Clinical Case No. 3. Generalized Anxiety, Panic Attacks and Financial Instability

Symptoms amid genuine uncertainty

Illustration (Case No. 3 · Anxiety and Panic)Zoom

Amir is 41. He lives with his wife and two school-aged children in Kelowna and works in logistics. After his hours are reduced, the family budget depends on both adults' variable earnings. Rent has risen, and summer visits to relatives are no longer affordable. Initially, his anxiety has an understandable focus: whether there will be enough money next month.

Over eight months, it moves far beyond checking bills in the evening. Almost daily, Amir expects trouble, tenses his shoulders, sleeps poorly and checks work messages even at night. He now worries about more than rent: the children's health, errors in documents and his own memory. His wife's reassurance helps for ten minutes before the next "what if" appears.

One day in a shop, he develops palpitations, trembling, breathlessness and fear of dying. The emergency department evaluates acute physical causes according to his symptoms and risks; investigations find no evidence of acute coronary syndrome. Amir returns home relieved, but within days begins to fear another attack. He avoids queues, stops travelling far from home and asks his wife to stay beside him in the supermarket.

Further assessment identifies persistent generalized anxiety disorder with panic attacks. The clinician clarifies the frequency of unexpected attacks, sustained fear of recurrence and avoidance, and their relationship to caffeine, alcohol, medication and physical symptoms.

Amir drinks several large coffees daily and denies cocaine or amphetamine use. He has had no manic episodes. GAD-7 is 16. TSH, the complete blood count and neurological examination show no significant abnormalities. Financial instability and its effects on sleep and treatment costs are discussed separately.

Finding continuing care

Since moving, the family has not obtained a regular family physician. Amir receives his initial prescriptions and medical notes at different appointments. Each time, he begins with the story about his heart because it seems the most medically convincing. One record emphasizes panic symptoms; another emphasizes insomnia. At every appointment, he explains the previous investigations and prescriptions again.

Ideally, one clinical team would follow treatment response and help him reach CBT of the required intensity. Private psychotherapy costs more than the family can pay regularly. His employer covers only a limited share. The suggestion to "find a psychologist" leaves Amir choosing between treatment and current bills.

Regular sessions can be expensive. The British Columbia Psychological Association's recommended rate for 2025 to 2026 is 245 CAD (approximately 73.1 CAD PPP) per hour; private practitioners set their own fees. Four sessions at this rate would cost 980 CAD (approximately 292 CAD PPP). For Amir, even the portion left after insurance reimbursement competes with rent. [46]

Free materials can be opened in the evening, but by then Amir is exhausted and there is little quiet space at home. The physician assesses the suitability of BounceBack, designed for mild to moderate anxiety, while looking for regular psychological work on his marked avoidance. [41]

Treatment while waiting and subsequent CBT

At later appointments, repeat contact with the same physician becomes possible. She agrees on a low starting dose of sertraline and slow increases, as Amir closely monitors his heartbeat. They discuss initial anxiety, gastrointestinal adverse effects and delayed benefit; CBT is planned in parallel. [121, 122]

After gradual titration to 100 mg sertraline, attacks become less frequent. Avoidance of transport and shops persists, so functional goals need separate work. Amir also reduces caffeine.

Eventually, he begins a limited course of accessible CBT. The psychologist works on catastrophic interpretations of bodily sensations, checking and avoidance. Exercises progress gradually: a short journey, standing in a queue, returning to a task without checking his pulse again. Interoceptive exposure is used when appropriate after clinical assessment. Homework is fitted around his changing shifts and reviewed at the next session. [121]

A social worker helps with available benefits and bills. Following their shared plan, his wife gradually reduces her accompaniment: first she waits outside the shop, then Amir shops alone.

Regaining independence

After six months, Amir travels to work again, shops independently and sleeps better. GAD-7 falls to 7. With income still unstable, he can now discuss expenses, make a necessary phone call and continue his day after bad news.

Maintenance treatment continues with periodic review. If sleep worsens again, Amir has his physician's contact details and a plan for returning to CBT exercises.