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Presenting problem
A.K., a 29-year-old graduate student, describes nine months of constant worry about grades, money and her parents' health. She says she "can't switch it off," lies awake planning for things that might go wrong, and has started skipping seminars when she feels unprepared. Her GAD-7 score is 14.
Diagnostic reasoning
DSM-5-TR criteria for generalized anxiety disorder require excessive anxiety and worry about a number of events or activities, occurring more days than not for at least six months, that the person finds hard to control, with at least three of six associated symptoms in adults (American Psychiatric Association, 2022). A.K. reports restlessness, fatigue, poor concentration, muscle tension and disturbed sleep, with clear academic impairment. Her GAD-7 score falls in the moderate range; scores of 5, 10 and 15 mark mild, moderate and severe anxiety (Spitzer et al., 2006).
Other explanations are ruled out first: thyroid function is normal, she drinks one coffee a day and uses no stimulants, a PHQ-9 shows only mild depressive symptoms, and she denies panic attacks.
Cognitive behavioral formulation
- Trigger: an upcoming statistics exam.
- Automatic thought: "If I fail, I'll lose my funding and let everyone down."
- Emotion and body: anxiety rated 80/100, tight shoulders, poor sleep.
- Behaviors: hours of overpreparation, seeking reassurance from classmates, avoiding seminars.
- Underlying assumption: "If I worry about everything, I'll be ready for anything."
- Core belief: "I'm not capable."
Worry and avoidance bring short-term relief, which reinforces them and leaves the core belief untested (Beck, 2021).
Treatment plan
Twelve weekly sessions of cognitive behavioral therapy (CBT):
- Sessions 1–2: psychoeducation on the anxiety cycle and self-monitoring with a worry log.
- Sessions 3–6: cognitive restructuring with thought records and Socratic questioning of catastrophic predictions.
- Sessions 7–10: behavioral experiments, such as attending seminars without overpreparing, plus scheduled worry time and progressive muscle relaxation.
- Sessions 11–12: a relapse prevention plan.
The GAD-7 is repeated every two weeks, aiming for at least a 50% reduction. If the response is limited by session 6, A.K. and the PMHNP will discuss adding an SSRI.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press.
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097. https://doi.org/10.1001/archinte.166.10.1092
