13 Session Overview
Initial Assessment with Maggie
Presenting Problem & Referral Context
Mood & Presentation: Maggie attended her intake session after referral from her primary care physician (PCP), Dr. Munson, following an acute episode at work involving palpitations, tachycardia, hyperventilation, and diaphoresis. Emergency evaluation ruled out cardiac causes, and she was diagnosed with anxiety. Dr. Munson prescribed PRN (as needed) Xanax (.25 mg) and recommended therapy. Maggie has not yet begun taking the prescription medication given her nursing background, expressing concerns about the risk of dependence with benzodiazepines. When asked, no concerns about misuse of prescribed or illicit substances were identified.
CBT Skills
- Rapport building
- Began during the initial phone call with Maggie, but will continue to grow and evolve with each session
- Assessment
- Explored presenting symptoms
- Conducted biopsychosocial assessment
- Psychoeducation
- Cognitive distortions
- Catastrophizing
- All-or-Nothing Thinking
- Overgeneralization
- Self-Blame
- [Negative] core beliefs
- e.g., “I am weak.”
- [Negative] automatic thoughts
- e.g., “I can’t handle this.”
- Cognitive distortions
- Sleep hygiene and relaxation techniques
- Generational patterns
- Identified strengths, resources, sources of stress, and areas of resilience
- Treatment planning
- Cognitive Behavior Formulation
Symptom Profile & Functional Impact
Maggie describes chronic, pervasive worry with episodes of acute panic-like symptoms across multiple domains: work performance, parenting, financial strain, personal health, and long-term caregiving for her younger son, Theo, who has cerebral palsy (CP).
Symptoms observed/reported:
- Cognitive: Persistent worry, intrusive thoughts, difficulty concentrating, negative self-appraisals (“I’m weak,” “I’m falling apart”)
- Physiological: Muscle tension, tachycardia, sweating, sleep disturbance
- Emotional: Irritability, guilt, emotional exhaustion
- Behavioral: Sleep disruption due to nightly “to-do” lists, recurrent nightmares involving parental neglect/failure
Symptom Profile & Functional Impact
Maggie describes chronic, pervasive worry with episodes of acute panic-like symptoms across multiple domains: work performance, parenting, financial strain, personal health, and long-term caregiving for her younger son, Theo, who has cerebral palsy (CP).
Symptoms observed/reported
- Cognitive: Persistent worry, intrusive thoughts, difficulty concentrating, negative self-appraisals (“I’m weak,” “I’m falling apart”)
- Physiological: Muscle tension, tachycardia, sweating, sleep disturbance
- Emotional: Irritability, guilt, emotional exhaustion
- Behavioral: Sleep disruption due to nightly “to-do” lists, recurrent nightmares involving parental neglect/failure
Psychosocial & Cultural Identity
Maggie identifies her heritage as Cuban but does not feel connected to Cuban or Hispanic culture, instead identifying as American. She expresses uncertainty about racial/ethnic self-identification on official forms, describing feelings of being a “poser” when checking “Hispanic.” Her parents arrived in the U.S. as unaccompanied child refugees during Operation Pedro Pan, quickly assimilating and retaining only partial cultural practices (occasional Spanish, traditional cooking, etc.). She knew her maternal grandparents but lost both before age eight. Maggie maintains a small but supportive social network, including friends from nursing school and a monthly CP parent support group with sibling support for her older son.
Fill in the Blanks
Clinical impression:
F41.1 Generalized Anxiety Disorder, Chronic, r/o with panic attacks
Key Clinical Moment: Guilt About Theo’s Diagnosis
Maggie disclosed a core belief that Theo’s cerebral palsy is her fault. This belief is linked to being four months pregnant at the time of her father’s suicide and experiencing weeks of traumatic grief:
“No wonder his brain development got all screwed up… poor kid.”
Despite medical reassurances that grief could not cause CP, she continues to feel responsible, reflecting personalization and emotional reasoning. With gentle cognitive restructuring, you drew a parallel to her misinterpretation of panic symptoms as a heart attack. Maggie acknowledged the irrationality intellectually, but noted the emotional persistence of guilt, highlighting a future treatment target.
Safety, Trauma, and Relevant History
- Suicide risk: Denies suicidal ideation or attempts; cites commitment to children and mother’s emotional fragility
- Homicide/violence risk: Denies homicidal ideation, aggression, or property destruction; describes herself as an “internalizer”
- Other trauma: No history of abuse; primary significant loss was father’s suicide (Maggie age 26)
- Education & occupation: High school graduate, completed nursing school, employed as RN for 16 years
- Legal history: No criminal record aside from minor traffic violations
- Housing/financial: Stable home-ownership; income from nursing salary, Theo’s disability benefits, and intermittent child support; denies food insecurity
Treatment Goals
- Reducing persistent, intrusive worry that interferes with life satisfaction
- Addressing guilt related to Theo’s CP
- Processing unresolved guilt and grief over father’s death and perceived failure to foresee his suicide
Resources & Strengths
- Willingness to invest time in therapy despite limited free time
- Financial stability and insurance coverage
- Emotional support from mother and best friend
- Perseverance (“If I could get through nursing school, I can get through anything”), hard-working nature, strong will to change
Identified Barriers
- Limited time due to caregiving and work demands
- Theo’s health crises, which occasionally require prolonged hospital stays and suspension of all other commitments
- Need to prioritize therapy amidst competing demands
Cognitive-Behavioral Formulation
Core beliefs:
- “I must protect others at all costs.”
- “I am responsible for preventing harm.”
- “If something bad happens, it is my fault.”
Common distortions:
- Catastrophizing
- Personalization
- Disqualifying the positive
- Emotional reasoning
Diagnosis & Discussion
You reviewed diagnostic criteria for Generalized Anxiety Disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) with Maggie, confirming her symptoms met the diagnostic thresholds. Together, you discussed the treatability of GAD with CBT and introduced the workbook Overcoming Generalized Anxiety Disorder: A Relaxation, Cognitive Restructuring and Exposure-Based Protocol for the Treatment of GAD. Maggie expressed relief and optimism about a structured, evidence-based approach, comparing it favorably to clinical protocols she uses in nursing. This marked a visible “lightbulb moment,” strengthening treatment buy-in.
Multiple Choice
Initial CBT Interventions
- Psychoeducation: Anxiety physiology; CBT model linking thoughts, feelings, and behaviors
- Cognitive Restructuring (intro): Challenged personalization regarding Theo’s CP
- Behavioral Strategies: Discussed sleep hygiene; introduced nightly wind-down routine
- Coping Skills: Introduced grounding (5-4-3-2-1) and paced breathing for acute anxiety
- Homework:
- Read workbook sections “Session One” and “Preview to Session Two”
- Complete State-Trait Anxiety Inventory (STAI) for baseline measurement
- Begin daily thought log
CBT Skills: This is the time to get feedback from Maggie about the session, answer any questions, and outline homework goals.
- Psychoeducation:
- Ongoing assessment for trauma-related features or complicated grief
- Expand work on guilt-related cognitive distortions
- Explore intergenerational trauma and cultural identity as they relate to anxiety and caregiving
