Case Formulation [4Ps]

Client Goals

To reduce daily anxiety and panic attacks, return to full-time work as a project manager, and re-engage in social activities without relying on alcohol to cope.

Presenting Problem/S

34yo female (Sarah Jenkins, DOB: 14/05/1990, Medicare: 2948 58201 1) presenting with a 4-month Hx of escalating generalised anxiety, frequent panic attacks (3–4x/week) characterised by palpitations, SOB, and dizziness, alongside initial insomnia and occupational burnout. Currently on stress leave.

Predisposing Factors

• Biological: FHx of maternal anxiety and MDD.
• Psychological: High trait perfectionism, hyper-responsibility, and core beliefs centered on linking self-worth to productivity ("If I fail at work, I am worthless").
• Social: Childhood environment with high parental academic expectations and conditional praise.

Precipitating Factors

• Company restructuring in 11/2024 resulting in redundancy of peers and doubling of client's workload.
• End of a 5-year de facto relationship in 12/2024, requiring sudden relocation to a solo rental property and increased financial strain.

Perpetuating Factors

• Biological: Poor sleep hygiene, high caffeine intake (4–5 espressos/day), and evening EtOH use (2–3 glasses of wine nocte to initiate sleep), leading to rebound anxiety.
• Psychological: Catastrophic misinterpretation of somatic anxiety symptoms, chronic worry, and rumination regarding career progression.
• Social/Behavioural: Behavioural avoidance of workplace communications and social withdrawal from support networks, reinforcing isolation and perceived inability to cope.

Protective Factors

• High psychological insight and strong motivation for therapy.
• Supportive relationship with younger sister living locally.
• Financial stability via accrued sick leave and income protection insurance.
• Good baseline physical health; previously enjoyed regular Pilates and running.

Problem List

• Panic attacks with somatic symptoms (palpitations, SOB, dizziness)
• Pervasive occupational and financial worry
• Initial and maintenance insomnia
• Maladaptive coping strategies (behavioral avoidance, increased EtOH and caffeine use)
• Social withdrawal

Treatment Goals

• Reduce panic attack frequency from 3–4x/week to < 1x/month within 8 weeks.
• Eliminate evening EtOH use on weeknights and reduce caffeine to ≤ 2 cups/day prior to 12:00 within 4 weeks.
• Improve sleep efficiency, achieving sleep onset within 30 mins of lights out.
• Develop and execute a graded return-to-work (RTW) plan in collaboration with GP and employer over 10 weeks.

Case Formulation

Sarah is a 34yo female presenting with acute-on-chronic anxiety, panic attacks, and insomnia, precipitated by concurrent occupational overload and a relationship breakdown in late 2024. She is biologically predisposed via a maternal FHx of affective disorders and psychologically vulnerable due to entrenched perfectionistic schemas formed in a high-expectation childhood environment. The dual stressors of company restructuring and relationship dissolution activated her core belief of inadequacy. Her symptoms are currently perpetuated by a cycle of hypervigilance to somatic cues, catastrophic cognitions, and maladaptive behavioural responses, including avoidance of work reminders and social isolation. Physiologically, excess daytime caffeine and nocturnal EtOH use disrupt her sleep architecture and lower her threshold for autonomic arousal. Despite these challenges, Sarah possesses strong protective factors—including high insight, sisterly support, and financial buffer—which position her well to engage in psychological intervention.

Treatment Mode/Interventions

• Cognitive Behavioural Therapy (CBT): Psychoeducation on the panic cycle and fight-or-flight response; cognitive restructuring targeting perfectionism and catastrophic misinterpretations; interoceptive and in vivo graded exposure for panic and work-related avoidance.
• Arousal Reduction & Lifestyle: Progressive muscle relaxation (PMR), diaphragm breathing, sleep hygiene protocol, and stimulus control.
• Pharmacotherapy (per GP): Continue escitalopram (Lexapro®) 10 mg PO mane (commenced 3 weeks ago; GP reviewing at 6-week mark).