# Clinical Cases: Anxiety Disorders

## 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

---

## Case 2: Panic Disorder with Agoraphobia

### Patient Demographics
- **Age:** 27 years old
- **Sex:** Male
- **Occupation:** Software engineer (now working from home)

### Chief Complaint
"I had another attack at the grocery store. I thought I was dying. I can't leave my apartment anymore."

### History of Present Illness
The patient presents with recurrent episodes of intense fear accompanied by physical symptoms that come on suddenly and peak within minutes. His first episode occurred 6 months ago while driving on the highway. He experienced sudden onset of pounding heart, chest tightness, shortness of breath, sweating, trembling, dizziness, and a sense that he was "going to die." He pulled over and called 911. Emergency workup including ECG and troponins was normal. Since then, he has had approximately 3-4 similar episodes per week. He has become increasingly afraid of having another attack and has begun avoiding situations where attacks have occurred or where escape might be difficult. He now avoids driving (especially highways), grocery stores, movie theaters, airplanes, and crowded restaurants. For the past month, he has rarely left his apartment except for brief walks around his block. He works remotely but is worried about losing his job if required to return to the office. Between attacks, he is constantly worried about when the next one will occur.

### Mental Status Examination

**Appearance:** Young man, casually dressed, appears tired and worried

**Behavior:** Cooperative, restless, hypervigilant about body sensations

**Speech:** Normal rate and volume

**Mood:** "Scared" and "trapped"

**Affect:** Anxious, fearful, constricted

**Thought Process:** Linear, goal-directed, focused on fears

**Thought Content:** Preoccupied with fear of panic attacks and physical sensations, catastrophic thoughts about dying, fear of losing control, no suicidal or homicidal ideation

**Perceptions:** No hallucinations, heightened awareness of bodily sensations (interoceptive sensitivity)

**Cognition:** Alert, oriented x4, attention good

**Insight:** Partial - intellectually knows attacks won't kill him but emotionally convinced he is dying during attacks

**Judgment:** Impaired by avoidance behaviors

### Psychiatric Workup

**Screening Tools:**
- Panic Disorder Severity Scale (PDSS): 18 (severe)
- PHQ-9: 11 (moderate depression, secondary)
- Mobility Inventory for Agoraphobia: Severe avoidance pattern

**Laboratory Studies (prior workup):**
- ECG: Normal sinus rhythm
- Echocardiogram: Normal
- TSH: Normal
- CBC, CMP: Normal
- Holter monitor: No arrhythmias

### Diagnosis

**1. Panic Disorder (F41.0)**

**DSM-5 Criteria:**
- Recurrent unexpected panic attacks (physical symptoms + intense fear)
- At least one attack followed by 1+ month of:
  - Persistent concern about additional attacks - present
  - Worry about implications/consequences (dying, losing control) - present
  - Significant maladaptive behavioral change related to attacks - present (avoidance)

**Panic Attack Symptoms (4+ required):**
- Palpitations - present
- Sweating - present
- Trembling - present
- Shortness of breath - present
- Chest pain/discomfort - present
- Dizziness - present
- Fear of dying - present
(7/13 symptoms confirmed)

**2. Agoraphobia (F40.00)**

**DSM-5 Criteria:**
- Fear/anxiety about 2+ of the following:
  - Public transportation - present (avoids driving)
  - Open spaces - present
  - Enclosed places - present (movie theaters)
  - Crowds - present
  - Being outside the home alone - present
- Avoidance due to fear of panic-like symptoms - present
- Situations almost always provoke fear - present
- Disproportionate to actual danger - present
- Duration >6 months - present
- Causes significant distress/impairment - present

### Treatment Plan

**Pharmacotherapy:**
- Start paroxetine 10 mg daily (FDA-approved for panic disorder)
- Titrate to 20-40 mg over 4 weeks
- Note: SSRIs may initially increase anxiety; counsel patient

**Bridging anxiolytic:**
- Clonazepam 0.5 mg BID for 2-4 weeks while SSRI takes effect
- Plan to taper as SSRI becomes effective
- Avoid long-term benzodiazepine use

**Psychotherapy (Essential):**
- CBT with Interoceptive Exposure and In-Vivo Exposure
- Interoceptive exposure: Deliberately induce feared body sensations (spinning, breathing through straw, running in place) to reduce fear of sensations
- In-vivo exposure hierarchy:
  1. Walk around block
  2. Brief drive on local streets
  3. Grocery store during off-peak hours
  4. Crowded store
  5. Highway driving
  6. Eventually: airplane travel

**Psychoeducation:**
- Explain panic as false alarm (fight-or-flight system misfiring)
- Physical symptoms are uncomfortable but not dangerous
- Avoidance maintains and worsens panic/agoraphobia
- Importance of facing fears gradually

**Follow-up:**
- Weekly visits initially during exposure work
- PDSS monitoring

---

## Case 3: Social Anxiety Disorder

### Patient Demographics
- **Age:** 19 years old
- **Sex:** Female
- **Occupation:** College freshman

### Chief Complaint
"I've skipped so many classes I might fail out. I can't handle people looking at me."

### History of Present Illness
The patient is a college freshman referred by the campus counseling center after missing over half of her classes this semester. She describes intense fear and anxiety in social situations, particularly when she feels she may be observed or evaluated by others. She becomes extremely anxious in classes, especially when participation is required, fearing she will "say something stupid" and be judged negatively. She dreads being called on and will skip class rather than risk speaking in front of others. She avoids the dining hall, eating in her dorm room alone instead, because she fears others watching her eat. She has not made friends at college and spends most of her time alone in her room. She would like to join clubs and activities but the thought of meeting new people makes her feel "sick with anxiety." When forced into social situations, she experiences blushing, sweating, trembling voice, and racing heart. She reports these fears have been present since middle school and caused significant difficulties in high school, though she managed by having a small group of childhood friends. The transition to college, where she knows no one, has been overwhelming.

### Mental Status Examination

**Appearance:** Young woman, modestly dressed, minimal eye contact, blushing, appears younger than stated age

**Behavior:** Timid, soft-spoken, avoids eye contact, visible discomfort being observed

**Speech:** Soft volume, hesitant, brief responses

**Mood:** "Nervous" and "embarrassed"

**Affect:** Anxious, constricted, embarrassed

**Thought Process:** Linear, goal-directed

**Thought Content:** Preoccupied with fear of negative evaluation, believes others notice and judge her anxiety, no suicidal ideation (denies), no homicidal ideation

**Perceptions:** No hallucinations

**Cognition:** Alert, oriented, attention and concentration intact

**Insight:** Good - recognizes fears are excessive

**Judgment:** Impaired by avoidance (missing classes, isolation)

### Psychiatric Workup

**Screening Tools:**
- Liebowitz Social Anxiety Scale (LSAS): 95 (severe; >60 is clinical threshold)
- Social Phobia Inventory (SPIN): 48 (severe)
- PHQ-9: 14 (moderate depression, likely secondary)
- AUDIT: 8 (emerging problematic use - drinks before social events)

**Review of Systems:**
- Reports drinking 3-4 drinks before any required social event "to calm down"
- No other substance use

### Diagnosis

**Social Anxiety Disorder (Social Phobia), Generalized (F40.10)**

**DSM-5 Criteria:**
- Marked fear or anxiety about social situations where scrutiny is possible - present
- Fear of negative evaluation (acting in embarrassing way, showing anxiety) - present
- Social situations almost always provoke fear/anxiety - present
- Social situations are avoided or endured with intense distress - present (avoidance prominent)
- Fear is out of proportion to actual threat - present
- Duration >6 months - present (since middle school)
- Causes significant distress or impairment - present (academic failure, social isolation)
- Not attributable to substance/medication or medical condition
- Not better explained by another disorder

**Generalized specifier:** Fears include most social situations (not just performance)

**Comorbidity to Address:**
- Emerging alcohol use disorder (self-medication pattern)
- Secondary depressive symptoms

### Treatment Plan

**Pharmacotherapy:**
- Start sertraline 50 mg daily
- Titrate to 100-200 mg (higher doses often needed for SAD)
- Alternative: paroxetine, venlafaxine

**Consider for performance situations (adjunct):**
- Propranolol 20-40 mg PRN, 1 hour before discrete performances (presentations)
- Not helpful for generalized social anxiety but useful for specific events

**Psychotherapy (Essential):**
- CBT for Social Anxiety Disorder
  - Cognitive restructuring targeting core beliefs about negative evaluation
  - Exposure hierarchy (gradual practice in feared social situations)
  - Social skills training if needed
  - Video feedback to correct distorted self-perception
- Group CBT particularly effective (built-in exposure)

**Exposure Hierarchy Example:**
1. Brief eye contact with stranger
2. Asking stranger for directions
3. Eating in dining hall at low-traffic time
4. Answering question in small class
5. Attending club meeting
6. Initiating conversation with peer
7. Class presentation

**Address Alcohol Use:**
- Psychoeducation about alcohol as maintaining factor for social anxiety
- Avoid using alcohol to cope
- Referral to campus recovery support if use escalates

**Academic Support:**
- Disability services referral for accommodations (may include reduced public speaking requirements initially)
- Letter for medical withdrawal if needed for current semester

**Follow-up:**
- Weekly initially for CBT and medication management
- LSAS monitoring