Nalini is a 36-year-old marketing manager referred by her primary care physician for persistent anxiety. She describes two years of escalating worry across multiple domains: her children's health, her marriage, her job security, and minor daily logistics. She reports that when one concern resolves, her worry immediately attaches to the next uncertain situation. She obsessively checks weather forecasts before any outdoor activity, refuses to delegate work tasks, and calls her children's school multiple times daily. She has tried journaling and meditation apps without improvement. Her Hamilton Anxiety Rating Scale (HAM-A) score is 24 (moderate-severe). She also reports chronic fatigue, jaw pain from clenching, and difficulty falling asleep.

Mateo is a 16-year-old junior referred by his school counselor for declining grades and eight absences this semester. His parents describe him as "always shy" and report no behavioral concerns at home. On individual interview, Mateo reveals he has been skipping school primarily to avoid class presentations. He reports that on three occasions he attended weekend parties, but only after drinking "a couple of beers" in the parking lot first because "it's the only way I can walk in the door." He asks you not to tell his parents about the drinking. His Screen for Child Anxiety Related Disorders (SCARED) total score is 38, with the social anxiety subscale markedly elevated. He denies depressive symptoms or suicidal ideation.

Reggie is a 35-year-old electrician who presents to his primary care physician after his third emergency department visit in four months. Each time, he experienced sudden-onset racing heart, chest tightness, tingling in his hands, and difficulty breathing. Each cardiac workup (ECG, troponin, chest X-ray) was normal. He was told he has "anxiety" and given alprazolam 0.5 mg as needed. He now carries the alprazolam everywhere and takes it at the first sign of a rapid heartbeat. He has stopped his morning runs because "exercise makes my heart race and I'm afraid that'll trigger another attack." He avoids driving on the highway alone.

Iris is an 8-year-old girl brought to your pediatric office for her annual flu vaccination. Her mother warns you at check-in: "Last year it took four adults to hold her down, and she vomited on the nurse. The year before, she fainted." Iris is tearful in the waiting room. Her mother asks whether Iris can "just take something to calm down before the shot." She also mentions that Iris has started refusing to let her mother check her blood sugar at home. Iris was diagnosed with Type 1 diabetes six months ago. Her endocrinologist has flagged non-adherence to glucose monitoring as a serious concern.

Nolan is a 7-year-old boy referred by his pediatrician for worsening school refusal over the past three months. Each morning, he cries intensely, clings to his mother, and reports stomachaches that resolve within an hour of arriving at school. His mother has begun staying at school during first period because "it's the only thing that calms him down." He refuses sleepovers, has started sleeping in his parents' bed, and asks to call his mother multiple times during the school day. He recently told his teacher he was afraid "something bad will happen to Mommy while I'm at school." The School Refusal Assessment Scale-Revised confirms the refusal is driven by separation distress rather than social anxiety, tangible rewards, or bullying. His SCARED total score is 31, with separation anxiety subscale elevated.

Selma is a 39-year-old accountant referred by her couples therapist. Her husband's employer has offered him a promotion requiring monthly overnight travel. Selma has insisted he decline it. She describes overwhelming dread when he travels: she cannot sleep, calls him repeatedly through the night, and has vivid intrusive images of plane crashes and car accidents involving him. She recognizes this is "completely irrational" but cannot control it. Her husband is frustrated, and the couple is considering separation over the issue. Selma was diagnosed with "generalized anxiety disorder" in her late twenties. She was treated with sertraline (adequate dose and duration) with partial improvement. She was never assessed for separation anxiety disorder.

Wren is a 5-year-old girl referred by her kindergarten teacher, who reports that Wren has not spoken a single word in the classroom since the start of the school year four months ago. She follows instructions through nods and gestures, participates in written activities, and has one close friend who "translates" for her. Her previous preschool teacher noted the same pattern but assumed Wren would "grow out of it." Wren's mother reports that at home, Wren is "a completely different kid: loud, bossy, sings constantly." Her mother is frustrated: "She can talk. She just won't."

Otis is a 43-year-old sales representative presenting to his primary care physician for medication management. He has been on alprazolam 0.5 mg three times daily for two years, prescribed by a previous provider for "panic and anxiety." He reports that his panic attacks began three years ago after a dizzy spell at a conference. Since then, he has progressively restricted his life: he no longer flies for work, avoids crowded stores, refuses to sit in the middle of restaurant booths, and has stopped attending his children's school events. He says the alprazolam "keeps me functional" and asks for a dose increase because "the current dose isn't working as well." He reports prominent dizziness and a feeling of "unreality" during attacks. His wife drives him everywhere.

Bianca is a 27-year-old graduate student referred for anxiety treatment. She reports three concurrent diagnoses: panic disorder with monthly attacks, social anxiety disorder affecting classroom participation and conference presentations, and generalized anxiety disorder with chronic worry about academic performance and finances. She has been waitlisted for 10 weeks at her university counseling center for individual CBT specific to each diagnosis. Her therapist, who specializes in social anxiety disorder using the Clark and Wells model, has availability immediately but wonders whether treating only the social anxiety will leave the panic and GAD unaddressed.