Case Study of Patient with Anxiety

Client Demographics and Brief Background

 Mr. Jeff Beck is a 39-year-old Caucasian male. He lives with and has been married to his wife of twelve years and has an eleven-year-old son. Mr. Beck has been working full time at a thriving investment firm for over ten year and received a significant promotion eight months ago which put him in a position of high-level management. Mr. Beck presents at the office today by explaining, “I am unable to focus on anything and doing my job is impossible.” For more than two weeks, Mr. Beck has felt a sense of overwhelming anxiety that has been substantially impacting his daily functioning and states that he “feels like such an idiot in front of his colleagues.” After a discussion with his wife and at her request, he presents for treatment after another full-blown panic attack. Mr. Beck expresses that as he was waking up, he was drenched in sweat, tingly, “immobilized by fear”, and felt intense nausea as if he were going to “throw up.”

History of Presenting Problem, Symptoms, Observation, and Coping Skills

For the past two months, Mr. Beck has been coping with levels of anxiety unlike anything he has ever experienced. Also, his thoughts about himself and his current career have become increasingly negative. According to Mr. Beck, he is experiencing emotional symptoms of anxiety, fear, nervousness, and feeling overwhelmed. His cognitive symptoms include an inability to concentration, inability to control negative thoughts, and increasingly confused at times. Mr. Beck is experiencing behavioral symptoms of avoidance causing decreased productivity and increased absence from work along with physiological symptoms of nausea, sweating, heart rate acceleration, and dry mouth. As he sits in the chair across from the clinician, his legs are jittery, and he continuously wipes his hands on his jeans. He is having a hard time focusing and difficultly answering questions being asked of him. As we begin discussing if he feels supported and what he does to cope in times of high stress, Mr. Beck is able to focus a bit more thoroughly. He expresses that he feels a lot of support from his wife and son. He states, “they are always asking how my day is going and what they can do to help out.” Also, there is clear indication that he has the ability to succeed under pressure given the evidence by his academic achievements. However, Mr. Beck also expresses that he used to be able to use breathing techniques and taking a minute to reset was successful in times of stress but that his worry overcomes this now.

Aspects of Client’s Life and Potential Treatment Concerns

 Again, Mr. Beck is an educated man, over his academic career, he has earned a Master’s in Business Administration as well as a Master’s in Finance. Mr. Beck has been at the same firm since graduating over ten years ago. He expresses that over the years he has had great relationships with his family and friends. Regarding his medical history, he reports no issues in his past or present and takes nothing but a daily vitamin. He denies any history of physical, sexual, or emotional abuse. Also, Mr. Beck denies ever having any issues revolving around alcohol or substance abuse as well as no legal involvement. He explains that being on a golf course has always been one of his passions but lately like everything else, “I feel unable to succeed with that too.” When asked about any prior mental health issues, he simply states “I had some mild test anxiety back in school but never sought out treatment.”

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Focus of concern is on Mr. Beck’s feelings of worry that he will wake up every day to another panic attack, or worse, experience one at work. This is causing him to believe that he can no longer successfully do his job, and as a result, it is interfering with his productivity and potentially increases the risk of deciding to completely forgo attending. The decrease in productivity related to his fear then perpetuates his core belief that he is inadequate. He feels embarrassment in front of co-workers because he sees himself as incompetent and those negative automatic thoughts about himself are causing physically distressing panic attack symptoms. He has felt this way over the past two months and when distinctly asked how long he must cope with these “attacks” he explains that they can last up to an hour. However, there is anxious feelings every day, for most of the day and as stated, he constantly fears having another panic attack.

Assessment of Client

 Mr. Beck presents for treatment on his own accord dressed appropriately for setting and season. He appears current age and is pleasant and cooperative. He reports that his mood is “nervous” and his affect is congruent with stated mood as he appears anxious. Mr. Beck is experiencing recurrent panic with multiple symptoms over the past two months such as intense sweating, nausea, accelerated heart rate, and persistent worry about future panic attacks all consistent with a diagnosis of panic disorder. His symptoms are not a result of the use of substances as Mr. Beck denies any current or past use. His symptoms are also not better explained by another mental health diagnosis, or cognitive dysfunction. Of note: Recent career transition to a position of high stress and responsibility. DSM-5 Diagnosis: Panic Disorder 300.01 (F41.0)

Mr. Beck’s recent promotion to a high-stress role as a senior level manager likely precipitated an onset of panic disorder. Although he was hoping for this promotion, he began to feel overwhelmed quickly and feeling as if he was inadequate for the role and concerned for the risk of rejection due to the amount of stress caused by the increased level of responsibilities especially when combined with his clear history of heightened level of anxiety as self-reported and his current level of anxiety that is decreasing his ability to effectively do his job. It is reasonable that Mr. G feels overwhelmed by the work and the new expectations. He then began having panic attacks which subsequently increased the fear and anxiety surrounding his new professional role and he began believing that his reputation at work was going to be affected and his job would be in jeopardy. These newly developed cognitions have ultimately begun to dictate his effectiveness in the role. 

An MMSE is cooperatively completed by Mr. Beck. He is oriented times four. He is aware that it is springtime and where he is at regarding facility, city, county, and state. Mr. Beck is asked to test his memory by listening to three words and repeating them. He is successful in this in only one attempt. He is then asked to count backwards starting with one hundred and reducing the number by seven with each response. Although he presents with nervous movement (wiping hands on pants) and must ask two times to clarify what is asked of him, he is successful until told he can stop. Mr. Beck is successful in a three-stage command of grabbing, folding, and putting paper on the table. After being asked to read and do what is asked of a card that says, “blink twice”, he can do so. Mr. Beck is able to write a coherent sentence obtaining a noun and verb. Lastly, Mr. Beck is successful in copying a drawing of two interlocking pentagons. He is successful and receives a score of normal, but it is of note, he is noticeably sweating at a level perceived higher than normal for given tasks.

Cultural Formulation

 Like any assessment, cultural aspects must be reviewed, and the clinician must be competent regarding a client’s background. Mr. Beck is a Caucasian male who practices Christianity. His cultural background aligns with most of the US, but we must understand how this can differ from client to client. Anxiety issues, and specifically the interpretation panic attack symptoms vary greatly across cultures. Outside the United States there are many places such as Cambodia or Vietnam that view this disorder as a cultural syndrome that is induced by many factors such as the way intense wind plays apart in symptoms or how a specific situation will consistently bring on symptoms of a panic attack (DSM-5, 2013).

Theoretical Orientation

Treatment Planning

 After discussing what Mr. Beck would like to work on regarding treatment, there has been three defined goals which will be working on collaboratively with the clinician. First, Mr. Beck would like to work on his ability to reduce his negative thought process which he believes is leading to the extremely high levels of anxiety in which he is feeling regularly about his ability to find success in his work. Second, it has been collaboratively determined that Mr. Beck finds it important to once again achieve the self confidence that led him to earning a double masters and initial success in the business world. Lastly, Mr. Beck would like to focus on the creation of positive coping skills to help aid him when his high stress position feels like it is becoming overwhelmingly difficult.

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 Mr. Beck understands that these goals are difficult but feels a sense of hope that they are obtainable and will bring him the relief he is looking for. Mr. Beck and clinician have formulated an automatic thought chart to aid him in achieving the first goal of learning to reduce the negative thoughts he is having which revolve around his work. He will be able to jot down the when, where, situation, automatic thought, emotion, potential adaptive response, and outcome for the particular situation that induces the negative thought process. Second, Mr. Beck is going to set aside three hours per week in any fashion in which he allows himself the opportunity to use one hour to review some of his old text books and job duties to help him recapture the competence he feels he has lost within his work. The other two hours per week will be used to allow him the opportunity to focus on self-care and the game of golf which he loves. Previously, Mr. Beck found much self confidence in his knowledge of the ins and outs of his work along with the success he achieved on the golf course. It has been collaboratively determined that both aspects should be reincorporated into his weekly schedule. Lastly, within the weekly therapy session that have been determined as part of the therapeutic intervention, a “My Anxiety Plan” (MAP) will be constructed to aid Mr. Beck in gaining the tools he needs to take control and manage the stressful anxiety that inevitably part of his newly promoted position (My Anxiety Plan, n.d.). Mr. Beck is promoted by not only his loving family, but his firm is aware of his need for treatment as well. Both are behind him and intend to give him the adjunct support he needs to succeed.

Added Recommendations and Prognosis

 Mr. Beck has been referred to the outpatient psychiatrist for an evaluation regarding the potential for pharmacotherapy as a therapeutic co-intervention for the treatment of his mental health diagnosis. Also, he will be provided psychoeducation on his diagnosis and how effective coping will allow for successful remission. Resources such as self-help groups for other high-ranking corporate professionals suffering from the stresses of their professional responsibilities will be offered as well. Mr. Beck is hopeful and focused on taking part in a treatment program on a weekly basis here at the Outpatient program. His prognosis is high for the potential to achieve a reduction of panic symptoms within his social and occupational functioning.

References

• American Psychiatric Association. (2012). Diagnostic and Statistical Manual of Mental Disorders, (5th Edition). Washington, D.C.
• Seligman, L. and Reichenberg, L.W. (2016). Selecting Effective Treatments: A Comprehensive, Systematic Guide to Treating Mental Disorders, (5th Edition). Hoboken, NJ: Wiley & Sons
• My Anxiety Plan (MAP) for Adults. (n.d.). Retrieved from https://maps.anxietycanada.com/courses/my-anxiety-plan-map-for-adults/