CW is a patient that I’ve seen twice in an outpatient private practice setting, as referred for therapy services by a psychiatrist in the same practice. CW is a 25-year old white homosexual male with a diagnosis of anxiety NOS with somatization focus. He also has obsessive-compulsive personality features and engages in episodic alcohol excess. He lives with his partner of three and a half years, has a bachelor’s degree, and is employed as a grants manager in a local law enforcement agency.

 

CW sought mental health services for “anxiety, catastrophic thinking, and fear of illness.” He admits to being “somewhat of a hypochondriac,” but feels like his symptoms have worsened over the past year or so. He did give some examples of his illness anxiety fears. He experienced headaches with mild facial numbness at work, and felt convinced it was a brain tumor. Sought care and had negative MRI. Most recently, he experiences intermittent tremors in his hands or feet and is worried he has ALS. Neurologist did an EEG, which was negative, and now he can’t stop thinking that perhaps he also needs an EMG for a more complete evaluation.  He realizes this kind of thinking is irrational, and he is hoping that therapy will effectively help him to quit.

 

Past medical/surgical history is significant for bilateral hip surgery (open reduction internal fixation) at age 13 and again at age 14. Patient has no current relevant medical issues or disabilities, and he denies any other past psychiatric history or psychotropic medication use.

 

His parents divorced when he was an infant, and he was raised by both his mother and stepfather. He reports having a good relationship with both, although stepfather just recently learned of his homosexuality (mother hid this information from him). His mother drinks alcohol, and both she and his stepfather smoke marijuana. His older brother was involved in drugs and spent some time in prison. Patient admits to binge drinking on the weekends, typically having at least six mixed drinks at a time. Smoked marijuana occasionally in college, but found this to be too anxiety provoking.

 

CW is alert and oriented to person, place, and time. He is well groomed and pleasant. Intelligent and articulate, with coherent thought processes and good insight. Recent and remote memory is intact. Appears calm but mood does project an undercurrent of anxiety.

 

The psychiatrist started him on sertraline and hydroxyzine, and advised to cut back on alcohol use.

 

During the course of the therapy sessions (in which I primarily observed), he recalled a moment when he was eight years old, in which he fell off a trampoline and injured himself. He went to his mother crying and looking for comfort. She called him a hypochondriac, said that he was fine. He recently realized that comment has stuck with him ever since. He also recalled developing a limp when he was 13 years old. His parents “blew it off” and thought he was just looking for attention. He ended up needed surgery in both hips, not once but twice. He feels like both of these episodes are somehow connected to the somatic anxiety he has today.

 

The therapist did ask some solution therapy based questions. For example, “What would be different and how would you see that therapy will have been a success?” His response: “I would be coping better with body symptoms and my anxiety. When I have tremors in my hands I could move on and not dwell on the symptoms.” Indeed, during the next session he pointed out that work distraction helps him to change his thought processes and focus on something else. When asked what he wants to work on primarily in therapy, his response is “health anxiety.” Patient is still wondering about ALS, and wants to go back to the neurologist to request an EMG.

 

The therapist is trained in EMDR therapy, and she feels that this process can help CW tremendously. She feels like he did not effectively process the earlier life events as described above. He was very open to trying EMDR, and agreed to start with phase one right away (history and treatment planning). In the next session, phase two (preparation) was started. I was present while they engaged in creating a safe place exercise. It was very interesting to watch. The patient closed his eyes, took deep breaths and created/described his safe place. In his scenario, he is driving a red convertible Mazda Miata along the pacific coast. He went on to describe the car, road, scenery, weather, what he was wearing, what he was hearing, and what he was thinking. He was asked to do a body scan before and after, and he did note that his initial chest tightness, flushed body, pounding heart, and self-conscious breathing had dissipated. He felt more relaxed in the arms and chest. The bilateral slow eye movements were directed by the therapist’s marker. He was instructed to practice conjuring his safe place two to three times per day at home. The next visit will consist of starting to reprocess past thoughts and feelings.

 

I chose this particular case because I find EMDR therapy to be very interesting.  It is fascinating to me that this form of therapy can help to reprocess negative/traumatic information (memories, thoughts, emotions) into less distressing information, thereby improving overall function of the patient.

 

The two questions I have are:

 

Based on the information I have presented, do you think CW is a good candidate for EMDR therapy even if he does not suffer from PTSD? Why or why not?

 

CW noted that his main reason for seeking mental health services is for assistance with his somatic anxiety. Do you think that his episodic alcohol excess and obsessive-compulsive personality tendencies should also be worked through? If no, why not? If yes, how would you go about incorporating this into a session when EMDR is being conducted?

 

 

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