Interview Context:
I met with Sarah Johnson and her husband, Tom. Sarah expressed concern about her increasing anxiety levels and their impact on her daily life. Tom provided additional context and observations regarding Sarah's symptoms.
Profile:
Sarah Johnson is a 35-year-old married woman living in suburban Melbourne. She works as a primary school teacher and enjoys gardening and yoga in her free time.
Presenting Complaint:
Sarah is seeking help for worsening anxiety symptoms that are interfering with her work and personal life.
History of Presenting Complaint:
Anxiety symptoms began six months ago, gradually intensifying. Sarah experiences frequent worry about work performance, health, and family matters. Difficulty controlling these thoughts, often leading to physical symptoms.
Anxiety symptoms:
Excessive worry about various aspects of life. Racing thoughts, difficulty concentrating. Physical symptoms include rapid heartbeat, sweating, and trembling. Avoids social gatherings and public speaking at work.
Mood symptoms:
Low mood accompanying anxiety episodes. Feelings of worthlessness and guilt, particularly related to work performance. No significant changes in appetite or weight.
Vegetative features:
Insomnia, taking 1-2 hours to fall asleep. Wakes multiple times during night. Fatigue throughout the day, affecting work performance. Concentration difficulties, especially during anxious periods. No significant diurnal mood variation.
Manic or Psychotic features:
No manic symptoms or episodes reported. No hallucinations, delusions, or other psychotic features observed or reported.
Risks:
No current suicidal ideation or intent. No history of self-harm or suicide attempts. No homicidal ideation or aggressive behavior.
Recent stressors:
Increased workload at school. Mother-in-law diagnosed with cancer three months ago. Financial concerns due to recent home renovation. Attributes anxiety to work stress and family health worries. Overall functioning impaired, particularly in work and social domains.
Past History:
- Mild depressive episode at age 25.
- Appendectomy at age 18.
- Asthma diagnosed in childhood, well-controlled.
Medication:
- Salbutamol inhaler PRN for asthma
- Trial of sertraline 50mg daily for 2 months (discontinued due to side effects)
Alcohol / Substance Use:
- Alcohol: 1-2 glasses of wine per week, socially
- No illicit substance use
- No smoking
Family History:
- Mother: Generalized Anxiety Disorder.
- Father: Type 2 Diabetes.
- Maternal grandmother: Depression.
Developmental History:
- Unremarkable pregnancy and delivery
- Met developmental milestones appropriately
- Described as a shy child, difficulty making friends in primary school
- Parents divorced when patient was 14, experienced adjustment difficulties
- Excelled academically throughout schooling
Mental State Examination:
Appropriately dressed, well-groomed woman appearing stated age. Mild psychomotor agitation, fidgeting with hands. Speech normal in rate and volume. Affect anxious, mood congruent. No perceptual disturbances. Thought process logical and coherent. No evidence of thought disorder or delusions. Cognition intact, oriented to time, place, and person. Good rapport established. Partial insight into condition. Judgment unimpaired.
Impression:
Sarah presents with symptoms consistent with Generalized Anxiety Disorder (GAD) as per DSM-5 criteria. Biological factors include genetic predisposition (family history of anxiety). Psychological factors involve perfectionist tendencies and negative self-talk. Social stressors include work pressure and family illness. Precipitating factors: increased work responsibilities and mother-in-law's cancer diagnosis. Maintaining factors: avoidance behaviors and rumination. Protective factors include supportive spouse and engagement in yoga. No immediate risk to self or others identified. Differential diagnosis includes Adjustment Disorder with Anxiety.
Plan:
- Commence cognitive-behavioral therapy (CBT) for anxiety management
- Consider trial of SSRI (e.g., escitalopram 10mg daily) for symptom relief
- Encourage continuation of yoga and introduction of mindfulness practices
- Provide psychoeducation on anxiety and sleep hygiene
- Review in 4 weeks to assess progress and medication response if initiated
- Liaise with GP for ongoing physical health monitoring
