436- Anxiety Case Study
Using the PACER Method
Counselor Toolbox Podcast Episode 436
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs.com

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Podcast Host: Counselor Toolbox and Case Management Toolbox
– Review a case study using the transdiagnostic, transtheoretical PACER approach

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

– 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)

– 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.

– 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.

– 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

– 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

– 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- _______ 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- ___-_____

– 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

– 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__

– 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__

– 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.

Cognitive: Hardiness
– 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.

– 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__
– 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___
– 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

– 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.

– 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.

– 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.

– Specific Worries for Discussion
– 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.

– Specific Worries for Discussion
– 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.

– 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.

Case Study Review
– Assessment Sheet