Sunday, June 30, 2013

Piglet: Generalized Anxiety Disorder

Client: Piglet

Background Information: Piglet is a young male pig from the Winnie the Pooh Series by A. A. Milne.  Piglet is not currently employed and resides in the Hundred Acre Wood.  Piglet lives alone in a home that, according to Piglet, once belonged to his grandfather, "Trespassers William".  His housing is stable and the house is well cared for.  Piglet does not have any physical health problems.  Piglet's goal is to become brave and be not so timid. 

Description of Problem: Piglet is very timid and displays frequent and severe characteristics of anxiety and nervousness.  Piglet stresses and worries that any situation can go wrong and dwells on what he will need to do if everything does go wrong.  For example, in conversation with his best friend Pooh Bear, Piglet asked, "Supposing a tree fell down, Pooh, when we were underneath it?".  Piglet is afraid of the dark and the wind.  He also has an unrealistic fear of heffalumps and woozles.  Some of Piglet's other worries include, being abandoned and his small size.  Piglet frequently gets flustered during conversations and stutters when he talks. 

Diagnosis: 300.02 Generalized Anxiety Disorder

A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities.  

Piglet meets the duration criteria as he has had excessive anxiety and worry (apprehensive expectation) for his whole life.  

B.  The person finds it difficult to control the worry.

Piglet is unable to control his worries and feel like he constantly lives under the weight of his anxieties.  Piglet frequently discusses his fears with his friends and he wishes that he was brave. 

C.  The anxiety and worry are associated with three (or more) of the following six symptoms.

1. Restlessness or feeling keyed up or on edge
Piglet frequently shows signs of restlessness and being on edge as he is frequently startled.   Piglet becomes agitated and anxious when he leaves his house because he believes something will always go wrong.  In stressful situations, Piglet's anxiety levels tend to elevate and worsen.

2. Being easily fatigued 

3. Difficulty concentrating or mind going blank
Piglet has difficulty concentrating when listening to others speak.  Piglet's thoughts often race and jump from one bad scenario to another with little control over the anxious thoughts. 

4. Irritability

5. Muscle tension
When Piglet is anxious or afraid he displays symptoms of autonomic hyper-arousal, such as rapid heart beat and shortness of breath, accompanied by muscle tension.  

6. Sleep disturbances (difficulty falling or staying asleep, or restless unsatisfying sleep)
Piglet has difficulty falling asleep as he is afraid of the dark and will frequently hide under the covers when he is anxious.  Piglet frequently has nightmares and restless sleep where he wakes up feeling tired. 

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during post-traumatic stress disorder.
Piglet's anxiety and worry are not a result of panic disorder, social phobia, obsessive-compulsive disorder, separation anxiety disorder, anorexia nervosa, somatization disorder, hypocondriasis, or related to PTSD.  

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  
Piglet's anxiety causes him clinically significant distress.  Piglet's anxiety and worry are debilitating and distressing for Piglet because he spends a significant amount of time dwelling on and preparing for worst case scenarios.  Piglet's anxiety impairs his social functioning.  For example, Piglet's fear of the wind prevents him from leaving his house to see his friends.  

F. The disturbance is not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.
Piglet does not use drugs and is not on any medications.  Piglet does not have any medical conditions.

Strengths: A strength of Piglet's is that despite his overwhelming anxiety he often pushes through his fears to rescue his friends.  Piglet shows considerable resilience.  Piglet has a great support network of friends who live in the same neighborhood, especially his best friend Pooh Bear.  Another strength of Piglet's is that he is open to talking with his friends about his fears and anxieties.  Piglet frequently uses positive self talk to encourage himself to face his fears and to calm himself down when anxious.

Treatment Plan: Cognitive Behavioral Therapy (CBT) is an evidence-based approach that is effective for treating generalized anxiety disorder.  Piglet  has shown previous success with cognitive techniques.   For example, Piglet asked "Supposing a tree fell down, Pooh, when we were underneath it?".  Pooh carefully thought and then replied, "Supposing it didn't" and Piglet was comforted by this.  CBT could help Piglet learn to monitor his anxiety symptoms and to recognize his negative thought patterns.  Through cognitive restructuring, Piglet could learn to challenge and replace the negative thoughts that contribute to his anxiety.  Piglet could benefit from learning relaxation techniques and breathing exercises to reduce tension and help him learn how to relax during stressful situations. 

Winnie the Pooh Series by A. A. Milne
Winnie the Pooh Series by A. A. Milne
Winnie the Pooh Series by A. A. Milne
Winnie the Pooh Series by A. A. Milne


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