Endgames Case report

Tired and anxious

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1241 (Published 01 October 2008) Cite this as: BMJ 2008;337:a1241
  1. Chris Gale, senior lecturer,
  2. Oliver Davidson, associate professor
  1. 1Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, New Zealand
  1. Correspondence to: C Gale christopher.gale{at}stonebow.otago.ac.nz

    Case history

    A 55 year old accountant presented to you three weeks ago. He said that he was tired, sad, tense, and had little enjoyment in life. His sleep had worsened and he had little energy.

    He reported that he had found some aspects of his work difficult during the past 15 years, especially formal presentations and work related social functions. He had been married for 27 years, and his two children were now at university. He did not recall anyone in his family having any serious mental health problems, although his mother was quite anxious, and his wife had been treated for depression three years ago. He could not think of any stressor in his life other than his work. His wife confirmed this and said that he has always avoided social events.

    His general health was unremarkable, and he was taking no drugs. He said he drank between two and five glasses of wine a day.

    You prescribed him a selective serotonin reuptake inhibitor (SSRI) and referred him to a counsellor, but she has advised him to see you again because he drinks up to five glasses of wine before any social situation.

    Questions

    • 1. What is the most likely diagnosis?

    • 2. What questions would you ask when you see him again?

    • 3. He tells you that he is not taking the medication. What advice would you give him?

    Answers

    Short answers

    • 1. The patient seems to be moderately depressed and is a habitual drinker, but these are the consequences of a social phobia.

    • 2. You should clarify the nature of his anxiety—how specific is his anxiety to particular situations, how avoidant has he become, what is the nature of his associated cognitions and worries? You should also ask about his mood, his risk of self harm or suicide, and his past and current …

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