Anxiety case study

Anxiety Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 436
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com
Podcast Host: Counselor Toolbox and Case Management Toolbox
Copyright 2019 Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 1

Objectives
 Review a case study using the transdiagnostic,
transtheoretical PACER approach
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment 2

 As they say on Law and Order…
 The following story is fictional and does not depict any
actual person or event.”

Case
 Sally is a 49 year old female with one child in college and
a second child who is a senior in high school. She has
started having anxiety, difficulty sleeping and panic
attacks over the last 6 months.
 Her doctor prescribed her Xanax to take as needed to
prevent panic attacks and help her sleep. She says the
rebound anxiety from that is terrible and won’t take it
anymore. She cannot identify any particular precipitating
factor. She says the anxiety came on kind of gradually
over the past few months and the panic attacks only
started in the past few weeks.
 She reports that she was in counseling for a month with
someone else but it wasn’t helping very much. Things are
getting worse and her doctor

Physical
 Sleep
 On an average night how much sleep do you get? REM _2__
Deep _.5__ Light _6___
 On an average night how many times do you wake up?
__3-4___
 After an average night’s sleep how do you feel? Tired
_x__ Okay ___ Energetic ____
 When you wake up feeling refreshed, how much sleep do
you get? REM __3_ Deep __2+_ Light __3+__
 (Sleep has worsened significantly in the last 4 months.)
 Sleep hygiene self assessment. (This will also address
caffeine after noon and alcohol)

Physical
 Nutrition
 Using a free app like SparkPeople, track your nutrition for a week.
 Which nutrients do you get less than 75% the full RDA? Mg, Zn, Fe
 Which nutrients do you get less than 25% of the RDA? None
 When was the last time you had a full panel blood test to examine
your kidney and liver function, thyroid and vitamin D levels?
___18 months
 Describe your eating habits: I eat pretty healthy but tend to be a
stress eater and have cut out all processed foods (breads, cereals)
and red meat
 Do you eat due to stress or for comfort when you are upset? yes
 Do you drink at least 64 ounces of noncaffeinated, nonalcoholic
beverages each day? yes
 How much caffeine do you have on an average day? (100-150
mg/8oz of regular coffee; 35-50 mg/8oz of soda) 1200 (one pot)
Counselor Toolbox Podcast: Overview of the PACER Method and Transdiagnostic Assessment
6

Physical
 Nutrition
 How much nicotine do you have on an average day? (1mg/1 cigarette;
6-24mg/vaping cartridges) __0___
 Are you currently over or under fat? (Note: People can have a lot of
muscle and not be unhealthy) _no____
 Have you recently had any problems with excessive thirst or hunger?
__no
 Do you have problems with hypoglycemia (your blood sugar dropping)?
_yes
 Has your doctor tested your blood sugar lately (fasting blood test)?
__no
 Do you mainly gain weight around your belly? __yes__
 Referral to PCP for physical to include nutritional evaluation, hormone
evaluation and possible addition of multivitamin to address nutritional
deficiencies. Discuss with PCP sleep problems with onset ~beginning
of Mirapex and the possibility of iron deficiency anemia causing RLS.
Discuss with PCP the frequent headaches with floaters. Discuss with
PCP chronic pain issues and possibility of a physical therapy referral.
7

Physical
Medication/Drug/Herb Reason for Taking
It
How Long Prescribing Doctor
(if any)
Mirapex Restless Legs 4 months Dr. Smith
Diet pills without
caffeine
(hydroxycitric
acid/Garcinia
Cambogia, bitter
orange, Yohimbe)
Lose weight 2 months None
Zyrtec (fatigue) allergies 1+ years Dr. Smith
Flexeril Back injury PRN 18 months Dr. Smith
8
Educate about the anxiety side effects of hydroxycitric acid, Mirapex, zyrtec.

Physical
 Pain
 Do you have any chronic pain? __Yes__
 If so what causes it?____Back injury_______________ How
long have you had it? _18 months___
 What makes it worse? __Bending, sitting_________
 What makes it better? _heat, ice, muscle
relaxants____________________
 How has it impacted your
mood/relationships/energy/sleep/self-esteem? Frustrating
to be in pain and tired all the time and not able to do my
gardening_
Educate about ergonomics. Ergonomic self study.

Physical
 Exercise/sedentariness
 Do you exercise? ____yes______ If yes, how often
and for how long? ____daily 45 minutes_____
 How is your energy, mood and appetite after you
exercise? ___good________________
 Do you sleep better on days you exercise? __Y___
Does muscle soreness make it harder to sleep? __Y___
Discuss methods for reducing muscle soreness to improve
sleep

Physical
 Energy
 Which best describes your average energy level
Low___ I can get through the day_x__ Great! ___
 Have you had your thyroid levels tested lately? __N__
If so were they in normal range? __?__
 Using a pulse ox monitor: What is your resting heart
rate? __65_ What is your O2 saturation? __98___
 Do you have high blood pressure? _Y__ (managed with
diet) Heart conditions? _N____ if so, what

Physical
 Libido/Sex hormones
 How is your sex drive? Low __x___ Good _____
Incredible______
 Has there been any change in your sex drive? __Y___ If so
when and what caused it? ____?__
 If you are over 45 have you had your sex hormone levels
tested in the past year? ___N___
 How often do you masturbate or have sex? ___<1_____/
week

Physical
 Do you tend to feel on edge and startle easily? ___N___
 Do you have a history of trauma? ____N___
 Do you have any autoimmune issues/inflammatory conditions like psoriasis,
rheumatoid arthritis, Chron’s disease, lupus etc.? ___N_
 Have you ever had a concussion or other traumatic brain injury? ___N_____
 How often do you have headaches? ____Y__ What triggers them? _stress_
 What helps them go away? ______neck massage or ice/heat___
 Do you ever see spots or floaties when you get a headache? Y__
 Do you get migraines? ___N_____
 How often do you drink alcohol? _daily_ What do you drink? Beer/wine _X_
 How many drinks do you have in an average week? __2-3/night to relax__ 14-21/wk
 Do you gamble or play the lottery? __N___ How much money do you
spend on it each week? _______
13

Affective
 For each of the following feelings, identify how often you feel
it each week, what triggers it and what makes it better.
 I feel happy 0-3 days a week __3__ 4 or 5 days a week __ More
than 5 days a week __
 What 5 things help you feel happy? ___my kids, dogs, shopping,
watching funny movies, hiking___
 I feel sad or depressed 0-3 days a week __0__ 4 or 5 days a week
____ More than 5 days a week ____
 What triggers it? NA
 What helps you feel better? NA
 I feel stressed or overwhelmed 0-3 days a week ____ 4 or 5 days a
week _x___ More than 5 days a week _____
 What triggers it? ___Work, finances, not being able to workout like I
want, too much to do around the house__
 What helps you feel better? __focusing on my kids, cooking

Affective
 I feel anxious or worried 0-3 days a week __ 4-5 days a week
_ >5 days a week __7__
 What triggers it? __kids happiness, whether I was a good parent,
finances, my health, family hx of cancer (Dad died when he was my
age)__
 What helps you feel better? ______?____
 I feel angry, resentful 0-3 days a week __0_ 4 or 5 days a
week __ >5 days a week
 What triggers it?
 What helps you feel better?
 I feel guilty 0-3 days a week __3_ 4 or 5 days a week __ >5
days a week
 What triggers it? ___I regret not doing more with my kids when they
were younger. I feel bad for not being as good of a friend as I should.
 What helps you feel better? ___?_____
15

Affective
 In the past year, I have experienced the following losses which caused me to
feel grief: My dog died. My mother died. My grandmother died. My oldest
child moved out and started college. My best friend barely has time to talk to
me anymore. (NOTE: Youngest child is a senior ---preparing for empty nest)
 What stressors are currently present? __So much misery and hate in the
world. Trying to save for retirement. Work regularly has layoffs. Back injury.
Worried about kids’ choosing a path that will help them be successful and
happy.
 What is different when you are happy? I am spending time with my family
and animals, have time and energy to exercise and go hiking. I am 15 pounds
lighter and the house is clean.
 How long does it take for you to calm down after you get upset? _+/- 1hr
 What helps you calm down? __distracting myself or solving the problem___
Educate about HPA-Axis activation, biofeedback and relaxation techniques. Have
her use her fitness tracker to practice a variety of relaxation techniques when
she starts to feel stressed and/or starts getting a stress headache to reduce her
heart rate by 5 or more bpm
Discuss affective issues in counseling
16

Cognitive
 How is your attention/concentration? ___awful___
 Have you ever been diagnosed with ADHD? _N____
 Has there been a change in your ability to concentrate lately? _Y__
How long? ___6 months___
 If so, what is causing it? __lack of sleep? Stress? I don’t know.
 Does it seem to be taking longer to process information? _Y_
 How is your memory? __Good______ Have you been more forgetful
than usual? ___N_____
 If so, when did your forgetfulness start? NA What is causing it?
 When you think about yourself, your life, the world, other people, do
you tend to feel angry, suspicious or hopeless? ___Y___
 If yes, have you always felt this way or did something happen to
change your feelings? __Started watching the news and spending time
around people__

Cognitive
 Negative self-talk
 Do you frequently judge or criticize yourself? ___Y_______
 Do you hold yourself to a higher standard than you hold
other people? ____N______
 Do you think you are lovable/likeable only if you are perfect
(or almost perfect)? ___N_______
 Where did you learn your negative self talk? __my family,
teen media__

Cognitive
 Pay attention to your thoughts for a week. Place a check by the thinking
errors which are most common for you and contribute to your
unhappiness.
X All or none thinking Find Exceptions
X Assuming/Jumping to conclusions without all the facts Get the facts
X Focusing on a small aspect instead of the bigger picture Consider alternate
explanations
 Expecting life to be fair
X Taking things too personally Consider alternate explanations
 Taking something bad and blowing it out of proportion (catastrophizing)
 Focusing on the negative and ignoring the positive
X Expecting people to be able to read your mind Evaluate how you communicated
what you wanted and practice assertive communication
X Assuming you know what others are thinking. Evaluate your evidence and get the
facts.
Educate about cognitive distortions and interventions. Provide worksheets to
address CDs.
19

Cognitive: Hardiness
What parts of this relationship, experience or thing can you control?
Children
Time quantity and quality I spend with them now. Praise the positive
Spouse/Partner
Time quantity and quality I spend with him now. Pick my battles.
Friend 1:
Time quantity and quality I spend with them now. How I react to the ongoing drama
Friend 2:
Time quantity and quality I spend with them now. How I react to the onesidedness of our
relationship
Friend 3: Reach out to her more often on Facebook. She lives in another state.
Job/School
Set realistic goals. Do things I don’t like but have to and spend the rest of the time doing
things I really enjoy. Find ways to increase my job security.
House Get family to help with cleaning. Keep holiday decorating simple.
Pets
Make an effort to spend time with them. Work on their obedience so they don’t bark as much
and drive me crazy.
Money Develop a realistic budget so I know how much I actually need.
Volunteering
Get my friends to volunteer with me. Set boundaries on my volunteering so I don’t get
overwhelmed by offering to do too much
Health
Exercise and stretch each day. Eat a reasonable diet. Get enough sleep. Don’t smoke.
20
Educate about psychological flexibility and discuss how, how much and how often you intend on doing each of these
things and make a schedule or checklist for 1 week to remind you to do them. Repeat weekly.

Cognitive
 Time management
 How effective are you at managing your time? ___Good if I
give up sleep_____
 Do you often take on too much and feel overwhelmed or
rushed? Yes
 Are you a perfectionist? __N___ If yes, how does that
impact your mood, sleep and relationships?
 Do you procrastinate? __Y__ If yes, how does that impact
your mood, sleep and relationships? __I tend to get irritable
when I have something to do that I am procrastinating then
irritable when I feel rushed.
Develop a schedule that includes the “must dos” delegates and
simplifies when possible.

Environmental
 Do you feel safe most of the time? _____y___ If no,
where do you not feel safe and why?
 What helps you feel safe? __My dogs. My
neighborhood.______
 Are you able to have peace and quiet when you want it
and when you sleep? ___Yes_____ If no, what can you do
to reduce unwanted noise?
 During the day are you able to access natural light, or at
least a really bright working area? ___Yes_
 When you sleep, are you able to make your room totally
dark or block out the light? _Y_
 Do you eliminate blue light from television and electronic
devices at least 2 hours before bed? ___Y__
22

Environmental
 What smells are you regularly exposed to?
 Noxious/unpleasant/irritating __Dog poop, burned food__
 Triggering (reminds you of something unpleasant) __musty smells
(old buildings)___
 Happy/relaxing/energizing __rosemary, basil, roses, caramel, wax
tarts___
 Are you able to keep your environments at a temperature
you find comfortable? __Yes except during hot flashes___
23

Relationships
 Do you feel you are capable, lovable and deserving?
_y____ If not, why not? ___
 Do you have healthy relationships or regularly fear
abandonment? ____Healthy overall______
 Can you effectively identify and communicate feelings and
thoughts and get your needs met? ___y_____
 Do you have a social support system that can provide
practical assistance and emotional support? __practical
assistance, yes…emotional support not as much___

Initial Tx Plan goals
 Referral to PCP for nutritional and hormone evaluation, medication
side effects, headaches. and chronic pain—PT referral (due week 1)
Get feedback from physician visit.
 Sleep duration and quality--Sleep hygiene assessment handout (Due
week 1) Make a sleep hygiene enhancement plan based on handout
data. (Review progress and impact weekly through week 8)
 Emotional dysregulation and biofeedback (Weeks 0-8. Week 1 belly
breathing and object focus) Keep a log of when you do it and the
results. (Repeat each week with different relaxation and distress
tolerance activities)
 Pain frequency, intensity, impact and interventions including
ergonomic assessment (due week 2)
 Cognitive distortions worksheet/log (due week 2-8)
 Hardiness Enhancement with Psychological Flexibility to increase
positive chemicals (Week 3-8)

Initial Tx Plan goals
 Specific Worries for Discussion (Beginning Week 1)
 Kids' happiness
 Whether she was a good parent
 Finances
 Personal health and anxiety related to family hx of
cancer and the possibility of current pain being
permanent
 Guilt for not being the parent she thinks she should
have been and the friend she things she should be
 Grief over empty nest, deaths

Reassessment
 PCP provided PT referral which seems to be reducing pain. Hormone
levels indicated early stages of menopause. Normalized heart
palpitations associated with hot flashes. Blood pressure is stable.
Started taking a multivitamin and eating more grains and green leafy
vegetables to improve nutritional profile. D/cd Mirapex and started
taking iron and magnesium supplements.
 Reports sleeping somewhat better. Still waking up occasionally, but
getting more deep sleep. Energy seems to be improving.**
 Still drinking a full pot of coffee each day, but is drinking half caf. and
stopping caffeine after 3pm. Working toward no caffeine after noon.
 Has cut back on alcohol at night, but still drinks occasionally. Started
taking (per MD 1mg Melatonin to help her get sleepy)
 Biofeedback seems to be helping. She got a new fitness tracker that
monitors her heart rate variability and prompts her to use belly
breathing when it detects she is “stressed” Stress episodes have
decreased from an average of 5 times per day to 3.5 times per day.

Reassessment
 Pain is improving with physical therapy. She got a stability
ball to sit on at her desk to prevent leaning and poor
posture and got a knee pillow to help keep her back in
better alignment when she sleeps.
 She is becoming more aware of her cognitive distortions
which she credits with reducing her “stress episodes” In
session she quickly corrects herself when she makes a
distorted statement and is effectively identifying 85% of
the distorted statements she makes. (I keep a tally sheet
as we talk)
 Hardiness Enhancement with Psychological Flexibility
activity has been her favorite. She reports that she feels
she is making much better use of her time instead of just
feeling stuck and confused.

Reassessment
 Specific Worries for Discussion
 Kids' happiness—She reports realizing that she cannot make
anyone else happy and is focusing now on helping her
children start to use the psychological flexibility tools she
learned in counseling.
 Whether she was a good parent-- Reports she has stopped
focusing on what she should have done to be a good parent
and is more objectively looking at her kids’ overall success
and mood compared to other adolescents.
 Finances—She recognizes that most of her stress about
finances comes from cognitive distortions of catastrophizing
and has made an objective budget and set savings goals
which she is adhering to. She also consulted with a financial
planner to get reassurance that she will have enough money
to retire and not have to work until she is 80.
29

Reassessment
 Personal health and anxiety related to family hx of cancer
and the possibility of current pain being permanent. She
assessed her lifestyle and risk factors for cancer and came to
the conclusion that, while it is possible, her main risk
factors are alcohol use and stress, both of which she is
working to reduce. Regarding her pain, the physical
therapist assured her that it is muscular and not nerve or
spine related so she should recover fully in 3-6 months. She
also recognized that catastrophizing was increasing her
stress about her injury.
30

Reassessment
 Guilt for not being the parent she thinks she should have
been and the friend she things she should be. She is still
working on radically accepting that she cannot change the
past and she is not happy about some of her choices, but she
can start making choices more congruent with her values
starting now.
 Grief over empty nest, deaths. It has not been a year since
her mother’s death and less than 2 years since her
grandmother’s death. They were the last “family” she had
besides her kids and spouse. She is still working through the
bereavement process for those losses and has recognized
that her daughter getting ready to go to college is triggering
a lot of feelings of isolation and loss.

Summary
 By understanding that “anxiety” is an excitatory response brought
on by activation of the HPA-Axis we were better able to
understand the impact of medications, alcohol use, nutritional
deficiencies, grief and chronic stress on HPA-Axis functioning and
resultant anxiety
 Anxiety is the result of stimulation of the HPA axis.
 Panic attacks may be the result of HPA-Axis dysregulation due to
chronic “stress” over the past year
 RLS medications typically increase dopamine causing insomnia
 Insomnia leads to fatigue, hypocortisolism and excessive caffeine
consumption
 Addressing the problem from the standpoint of identifying and
addressing the causes of HPA-Axis dysfunction instead of simply
addressing symptoms with talk therapy can prove much more
beneficial in the long-term.
32

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