The challenge
Nadia’s referral read simply: “social anxiety.”
A 39-year-old military spouse and mother of four, she reported feeling overwhelmed at social gatherings, cutting events short, “rushing through life.” Her GAD-7 showed moderate anxiety (7/21). Her PCP had already diagnosed Social Anxiety Disorder.
By all standard measures, she was a candidate for an SSRI and anxiety-focused therapy.
What standard care would have done
Standard care would have confirmed the Social Anxiety Disorder already in her chart, prescribed an SSRI, and referred for generic anxiety therapy. The caffeine connection would never have been explored. The probable ADHD would have remained undiagnosed. The compound grief would have been noted as a “stressor” without understanding its role as the acute trigger.
She would have received medication for a condition she didn’t have.
What Assess surfaced
Comprehensive assessment revealed a completely different clinical picture:
- Sensory overwhelm, not social fear. When we explored her symptoms, Nadia didn’t describe fear of judgment—she described sensory overload: “If somebody’s talking to me and there’s a TV on and music and people moving around, I can’t even hear the person. My brain is microprocessing every little thing.”
- Six espresso shots daily. Not “do you drink coffee?”—but how much, exactly. The answer: six espresso shots daily. Nadia had discovered years ago that coffee helped her focus, but she’d gradually escalated to doses that were now driving her anxiety. “When I stopped the caffeine before surgery,” she recalled, “those ‘I can’t breathe’ feelings went away.”
- Probable ADHD masked by caffeine self-medication. She was using caffeine to compensate for attention difficulties she’d never been evaluated for—which then amplified her anxiety. The psychiatrist’s conclusion: “She’s self-caffeinating herself to combat her ADHD. And if she gets treated properly, her brain will become sharp. And her anxiety will come down.”
- Compound grief as acute trigger. Her symptoms began “overnight” in 2020 when her father died of COVID in her home country—a funeral she couldn’t attend due to pandemic restrictions. Then twenty more family members and friends followed. She relocated her family alone while her husband was deployed.
- Critically low iron contributing to symptoms. Iron level of 7—low enough to warrant IV consideration—was contributing to fatigue and cognitive symptoms.
What changed
Diagnosis: NOT Social Anxiety Disorder. Generalized Anxiety Disorder with probable ADHD (pending evaluation), caffeine-induced anxiety contribution, and adjustment features from compound grief.
- Caffeine reduction as first-line intervention (not medication)
- ADHD evaluation AFTER caffeine stabilization
- CBT specifically for sensory overwhelm coping
- Iron supplementation monitoring
- Neurofeedback for attention/anxiety
- Military spouse support group connection
- No SSRI
”I'm rushing through events. I'm just looking forward to the end... There's no memory there for me or for my kids.
Nadia, 39PHQ-9: 8 | GAD-7: 7 | Caffeine: 6 espresso shots/day
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These findings came from real assessments at Texas Center for Lifestyle Medicine. We have detailed documentation on 50+ patient evaluations, with more being added from ongoing clinical work.
