Chapter 1. Patient: Allison

1.1 Introduction

1.2 Presenting Complaint

Allison, a 33-year-old white woman, knew that it was finally time for her to seek psychological services. She had always been an anxious person and, for years, had managed to keep it under control. But, this time she felt as though she was fighting a losing battle and worried that it was going to result in her being fired from her job. Allison worked as a flight attendant for a major airline and loved interacting with the passengers. She was particularly proud of her extensive knowledge of aircraft safety regulations and had confidence in her ability to properly manage a crisis situation should it arise. However, over the past year she had missed a significant amount of work because of her extreme anxiety about flying and staying in hotels in different cities. She had wanted to believe that her worry about her career was justified, but she knew deep down that she worried about everything, not just work. She worried about other things that most people would see as trivial: whether she would be caught in the rain without an umbrella, if she was going to remember to pay her bills on time, or if the bus she was riding would break down and leave her stranded.

Allison recalled that she noticed a change in her thinking after the terrorist attacks of September 11^th, 2001. She repeatedly thought, “That could have been me in that plane. What would I have done? This is just one more sign that the world has become a very dangerous place.” Allison finds that she can’t relax on her days off because she spends the entire time worrying about taking her next flight. “I worry all the time--about everything.” She worries that she will miss the bus to the airport and be late for work. She worries that she will have a panic attack on the airplane and the pilots will have to make an emergency landing. Allison has experienced a few panic attacks in her life, but has not had a panic attack in more than two years. But she still carries Xanax with her everywhere she goes, just in case she needs it. In the past, once Allison made it to work she was able to relax somewhat. But now, she worries about being the target of a terrorist attack or dying in a plane crash. She also worries about where she will be staying once she reaches her destination. “We always arrive so late, and have to take a cab to our hotel. Some of those cities have very high crime rates and are extremely dangerous. It’s just not safe to be a single woman out at that time of night.” Allison finds that she can worry about all of these different issues almost simultaneously, which leaves her feeling exhausted and overwhelmed. This is usually when she calls in sick to work and goes back to bed.

Although she always hopes that she can just sleep away her problems, Allison inevitably finds that a good night’s rest is ellusive. It is always the same: When she goes to bed she can’t shut her mind off and her thoughts keep racing. Many nights she spends hours trying to fall asleep, which just causes her to worry that she will be less able to function adequately in her job when she is sleep-deprived. Furthermore, she notices that she has a much shorter fuse with the people around her when she is stressed and tired. Allison worries about this, too, because she doesn’t want to lash out at one of her co-workers and create tension among the staff.

From as far back as she can remember, Allison has always been called a “worry wart.” She recalls that when she was 7 years old she would walk around the house making sure that all the appliances were unplugged before she went to bed for fear that a fire would break out and burn the house down while everyone was sleeping. In the 3^rd grade, after hearing doctors talking about the relationship between cancer and smoking, she became convinced that her mother was going to die of lung cancer because she had been a smoker for many years. Furthermore, she began to worry that everyone else in the family would also become ill from the second-hand smoke. Many years later, even after her mother quit smoking, Allison still worried about dying from cancer.

She also often worried about someone in her family getting killed in a motor vehicle accident. Allison was not a typical 16-year-old adolescent because she had no desire to learn how to drive. Driving was a very scary and dangerous activity. One day her father told her that she absolutely needed to know how to drive and signed her up for driving lessons. She eventually received her driver’s license and within the first six months of driving was involved in two accidents, neither of which were her fault. After the second accident, Allison came to the conclusion that driving is just not safe and that she had used up her good luck in the first two accidents. She has never driven since and instead rides the bus.

One of the reasons it has been difficult for Allison to seek treatment is that, although she knows her anxiety is starting to interfere with her life, there is a part of her that feels afraid to give it up. She also believes that some of her anxiety has been helpful. For example, she believes that worrying about safety and being vigilant has been a good thing because it has kept her safe until now. She feels that people, in general, aren’t concerned enough about personal safety and that is why they end up in dangerous situations. In addition, years of experience have taught her that if she worries, it seems to help prevent the negative event from occurring. Although some people call her superstitious, Allison points to the fact that one of the reasons her mother quit smoking was because she didn’t want to add to Allison’s stress, and as a result of Allison’s continued worrying, her mother never started smoking again and is healthy and cancer-free today.

Even so, Allison found herself in the psychologist’s waiting room doubting whether she had made the right decision. “After all,” she thought, “everyone has some anxiety, right? What if this doctor thinks I’m really crazy for thinking this is such a problem? Even worse, what if she tells me that I’m so messed up that I’m beyond help! Then what will I do?”

1.3 Social/Family History

Allison was born the youngest of six children. She and her siblings were raised by both biological parents in an average-sized town in Ohio. She always considered herself the “black sheep of the family.” Her four eldest siblings were boys and although she got along with them fine, the age and gender difference made her feel that their relationships were more paternalistic than anything else. She had one sister who was three years older; however, she described their relationship as “superficial” because they had such different personalities and views of the world. Allison’s sister never seemed to worry about anything. She took every day as it came and couldn’t understand why Allison was always thinking about the future and not living in the present. Allison felt inadequate around her sister, who seemed to be successful in everything she did, and she believed that her sister looked down on her for having problems with anxiety.

Her father never seemed to understand her either. Allison always felt as though her father was very distant and difficult to impress. He wasn’t just like this with her. In fact, he seemed to have little to do with any of the children. Her father worked long hours and when he was not working he had to take his wife out to run errands since she was afraid to go out alone. Allison tried so hard to do well in school just to impress her father, but it seemed as though whatever she did wasn’t quite good enough to get his sustained attention.

Allison often had to rely on her older siblings to take care of her as her mother was always “sick.” Her mother rarely left the house, unless she was with her husband, and would spend hours locked in her room. It seemed as though the whole family just accepted the way her mother was and never questioned if she may need treatment of some sort. As an adult, Allison came to believe that her mother suffered from agoraphobia. She remembers from a very young age how her mother would talk to her about how dangerous the world is. They would often watch the news together and her mother would point out all of the terrible things that could happen to people if one is not extremely cautious at all times. She remembers never being allowed to play out on the street with the other neighbors or spend time at a friend’s house unless a parent was directly supervising. As a result, she did not have many friends growing up, which added to her feelings of being different from everyone around her.

When she was 8 years old, the only person Allison was allowed to spend unsupervised time with was their neighbor, Mr. Jack. Mr. Jack was 45 years old, never married, and loved to work in his garden. Allison was permitted to help Mr. Jack in his garden while her mother was either in the kitchen or on their deck. This way she could still see Allison but did not have to be right by her side.

Allison was well aware of the rules but started accepting Mr. Jack’s invitation to come in the house for a quick drink of iced tea and some candy as a thank you for her hard work. One day, while her mother was gathering laundry downstairs, Mr. Jack invited Allison over for cookies and milk. She figured she could be back home before her mother found out and rushed over to Mr. Jack’s house. That day, Allison was sexually abused by Mr. Jack. She never told anyone in her family about what had happened and never went over to his house again. Allison still experiences an extreme amount of guilt related to the molestation because she didn’t listen to her mother and believes that the abuse was her fault because she trusted someone she didn’t know very well.

Allison struggled with romantic relationships while she was growing up. She knew she had problems with trust, but given her past experiences she didn’t know when it was safe to trust someone. When she was 29 years old, she began dating someone with whom she felt a true connection. He was an airline pilot and therefore understood some of her anxieties about flying and spending so much time away from home. After they had been dating for two years, Allison found out that she would be required by her job to move to Seattle, Washington. Initially, she was very wary of such an abrupt change; she had lived in Ohio her entire life. However, when her boyfriend told her that he would move with her she became excited about their future and agreed to the transfer. Because of different flying schedules, it was necessary for Allison to move to Seattle a week before her boyfriend. While she was there, setting up their new apartment, her boyfriend called and informed her that he was not going to move and “wanted some time apart.” Allison was completely crushed, had a severe panic attack, and spent her first night in Seattle in the emergency room. Since that time, she has not dated anyone seriously and while she lives alone, she claims that she is terrified of being burglarized. In fact, she even keeps a large pair of men’s tennis shoes and a large dog bowl outside her front door despite being single and not owning any pets.

1.4 Multiple-Choice Questions

1.5 Treatment