CASE STUDY
The following case presentation illustrates a patient presenting with multiple anxiety
disorders and a history of antidepressant therapy. The patient is a 29-year-old man with
worsening anxiety associated with poor school functioning for the past month. He describes
waking in the morning with a nervous stomach, nausea, and poor appetite. He experiences
overwhelming worries that he would make a fool of himself at school. He experiences strong
urges to avoid anxiety-provoking situations. He endorses feeling nervous, tense, and tremulous
most days. He is often overwhelmed by fears of failure at school and in a future career and
worries over the health of his family and financial issues. History revealed a pattern of binge
drinking and daily marijuana use that reportedly stopped 3 months ago and a more distant history
of polysubstance experimentation with cocaine, LSD, and psilocybin mushrooms.
Psychiatric treatment occurred 10 years ago and consisted of medication management
and supportive psychotherapy. The patient was placed on a combination of mirtazapine
(maximum dose of 30 mg at bedtime for 3 months) and alprazolam (0.5 mgd as needed).
Because of unfavorable adverse effects, including weight gain and daytime sedation, he
discontinued the drug. He found that alprazolam was tolerable but noted little to no long-term
benefit. Several weeks after discontinuing pharmacotherapy, he initiated supportive
psychotherapy that lasted for 1 year. After termination, however, he had several relapses of
anxiety and comorbid depression.
At intake, the decision was made to initiate combined treatment. This recommendation
was based on previous benefit with supportive psychotherapy. In addition, the patient requested
to learn specific skills that would provide him with better coping mechanisms. The patient also
wanted to try medications again, because his maternal uncle who suffered with similar symptoms
benefitted from sertraline.
Over the past 1.5 years, he has improved on combination therapy. His pharmacologic
regimen consisted of sertraline (up to 250 mgd), with the addition of bupropion XL (100 mgd)
as an antidote for delayed ejaculation. This was the only adverse effect he experienced from the
sertraline. In addition to being an effective antidote, bupropion XL also provided him with extra
energy without exacerbating his anxiety symptoms. The CBT goals focused on self-identified
areas of poor social functioning, the most important of which was among peers. In treatment, we
focused on identifying his cognitive misinterpretations of social situations. We identified times
when he ruminated on past performances and provided in session exposure by reenacting
anxiety-provoking situations and practicing alternative strategies. He also tested out his thoughts
about being ridiculed in vivo by ad-libbing an extra credit report for class rather than tediously
preparing and practicing it in advance. Over time, the patient formed stable and meaningful
friendships. The episodes of binge drinking decreased in frequency, and he was less avoidant,
making significant scholastic improvements possible. He recently described himself jokingly as
“one of the popular kids.” Through combined treatment, he became less symptomatic and better
able to endure anxiety-provoking situations. His newfound tolerance undoubtedly helped him
stay the course of therapy. He was able to successfully practice and implement skills learned in
session outside of the office. These skills eventually helped him improve his interpersonal
interactions, conquer his anxieties, and reshape the course of his life.