A few years ago, Gary, a young radiologist, called seeking treatment for persistent problems with anxiety. When we met for our initial session, he described himself as having always been a very nervous person and said I put a lot of pressure on myself and I1ve always worried a lot. He was tall and thin and appeared tense throughout the session. He reported that he was experiencing considerable tension at work, had difficulty sleeping, and was having problems with Irritable Bowel Syndrome (IBS).
Gary also said that he lacked confidence in himself and that he frequently double-checked his work due to his insecurities. He asserted whatever confidence I have comes from my girlfriend. He was quite concerned about confidentiality because he had been managing his anxiety by taking Valium from hospital stores and he feared that he would lose his job and his medical license if this was discovered. He had discontinued his use of Valium several weeks previously and said that he was determined not to take it any more. He also reported that from time to time he would suddenly become quite angry for no apparent reason. When asked why he sought treatment at this particular time, Gary said that the most pressing reason for seeking treatment was that the stress of starting graduate school was aggravating his long-standing problem with IBS and he feared that he could develop severe diarrhea at any time.
When I asked about sources of stress, Gary said that he was under considerable stress. In addition to the stress of practicing as a radiologist, he was enrolled in a MBA program and was quite anxious about upcoming examinations. He also reported that he had a very irregular schedule, was frequently on call, and that he found living with his parents to be quite stressful. He reported that his only sources of support were his girlfriend and an older sister.
Gary was the third of five children in a middle-class family. In describing his family background Gary said my parents always did things for me and tore down what I did. He also reported that his sisters always wrote his school papers for him and then told him that he was dumb. When I asked him to describe what his mother was like as he was growing up, he said she1s different. He went on to describe her as being down on men, as always tearing him down, and as never letting him invite friends over because the house was too messy. In describing his father he said I never really got to know the man and said that his father was a workaholic who never believed in me.
He described being a good student and having friends until sixth or seventh grade and said that after that he just got by and was pretty much a loner in high school. He said that he did not know why things changed at sixth or seventh grade. In college, Gary had wanted to become an engineer but his parents had insisted that he go to medical school. Despite his doubts about his ability, Gary had done well in medical school and seemed to be doing well in his practice. He had decided to pursue a MBA so that he could advance into an administrative position. He reported that he had always been uncomfortable with dating and that his current girlfriend was the only girl with whom he had had a long-term relationship. He had been seeing her steadily for about three years.
Gary reported that his parents had taken him to a psychiatrist when his school performance declined in sixth or seventh grade. He reported that therapy was not helpful at that time because I wouldn1t talk to him. Gary said that he had no idea why his school performance declined at that point and said that he did not remember any major events which might have been responsible.
Gary1s top priority for therapy was to cope more effectively with stress and anxiety so that his IBS would cause less distress and he would be able to continue working towards his MBA. He said that once he was coping better day-to-day, he was interested in working on his lack of confidence, his tendency to worry, and his episodes of sudden anger. My initial impression was that Gary was a capable individual who was unrealistically insecure, worried excessively, and was unskilled at coping with stress and anxiety. His ideas about goals and priorities for therapy seemed quite reasonable. My sense was that work on stress management techniques would be quite helpful to him. My plan was to work on decreasing his tendency to worry excessively and increasing his self-confidence once he was coping with stress more effectively and to watch for opportunities to collect more detailed information about his unexplained episodes of anger.
Initially, the case seemed fairly straightforward and the initial interventions directed towards helping him to learn more effective ways of coping with stress and to learn to control his excessive worries went well. Progressive Relaxation Training was introduced as a technique for coping with anxiety and for ameliorating the impact of stress on his IBS. When I guided him through Progressive Relaxation the first time he had some difficulty concentrating and reported worrying Am I going to be able to relax? and Will it help? Despite this, the initial relaxation session went well and he was able to become quite relaxed. The remainder of the second session was devoted to developing a better understanding of Gary1s worries and concerns. He reported frequently worrying that his IBS would result in uncontrolled diarrhea while he was away from home, even though this had never occurred. He also reported frequently worrying about whether he would do well in school, worrying about his finances, worrying whether his girlfriend would leave him, and worrying about making serious mistakes at the hospital. These worries persisted despite the fact that he had a record of good academic performance, was well-off financially, had a stable relationship with his girlfriend, and had practiced radiology for a number of years without making any serious mistakes.
His homework assignment at the close of the second session was to practice the relaxation exercises daily and to use Beck1s Daily Record of Dysfunctional Thoughts (often referred to as a thought sheet) to record the situation, his thoughts, and his feelings at times when his stress or anxiety flared up.