Ann, a 58-year-old breast cancer survivor, was referred to me by her outpatient oncology physician due to anxiety related to her upcoming annual MRI scan. After reading her oncologist’s notes as well as conducting my own assessment, I can confidently diagnose Ann with 300.02 Generalized Anxiety Disorder.
Ann has been cancer free for 15 years, however the anniversary of her diagnosis is approaching, and she is worried that her cancer has come back. She has had excessive anxiety and worry regarding getting cancer again every day for the past six months. Ann has difficulty controlling this worry and calls her physician any time she has any physical symptoms that could be associated with cancer. She also worries whether her kids are ok, if she is being a good teacher, what is happening with her parents, and any upcoming work projects and responsibilities. Ann even worries that she will bring on cancer by worrying so much. She catastrophizes, often thinking that she has cancer lurking and by the time doctors diagnose her the cancer will have metastasized.
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Ann shared that lately she has had difficulty concentrating, and it is harder for her to focus on her work at school has found it more difficult to grade papers. Ann also told me that she has felt more irritable lately and has been experiencing frequent headaches, likely a result of tension in the body. She has felt more fatigued lately, often sleeping on the couch right after work, and she has a harder time falling asleep and staying asleep. Ann’s anxiety, worry, and physical symptoms have been present more days than not for at least six months, and they are causing clinically significant distress and negatively impacting her quality of life. My treatment plan for her will work towards reducing the negative effects of her Generalized Anxiety Disorder, addressing her anxious body and her anxious mind.
The first strategy I would apply in Ann’s treatment plan would be to address her caffeine and alcohol intake and discuss how these substances are exacerbating her anxiety and worry. During our initial consult, Ann shared with me that she drinks three to four cups of coffee each day to combat her tiredness and to get her through the day. In addition to her caffeine consumption, Ann also usually has a glass of wine before going to bed at night.
Firstly, I would educate Ann on the effects that caffeine has on the body and how it may be contributing to her overall problem with anxiety. Research has shown that caffeinated beverages such as coffee effect the nervous system and cause increased levels of tension in the body. Ann has presented with frequent headaches, which are likely the result of this increased tension. To help mitigate this discomfort, I would suggest to Ann that she should decrease her coffee consumption on a daily basis. Each day I can have Ann track and record the changes in her mood, tension, and anxiety after consuming coffee, as well as the amount of coffee, in order to find her caffeine limit and alter it accordingly. If Ann’s goal is to reduce her daily caffeine intake, I would have her work on this reduction over the course of a couple months to avoid adverse effects. I would also recommend to Ann to increase her water intake and to do certain stretches or exercises to her get her body going in the morning.
Ann also shared that she likes to have a glass of wine at night before she goes to bed. Even though alcohol helps Ann temporarily relax and unwind at night, it is causing her more anxiety than she realizes. I would first describe to Ann how alcohol leaves the body in an agitated state after it is detoxified from the liver. The alcohol may help Ann relax while she consumes it; however, it is likely the main cause of her disturbances in sleep. If Ann chooses to keep drinking wine and not give it up altogether, the best solution to her middle-of-the-night awaking would be to restrict her wine consumption to earlier in the evening so that the particular phase of detoxification is complete before she goes to bed. Ann also shared that she often has racing thoughts at night and that she finds it difficult to unwind and relax without wine. I would suggest to her that she drink a glass of herbal tea, such as chamomile or lemon tea, to help her achieve drowsiness without the adverse effects of waking up in the middle of the night. I will have Ann also track the quality of her sleep on nights that she drinks wine earlier in the evening and has tea right before bed. By maintaining this journal over the course of a couple months, Ann can identify how alcohol affects her mind and her body.
Ann shared with me that she has been contacting her oncologist frequently, worrying that her cancer has come back. If she ever feels tired, nauseous, dizzy, or has any intestinal problems, she calls the office right away out of fear that her cancer is spreading. She worries that if she does not go to the doctor to get checked when she is feeling this way, she will allow the cancer to metastasize and her life will be cut short. The doctor has confirmed via blood tests that she does not have any cancer, and that these symptoms are not the result of any other physical issues.
Ann’s hypervigilance is the result of increased levels of norepinephrine in the brain. This hypervigilance, often common in individuals who are more anxious and tenser, can present itself in the form of an uneasy stomach or queasy gut. Ann’s worried mind is searching for reasons to explain her worried body; her interpretation of these somatic responses is that her cancer has returned. Ann is so over-focused on these physical symptoms as signs of cancer that she does not stop to reflect on other reasons she may be feeling this way. With Ann, I would ask her to keep track of and record the different kinds of sensations she feels on a daily basis in a journal, as well as the emotions that accompany them. This homework exercise will help Ann get better at reading her body and help her learn to decipher the difference between anxiety and other emotions. The hopes with this exercise is that if Ann feels this sense of dread as a true warning sign, she will be more informed about it and will not have any confusion whether she should feel it or not. By practicing this and being more in tune with her emotions, Ann will be able to more confidently label her uneasy stomach, intestinal problems, and dizziness as products of her anxiety and use thought defusion techniques to disassociate these feelings and thoughts from cancer.
Ann’s worry has caused clinically significant distress in her life and has robbed her of joy. Her fatigue and inability to focus has also impacted her work and her overall quality of life. It is unreasonable to expect Ann to avoid worry altogether; however, we can implement certain techniques to contain her worry.
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