Diano, Christina Joyce B.

BS Psychology 3A

CASE STUDY: "I CAN'T STOP MY HEAD": THE CASE OF THE

PERSISTENT WORRIER

Nancy L., a 45-year-old married lawyer, presented with exacerbation of her chronic
generalized anxiety and recurrent depressive symptoms in January 2005.
Nancy had a history of anxiety dating back "as far as I can remember." She was
an anxious young girl with separation anxiety and shyness that manifested in
elementary school. As she grew up, she experienced ongoing anxieties about the
health of her parents (worrying that her parents would die, even though they were
in good health) and her school performance (though she was a good student). She
remembers marked fears, including fears of the dark and thunder, most of which
she "outgrew" except for a persistent fear of insects, particularly spiders.
Her anxiety became more prominent and persistent after she left home at age
18 and entered college. She sought care at the university health service and
received a prescription for diazepam that she used over the next 4 years on an asneeded basis during periods of increased anxiety such as examinations; she also
met episodically with a therapist at the counseling center. In the spring of her
freshman year, she experienced her first major depressive episode following a
break-up with a boyfriend. She was prescribed imipramine, which she took for a
couple of months but then discontinued because of intolerable side effects (dry
mouth and lightheadedness). The depression gradually resolved over the next 6
months.
Nancy continued to be plagued by persistent feelings of anxiety and worry
associated with insomnia, irritability, tension, and fatigue. Over the years, her
friends and family chided her for "worrying too much," and she reported difficulty
controlling her anxiety over her financial situation, job security, and her children's
safety, despite evidence that none of these were problematic. Her husband reported
that he found her persistent anxiety and ongoing need for reassurance "exhausting"
and that he noticed himself withdrawing from her, which led to significant tension
between them. The high quality of her work at the law firm was recognized and she
was well-compensated financially, yet she continued to worry about her
performance and was, in fact, passed over for promotion to team leader because, as
one of her annual reviews stated, her "constant anxiety makes everyone else too
nervous." In addition, over the last 25 years, she has had 5 or 6 episodes of major
depression lasting from 3 to 4 months to over a year. These episodes have
sometimes, but not always, been triggered by situational stressors; one occurred
during a postpartum period.
After college, she was treated intermittently with benzodiazepines at low
doses (eg, diazepam 5-10 mg), which she took on an as-needed rather than daily
basis when the anxiety worsened because of her concerns about addiction. As
noted, she was briefly on imipramine during college but discontinued it because of
side effects. About 10 years before the January 2005 examination, she was started
on fluoxetine 20 mg/day by her primary care doctor. She discontinued it after a few
days because it made her feel jittery and more anxious. She had been in supportive
therapy on and off since college to help her deal with situational stressors.

Other relevant aspects of her medical and psychiatric history include the fact
that her overall health had been generally good, although she had presented
numerous times to her primary care physician with a variety of somatic complaints,
including headaches, gastrointestinal disturbance, and muscular aches and pains
with no clear etiology. She had repeated thyroid testing with normal results. Her
mother had had a history of menopause in her early 40s and the patient noted that
her menstrual cycles had become more irregular over the last couple of years, and
her anxiety and irritability become notably worse premenstrually.
She smoked a pack of cigarettes a day and reported that having a cigarette
would sometimes temporarily decrease her tension and anxiety. She attempted to
quit smoking several times and noted that the increased anxiety and tension she
experienced during these attempts contributed to her lack of success in these
efforts. She typically had 1 or 2 glasses of wine at social occasions or on the
weekends; she has no history of abuse or dependence on alcohol but did say that a
glass of wine made her feel temporarily less anxious. She carefully monitored her
intake because of worry that she would become an alcoholic. She smoked marijuana
a few times in college but it made her feel dysphoric and more anxious, and she had
not used it or other illicit drugs since that time.
Symptoms
she experienced ongoing anxieties about the health of her parents (worrying
that her parents would die, even though they were in good health) and her
school performance (though she was a good student)
She remembers marked fears, including fears of the dark and thunder, most
of which she "outgrew" except for a persistent fear of insects, particularly
spiders.
She continued to be plagued by persistent feelings of anxiety and worry
associated with insomnia, irritability, tension, and fatigue.
her friends and family chided her for "worrying too much," and she reported
difficulty controlling her anxiety over her financial situation, job security, and
her children's safety
The high quality of her work at the law firm was recognized and she was wellcompensated financially, yet she continued to worry about her performance
and was, in fact, passed over for promotion to team leader because, as one of
her annual reviews stated, her "constant anxiety makes everyone else too
nervous."
She had presented numerous times to her primary care physician with a
variety of somatic complaints, including headaches, gastrointestinal
disturbance, and muscular aches and pains with no clear etiology.
She smoked a pack of cigarettes a day and reported that having a cigarette
would sometimes temporarily decrease her tension and anxiety.
Source: http://www.medscape.org/viewarticle/527758_4