dose due to SSRI activation risk in panic disorder), titrated to 100 mg over 4 weeks - Lorazepam 0.5 mg prescribed for rescue use, maximum 2-3 times per week - Referral for cognitive behavioral therapy with focus on: - Cognitive restructuring of catastrophic misinterpretations - Interoceptive exposure to feared physical sensations - In vivo exposure to avoided situations using hierarchy - Practiced interoceptive exposures in session (hyperventilation, spinning) - Developed exposure hierarchy starting with short drives, progressing to mall visits - At 8-week follow-up: panic attacks reduced from 4-5/week to 1-2/week - Agoraphobic avoidance improving with systematic exposure - Lorazepam use minimal; plan to discontinue once CBT complete **Clinical Pearl:** Panic attacks reach peak intensity within minutes and include at least 4 of 13 symptoms. Panic disorder requires recurrent unexpected panic attacks plus persistent concern or behavioral change. The initial worsening of anxiety that can occur with SSRI initiation necessitates starting at low doses and slow titration in panic disorder. Interoceptive exposure - deliberately inducing feared bodily sensations - is a key component of CBT for panic disorder and directly targets the fear of panic symptoms themselves. --- ## 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. --- ## Case 3: Social Anxiety Disorder - Performance Type ### Patient Presentation **Demographics:** 26-year-old male **Chief Complaint:** "I can't give presentations at work. I think I'm going to have to quit my job." **History of Present Illness:** A 26-year-old software engineer presents with severe anxiety specifically related to public speaking and presentations. He was recently promoted and his new role requires monthly presentations to his team of 15 people. During his first required presentation 2 months ago, he experienced severe anxiety with trembling hands (visible to others), quavering voice, blushing, and mental blanking. He reports intense fear that others noticed his anxiety and judged him as incompetent. He has since avoided three scheduled presentations by calling in sick, and he worries constantly about upcoming presentations for weeks in advance. He does not have significant anxiety in other social situations - he is comfortable in one-on-one conversations, can eat in public without difficulty, and has a close group of friends. He has always been a "nervous public speaker" but managed to avoid presentations throughout school and his previous job. **Mental Status Examination:** - Appearance: Well-groomed, appropriate - Behavior: Calm when discussing non-presentation topics, becomes visibly anxious when discussing presentations - Mood: "Anxious about work" - Affect: Anxious when discussing feared situations, otherwise euthymic - Thought content: Fear of negative evaluation specifically related to performance; no broader social fears - Insight: Good - recognizes fear is excessive **Workup:** - **Liebowitz Social Anxiety Scale:** Elevated scores specifically in performance situations; social interaction scores within normal limits - **PHQ-9:** Score 6 (minimal depressive symptoms) **Diagnosis:** Social Anxiety Disorder, performance only specifier **Treatment:** - Discussed that performance-only social anxiety is often amenable to multiple treatment approaches - Propranolol 20-40 mg prescribed for as-needed use 30-60 minutes before presentations (beta-blocker for peripheral manifestations) - Psychoeducation about the anxiety-performance cycle - Referral for CBT with focus on: - Cognitive restructuring (testing predictions about negative evaluation) - Gradual exposure starting with small groups, progressing to larger audiences - Video feedback to correct distorted self-perception - Attention training to focus outward rather than on self-monitoring - Practiced presentation in therapy with video recording - Video review demonstrated anxiety was far less visible than patient perceived - At 4-week follow-up: Successfully completed presentation using propranolol and exposure techniques - Plan to gradually reduce reliance on propranolol as confidence builds through repeated exposures **Clinical Pearl:** The "performance only" specifier applies when social anxiety is restricted to public speaking or performing. This presentation is distinct from generalized social anxiety disorder where fears extend across social interactions. Performance-only social anxiety often responds well to beta-blockers (propranolol, atenolol) for as-needed use, which block the peripheral manifestations of anxiety without cognitive effects. Video feedback is a powerful CBT technique demonstrating that visible signs of anxiety are typically far less noticeable to others than the patient perceives. --- ## Clinical Image ![Anxiety brain activation](case_01_image.jpg) **Image Description:** Functional MRI showing amygdala hyperactivation in anxiety disorders. The amygdala, highlighted in the temporal lobe, shows increased activation in response to threat stimuli in patients with anxiety disorders compared to healthy controls. **Attribution:** Brain imaging demonstrating neural basis of anxiety disorders. Educational use. Image adapted from neuroscience literature on amygdala function in anxiety. **Image Source:** Wikimedia Commons - Search for "amygdala fMRI" or "anxiety brain imaging"