Cognitive and Behavioral Practice 20 (2013) 247–250

www.elsevier.com/locate/cabp

COGNITIVE BEHAVIORAL CASE CONFERENCE

A Clinical Case of Generalized Anxiety Disorder

Melisa Robichaud, University of British Columbia and Vancouver CBT Centre

This article presents the clinical case of a 38-year-old man with generalized anxiety disorder (GAD). “William” reports longstanding
excessive and uncontrollable worry about a number of daily life events, including minor matters, his family, their health, and work. In
addition, he endorses chronic symptoms of restlessness and irritability, muscle tension, concentration difficulties, and sleep disturbance.
In an attempt to cope with his worries, William engages in excessive information and reassurance seeking, particularly with respect to
decision making, and he often double-checks even minor tasks. In addition, he engages in procrastination, and avoids spontaneous or
unplanned events. Although William describes himself as a born worrier, his GAD symptoms became noticeably problematic over the last
several years, subsequent to an increasing number of stressors. Comorbid conditions as well as predisposing and precipitating factors are
described in addition to the specific symptom presentation.

T HIS article serves as the clinical case example for the

subsequent series of papers in this cognitive-
behavioral case conference on the treatment of general-
diagnosis of irritable bowel syndrome (IBS) 5 years
prior, in the last several years, he had been prescribed
a number of antidepressant medications to address his
ized anxiety disorder (GAD). The present case does not symptoms. Although he initially derived some benefit
include a case conceptualization, but is rather a detailed from pharmacotherapy, he had recently begun experi-
description of a client's assessment results through the encing a significant increase in anxiety throughout the
illustration of presenting symptoms, associated behavioral day. William had also reported occasional panic attacks
difficulties, precipitating factors, and background history. at work that he attributed to stress, and was contem-
This clinical case is a composite of several clients in order plating taking medical leave for a few months.
to protect their respective anonymity.
Primary Presenting Problem
Demographic Information
William was assessed with the Anxiety Disorders
William is a 38-year-old married Caucasian man who Interview for DSM-IV (ADIS-IV; Di Nardo et al., 1994).
lives with his wife and 9-year-old daughter in a large urban He described longstanding anxiety and worry about a
city in North America. He holds a managerial position in a number of topics. He reported that he would typically
bank, and his wife works as a lawyer. He is the eldest of spend several hours a day “in his head,” worrying about
three children, having two younger brothers. He is very such concerns as his family, their health, and his work.
close with his immediate family, and is active in his For example, he stated that most every day he would
daughter's school; he regularly participates on parent- worry about how his daughter was doing in school,
teacher council meetings, and assists with coaching the whether she was getting along with other students, and
elementary school soccer team. if she was eating a proper lunch. At work, he spent a
William was referred for a psychological assessment great deal of time thinking about all the tasks he had to
by his family physician following frequent complaints of complete, any obstacles that might arise, and the best
chronic anxiety, fatigue, sleeplessness, stomach distress, way to address them. Although he found this time-
and low mood, all of which had increased in the consuming, he nevertheless indicated that as “the
months prior to referral. Although he had in the past worrier” at the office, he was able to consider all facets
undergone a number of medical tests to identify the of any problems that arose and was known by his
source of his complaints, and in fact had received a coworkers as an organized and conscientious individual.
He also endorsed excessive worries about minor matters
1077-7229/10/247–250$1.00/0 such as punctuality, stating that he would on occasion
© 2010 Association for Behavioral and Cognitive Therapies. be unable to sleep the night before an appointment due
Published by Elsevier Ltd. All rights reserved. to worries about being late. He further indicated that
248 Robichaud

small decisions cause him significant distress and However, he noted that if he is unable to make a clear
anxiety. For example, William reported that decisions choice between options, he will on occasion procrastinate
such as where to go for family vacation or what meal to making a decision or ask others to decide for him. For
order in a restaurant lead to significant worry and example, when deciding what flowers to plant in his
anxiety. When queried about this, he indicated that he garden in the spring, he consulted with at least six
fears potentially making the wrong decision and different gardening shops, asked friends and family their
regretting the decision at a later date. opinion, and spent hours on the Internet researching
William reported that his worries are excessive and flowers, gardening designs, and plant care. Ultimately,
uncontrollable, and that approximately 75% of his waking William reported that he experienced so much anxiety
day is consumed by worry. He stated that his wife and about this decision that he hired a landscape designer to
several of his friends have told him that he worries too plant his garden and referred all subsequent gardening
much, and he indicated that he often has difficulty decisions to his wife. At work, William copes with his
stopping himself from worrying, as he typically experi- worries by refusing to delegate tasks to others, stating that
ences a chaining effect where one worry leads to another. so long as he is completing a task, he knows that it is being
As an example of this, he described a recent episode done correctly. He also tends to be perfectionistic at work,
where he began worrying about his health (“What if I double-checking all of his work prior to handing it in, and
develop a serious illness?”), which then led to worries rereading emails to ensure that they are devoid of spelling
about his family's finances (“What if my wife had trouble mistakes. Although William believes that these behaviors
handling all the bills as a single parent if I died?”), and his ensure that he completes his work tasks well, he
daughter's social and academic future (“What if my nonetheless indicated that it is time-consuming, as he
daughter had difficulty adjusting to the death of a parent? will double-check even the most minor work-related
What if she started failing in school and didn't get into details. He further copes with his worries by maintaining
university? She might not be able to have a good a very predictable routine in his day, as he experiences
career…”). He described this process as highly time- significant anxiety if there is an unplanned change in his
consuming and exhausting, since each worry led to schedule. For example, he will frequently be unable to
significant scenario-building; that is, when he worries, sleep the night before an appointment, and he indicated
he will mentally elaborate upon the potential negative that this is due to both a fear of being late for the
outcomes that might occur, as well as potential solutions appointment, and a concern about whether the inclusion
to each scenario (e.g., “What if my wife had trouble of an appointment in his day will impact and potentially
handling the bills? That would be terrible, since she could shift the other activities that he would typically complete
lose the house and end up in debt; perhaps we can set up that day. He also indicated that he typically avoids
a budget now so that she can be prepared if something spontaneous social outings, preferring to plan and
happens to me; but what if she still ends up in financial prepare get-togethers well in advance.
trouble? She might be able to go to the bank for a loan William reported that his worries and anxiety cause
using our house as collateral; but what if she is not him considerable distress and interference in his life.
accepted for a loan? I suppose she could ask her family for For example, despite being actively involved in his
a loan if the bank does not give her one…,” etc.). daughter's life, he often does not enjoy his time with
With respect to physical symptoms, William reported her, as he spends most of the time worrying about
that he has had longstanding sleep problems wherein he potential negative events that might occur. He indicated
will toss and turn for hours thinking about what he needs that in general he has difficulty enjoying the present
to do the next day. He also stated that he is a light sleeper, moment, and because of his irritability, family outings
often waking up several times during the night, usually can often be rather stressful. Recently, he noted that his
triggered by worries. He further endorsed significant worries have also significantly affected his ability to
muscle tension in his neck and shoulders, feeling irritable work. Subsequent to changing work demands, he
at work and at home, feelings of restlessness, severe described feeling overwhelmed by his responsibilities,
fatigue throughout the day, and difficulty concentrating. and has had several worry-triggered panic attacks. As a
He indicated that all of these symptoms have been consequence, he finds that he has fallen behind on
present for several years, and are largely present more tasks, and will often procrastinate or avoid important
days than not. work-related decisions.
William engages in a number of problematic behaviors
in an attempt to cope with his worries. He indicated that Other Mental Health Problems
he often seeks excessive reassurance from others prior to Although William indicated that he has been experi-
making a decision, as well as engage in protracted encing several panic attacks, assessment with the ADIS-IV
Internet searches for information about his decision. suggested that he did not meet criteria for panic disorder.
 Cognitive Behavioral Case Conference: GAD 249

Specifically, he denied experiencing unexpected attacks, Precipitating Factors

as he was able to identify work-related worries as a clear William described himself as a “born worrier.” As a
trigger. Moreover, William did not endorse any anticipa- young child, he often worried about his family, including
tory anxiety about future attacks, nor was he fearful about such topics as the family finances, his parents' health, and
the consequences of the attack, such as a fear of dying, his brothers' performance in school, as well as worrying
going crazy, or losing control. about his relationships with friends and his own school-
William endorsed a number of symptoms consistent ing. Despite feeling like a “little adult,” William stated that
with a diagnosis of dysthymic disorder. He reported his worries were largely manageable. He reported that up
longstanding feelings of sadness and melancholy for until his early 20 s, he engaged in checking and
several years, which he described as a “grey cloud” reassurance- and information-seeking to cope with his
hanging over his head most every day. Within the past 2 worries and anxiety, although it did not occupy too much
years, he had experienced discrete periods of several of his time, nor did he experience significant sleep or
weeks in a row where his mood was normal, although concentration difficulties. When he began working as a
he denied having 2 months in succession where he did bank manager, William noticed that his worries became
not experience a depressed mood. William further more frequent and problematic. In addition to worrying
endorsed chronic symptoms of fatigue, insomnia, about tasks while at work, he would often worry while at
concentration difficulties, and feelings of hopelessness home. To cope with this, he would often distract himself
and low self-esteem. His low mood has had a significant or keep busy in order to avoid thinking about his work
impact on his life, as he finds that he is less social with obligations. Following the birth of his daughter, his
others, and his relationship with his wife has become worries increased in frequency and severity subsequent
somewhat strained. to concerns about her well-being and the “best way” to
Relevant Background Information raise a child. At that time, he became aware that he was
experiencing trouble sleeping, and often felt tense and
William is the eldest of three boys. He described his anxious throughout the day.
home life as a child as loving but chaotic. His parents Although his worries were noticeably problematic
married in their early 20 s, and are still currently together. following the birth of his daughter, and in fact, he had
His father works in construction, and his mother is a day consulted with his family doctor on several occasions for
care worker. He described his parents as very loving and medication, he nevertheless felt able to manage his home
social, albeit irresponsible and “flaky.” Of note, he stated and work obligations, albeit with difficulty. Within the past
that they would often buy gifts and candy for their few months, however, he described himself as being on the
children, but would forget to make school lunches for verge of a “nervous breakdown” subsequent to significant
their sons, and were frequently late paying household changes at work. Due to downsizing at the bank, William
bills. William believed that he had to be “the adult” of the was given a number of new responsibilities at work, many
family, as from a young age he would make breakfast and of which he had little experience addressing. As a
lunch for his younger brothers and ensure that they went consequence, he often felt unsure of how best to complete
to bed on time. work tasks. He stated that his anxiety was severe
William reported that he consistently excelled in throughout most of the day, occasionally culminating
school, obtaining good grades throughout high school into a panic attack. He noted that his work performance
and university. He was regularly on the honor roll, and suffered as a result of his anxiety: His concentration was
was active in several sporting teams and academic clubs. poor and he felt overwhelmed by even minor decisions.
While in university completing an M.B.A., he met his
wife, who was also completing a university degree. Both Diagnostic Summary
he and his wife obtained lucrative jobs in their Based on the assessment conducted with the ADIS-IV,
respective fields after university. Shortly after marrying, William received a primary Axis I diagnosis of GAD, with a
William and his wife had their first and only child. severity rating of 6 (on a 0 to 8 scale). This level of severity
Although he describes a very loving relationship with his was accorded based on the longstanding frequency and
daughter, William fears that his significant anxiety excessiveness of his worries, the chronic presence of all six
struggles are setting a poor example for his daughter somatic symptoms associated with a GAD diagnosis, and
and that she might have anxiety problems as well when the significant impairment and distress that William is
she gets older. He has in fact noticed that his daughter experiencing as a result of his worries. He further
spends an excessive amount of time completing her received a secondary diagnosis of dysthymic disorder,
homework, and will display significant anxiety about with an ADIS severity rating of 4. Although he indicated
upcoming exams in school, on occasion having difficulty that his low mood has had a marked negative impact on
sleeping the night before. his daily life, he nevertheless reported that his excessive
250 Robichaud

worries and associated anxiety were the most severe and Address correspondence to Melisa Robichaud, Ph.D., Vancouver CBT
salient problem at the present time. Centre, #708 – 777 West Broadway, Vancouver BC, Canada, V5Z 4J7;
e-mail: melisa.robichaud@ubc.ca.

Reference
Di Nardo, P. A., Brown, T. A., & Barlow, D. H. (1994). Anxiety Disorders Received: October 10, 2009
Interview Schedule for DSM-IV. San Antonio: Psychological Accepted: October 31, 2009
Corporation. Available online 2 November 2010