Can you create a case study for a patient with anxiety, including assessment and management plan?

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Last updated: October 4, 2026 • View editorial policy

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Case Study: Adolescent with Anxiety Disorder

Patient Presentation

Sarah, a 15-year-old female, presents to the clinic with her mother reporting escalating worry, difficulty sleeping, and avoidance of school for the past 6 months.

Chief Complaint

  • Persistent worry about academic performance and social situations
  • Sleep onset insomnia (taking 2+ hours to fall asleep)
  • Missed 15 school days in the past 2 months
  • Physical symptoms: headaches, stomach aches, muscle tension

History of Present Illness

Sarah reports constant worry about "everything going wrong" - particularly about tests, peer judgment, and family health. She checks her homework repeatedly (3-4 times nightly), seeks excessive reassurance from parents, and has begun avoiding social gatherings. Symptoms intensified after transitioning to high school. No history of trauma, substance use, or suicidal ideation.

Assessment Findings

Key diagnostic indicators to evaluate 1:

  • Onset timing: Symptoms began at age 14-15 (consistent with typical GAD/social anxiety onset in adolescence)
  • Functional impairment: School avoidance, social withdrawal, sleep disruption
  • Physical manifestations: Autonomic hyperreactivity (tension headaches, GI symptoms)
  • Comorbidity screening: Depression symptoms (low mood 3/7 days), no ADHD or substance use

Screening measures administered:

  • GAD-7: Score 16 (moderate-severe anxiety)
  • PHQ-9: Score 8 (mild depression)
  • Social Anxiety Scale: Elevated scores in performance situations

Diagnosis

Primary: Generalized Anxiety Disorder with comorbid Social Anxiety Disorder Secondary: Mild depressive symptoms (subsyndromal)

The comorbidity pattern is typical, as anxiety disorders show high heterotypic continuity and frequently co-occur 1.

Treatment Plan

First-Line Treatment: Cognitive Behavioral Therapy (CBT) is the recommended initial intervention 1, 2

Specific CBT protocol 2, 3:

  • Individual sessions with therapist trained in anxiety-specific CBT models
  • 12-16 weekly sessions (45-60 minutes each)
  • Core components:
    • Psychoeducation: Anxiety cycle, fight-flight response
    • Cognitive restructuring: Challenge catastrophic thinking patterns
    • Exposure hierarchy: Gradual confrontation of avoided situations (school attendance, social events)
    • Relaxation training: Progressive muscle relaxation, diaphragmatic breathing
    • Behavioral experiments: Test anxious predictions

If face-to-face CBT unavailable: Self-help with therapist support is an acceptable alternative 2.

Pharmacotherapy Consideration

Given moderate-severe symptoms with functional impairment, consider adding SSRI medication 1, 3:

First-line medication options:

  • Sertraline: Start 25 mg daily, titrate to 50-200 mg
  • Fluoxetine: Start 10 mg daily, titrate to 20-60 mg
  • Escitalopram: Start 5-10 mg daily, titrate to 10-20 mg

Rationale for medication: Sarah has moderate-severe symptoms (GAD-7 = 16), significant functional impairment (school avoidance), and comorbid depressive symptoms. Both CBT and SSRIs have "considerable empirical support as safe and effective short-term treatments" 1.

Critical safety monitoring 1:

  • Assess suicidal ideation at baseline and every 1-2 weeks for first 8 weeks
  • Monitor for behavioral activation, agitation, or mood destabilization
  • FDA black box warning: Increased suicidal thinking risk in youth (though absolute risk remains low)

Combined Treatment

There is no strong recommendation for routine combination therapy 2, however in clinical practice, combined CBT + SSRI may be appropriate for:

  • Moderate-severe symptoms with functional impairment (like Sarah)
  • Comorbid depression
  • Inadequate response to monotherapy after 8-12 weeks

Implementation Algorithm

Week 0-2: Assessment & Initiation

  1. Complete diagnostic assessment with validated measures
  2. Screen for comorbidities (depression, ADHD, substance use)
  3. Initiate CBT referral (priority given wait times)
  4. If moderate-severe: Start SSRI (sertraline 25 mg)
  5. Psychoeducation for patient and parents

Week 2-4: Early Phase

  • CBT sessions 1-4: Psychoeducation, cognitive model, identify thought patterns
  • Medication: Increase sertraline to 50 mg if tolerated
  • Monitor: Suicidal ideation, side effects, early response

Week 4-8: Active Treatment

  • CBT sessions 5-8: Exposure hierarchy development, begin in-vivo exposures
  • Medication: Titrate to 100 mg if partial response
  • Target: Return to school (gradual reintegration plan)

Week 8-12: Consolidation

  • CBT sessions 9-12: Advanced exposures, relapse prevention
  • Medication: Assess response (expect 50-60% symptom reduction)
  • Reassess GAD-7, PHQ-9 scores

Week 12+: Maintenance

  • Continue CBT if available (up to 16 sessions)
  • Maintain SSRI for 12 months minimum after remission 3
  • Monthly monitoring visits

Common Pitfalls to Avoid

Assessment errors:

  • Missing comorbid depression (present in Sarah's case) - requires integrated treatment approach 1
  • Failing to assess functional impairment beyond symptom counts
  • Not screening for behavioral inhibition or negative affectivity as vulnerability factors 1

Treatment errors:

  • Starting medication without psychotherapy referral (CBT should be prioritized or combined) 1
  • Inadequate SSRI dosing or duration (need 8-12 weeks at therapeutic dose)
  • Premature discontinuation of successful treatment (maintain 12+ months) 3
  • Using benzodiazepines in adolescents (not recommended as first-line) 3

Safety concerns:

  • Insufficient suicide risk monitoring during SSRI initiation 1
  • Not involving parents in treatment (family involvement improves outcomes)
  • Ignoring school-based accommodations (504 plan may be needed)

Expected Outcomes

Response timeline 1, 3:

  • CBT: Improvement typically by session 6-8
  • SSRI: Initial response 4-6 weeks, full effect 8-12 weeks
  • Combined: Potentially faster and more robust response

Target outcomes:

  • GAD-7 reduction to <10 (mild range)
  • Return to full school attendance
  • Resumption of social activities
  • Improved sleep (sleep latency <30 minutes)
  • Parent-reported functional improvement

Long-term considerations: Anxiety disorders show chronic, waxing-waning course with high recurrence risk 1. Maintenance treatment and relapse prevention strategies are essential. Sarah should continue SSRI for 12+ months after achieving remission, with gradual taper under supervision.

References

1
Guideline

clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders.

Journal of the American Academy of Child and Adolescent Psychiatry, 2020

3
Research

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - Version 3. Part I: Anxiety disorders.

The world journal of biological psychiatry : the official journal of the World Federation of Societies of Biological Psychiatry, 2023

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.