Debra first presented when she was 53 years old and was seeking support to manage her bone density, facilitate weight loss, and to optimise her health following a diagnosis of breast cancer 10 months prior. Debra had a lumpectomy and removal of several axillary lymph nodes followed by 30 sessions of external beam radiation. Recent bone mineral density assessment identified osteopaenia in the neck of the femur and osteoporosis in the lumbar spine.

Previous history included an old back strain following a fall and pneumonia 12 months prior. She has known allergies to Sulphur, Penicillin, Roxithyromycin (Rulide) in addition to marked side effects (nausea and vomiting) from codeine, and hot sweats from rhubarb. In addition, Debra reported a poorly defined reaction to vitamin C supplements in which she experienced altered taste and mouth numbness; it is not clear if the reaction was to an excipient or the form of vitamin C, colouring or some other factor; she is able to tolerate vitamin C rich foods.

Debra is married and has three adult children, all of who were living at home. She works full-time in a residential facility for people living with disabilities. Her family history included significant allergies in both of her siblings, parents, and one grandparent. In addition, her father had died from lung cancer and had multiple sclerosis. Her father and two siblings had been diagnosed and treated for depression.

Debra did not present initially for mental health concerns and no overt features of anxiety were observed as defined by the DSM-V [1]. During the case history, she disclosed experiencing depression following her diagnosis of cancer and having sought support from a psychologist at the cancer centre she attended, and that she felt that was a constructive and positive experience. Debra stated that she no longer felt depressed and denied any other mental health concerns during the initial consultation. Thus, the original assessments related to the reason she sought a consultation and included basic biochemical and metabolic assessments.

Over the following 12 months, Debra reported persistently elevated levels of stress, with triggers at work, in her marriage, her upcoming annual cancer check, and family health concerns. During this time she felt that physical exercise and some basic cognitive re-framing exercises were sufficient in managing her stress. Herbal anxiolytics were suggested and declined, as was the suggestion that counselling may be helpful. She reported that to some extent she “thrives” on the intensity of the type of work she does, and has never been a person to “lay around reading all day.” At this time she was still sleeping well, able to perform her job to the same standards, and had not altered social or family activity due to the stress.

Fourteen months after the initial consultation, Debra experienced a further, and significant, escalation of her stress as a result of serious family health concerns, children undergoing difficult times, financial strain and a prolonged episode of bronchitis.The following month she felt that her overall level of stress had decreased, though work was beginning to intensify due to annual additional workload requirements.

Two years and 3 months after the initial presentation, Debra reported feeling “tingling” in her feet and lower legs, and that they “felt puffy.” At times this extended to her arms and face as well. She had experienced tingling and swelling in response to sulphur drugs and penicillin. On a couple of occasions she had an unusual taste in her mouth that was not dissimilar to what she experienced with vitamin C supplements. There were no changes to any aspect of her life prior to these sensations and generally feels well other than being concerned about the paraesthesias due to her family history of MS. The first episode occurred on the way home from holidays, where she did not alter diet, supplements or medications. Debra was concerned and puzzled but not distressed by these symptoms.

Assessment by her oncologist included ceasing all medication to exclude them as being causative, a bilateral lower-limb Doppler’s ultrasound to exclude deep venous thrombosis, full-body CT scan, biochemistry assessment and physical examination. Nil abnormalities were identified. Assessment by a neurologist (seeking to exclude MS) identified nil abnormalities.

Upon reviewing the results, Debra’s general practitioner (GP) suggested she was experiencing anxiety. A broader exploration of her history revealed two second-degree relatives with bipolar disorder, that one sibling likely had significant anxiety as well as the previously mentioned depression, three of her sibling’s children had behavioural/neurological disorders, her mother likely had undiagnosed GAD with significant behavioural effects, and one of her daughters likely had an undiagnosed GAD. Later discussion revealed that another daughter had quite rigid thinking and a tendency to perfectionism, possibly with underlying anxiety.

Debra returned for a consultation once the GP had assessed the symptoms to be those of anxiety. She was referred to a clinical psychologist whom she saw regularly for several months and who assessed her as having a GAD with episodic panic attacks. In the following year, Debra reflected on her life and health and was able to identify numerous occasions spanning at least 30 years that were likely to be mild panic attacks.

The new therapeutics goals for Debra included: