Session 4 Assignment – Case Study

Case Study – Joe

Joe, age 28, came to counseling with sx of anxiety. He was referred by his family doctor. The following is the information he gave his therapist during his first visit.

Joe reported he had a happy childhood. The only problem in the house that he could remember revolved about money. Joe reported that his parents struggled to keep the family afloat. Joe’s father had a series of jobs as a handyman. Eventually he saved enough money and opened a small hardware store. The store mostly broke even, and Joe’s father forced Joe to work in the store everyday after school. When he was in 12th grade, Joe quit high school to work full time for his dad.

Although Joe was not 100% sure he wanted to leave high school before graduating, he began to become extremely involved in the welfare of the store. He worked hard and soon grew the store into a successful business that employed six employees. Joe was proud of his accomplishment, but deep down he felt shame and regret that he never completed high school.

When Joe turned 26, he met Florence, a college-educated administrator for an insurance company. When they began to get more serious in their relationship, Joe revealed to Florence that he never completed high school. Florence was impressed that he was able to grow a small business and become successful. The conversation strengthened their relationship. One year later, they got married.

Joe and Florence were on a plane leaving from a vacation to Miami when “catastrophe” struck. Joe reported that when he settled back in his seat he began having difficulty breathing. He described it as “It felt as if all of the air was sucked out of the plane.” Joe then described a “bizarre thought.” He said his thought was, “What if I can’t breathe, and I need to open the emergency door.” He then said he began imaging himself frantically opening the door. He knew this was an irrational thought. But he could not stop it. He looked at the rivets in the door and began to count them. He counted 12. He counted them again. 12. He counted them a 3rd time. Still 12. He thought, “I could unscrew all 12 of those rivets if I had to.” As he was trying to calm down, he noticed that his heart was beating very rapidly. He said that the beating was so strong he could actually hear it.

Joe reported looking over at his wife in the next moment. She was peacefully reading a magazine and oblivious to his condition. He did not share what was happening and because Florence was so tired, she soon fell asleep after take off. When his wife fell asleep, Joe felt as if he was going to die. He thought he was losing his mind. He reported not understanding what was happening.

Joe kept these feelings of terror to himself throughout the entire plane ride, but reported that the ride was “torture.” He was extremely relieved when he finally landed and ran out the door as fast as he could.

Joe reported that when they arrived back at their apartment, he felt better. He still did not share with Florence what happened to him on the plane. That night he reported that he slept well and in the morning, he felt “like his old self.” He decided to put the experience behind him and not worry about it.

Joe felt fine for three days. On the 4th night, he awoke in a cold sweat. He had a similar feeling of his heating beating out of his chest and the air being sucked out of the room. When he went to open the window, a memory of the airplane emergency door flashed before him, and he froze. He decided not to open it. He could not get the memory of the airplane door out of his mind. He kept thinking about it and picturing the rivets. Instead he sat at the edge of the bed motionless. He was breathing very hard and very loudly, and Florence awakened. Florence immediately thought he was having a heart attack. She dialed 911. When the emergency response team came, they administered oxygen to Joe, and soon he began to feel better. They took him to the hospital, and a cardiologist administered tests. It was determined that he did not have a heart attack. In fact, there was nothing physically wrong with him.

About one week later, Joe reported he was walking down the street on his way to the hardware store (a walk he had walked thousands of times) and he began to feel some of the same symptoms he felt in the plane and during that episode at night. He couldn’t breathe, his heart was pounding and this time he felt dizzy. He also noticed that his hands were trembling. He looked around for a place to sit and catch his breath. The environment around him looked “unreal.” He found it impossible to focus. He saw a stop sign and focused on the letters. He repeated the letters S T O P in his head 4 or 5 times. Joe decided to turn around since he was closer to home than the store. Joe began to feel like he didn’t want to leave his apartment for fear of experiencing these symptoms again. Joe stayed home that day and reported that he basically did not get off the couch. He went to the bathroom twice to wash his face because he thought it would help with the dizziness. He washed his face 4 times each visit to the bathroom. When Florence came home, she could see Joe was not himself. Joe told Florence what happened. She suggested they make an appointment for him to see their family doctor. It was the family doctor who recommended counseling and made the referral to the therapist.

DISCUSSION QUESTIONS. Please answer these questions with a minimum of 4 sentences each.

1. What do you think Joe’s diagnosis is? Why do you think this is his diagnosis?

2. What could be a differential diagnosis? Why?

HINT: Joe’s diagnosis could be any of the disorders we discussed in session 3 or 4.

There are basic themes to OCD:

Dirt and contamination

Violence and aggression



Anxiety disorders: GAD, Phobias, Social Anxiety and Panic Disorder

After reading the case study and attempting to give a diagnosis, talk about the challenges you think therapists and other mental health professionals might face when they are put in a position to have to give a diagnosis on the spot.

Please write a minimum of 3 sentences.

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