Comprehensive Therapy Session Notes - Performance Anxiety, R-CPD, and Relationship Financial Dynamics

Clinical Background and Client Overview

• Client & Therapist Context:

  • The client presented for a therapy session with clinician Gladys Sanchez, who was filling in for the client's usual therapist, Dr. Avila.

  • Gladys Sanchez is actively completing required clinical hours for her LP credential to obtain full licensure.

  • The client noted significant delay in scheduling the appointment, remarking he had been waiting for a long time to get checked in.

• Residential and Occupational Relocations:

  • Approximately one year prior, the client's partner, significant other, moved in with him.

  • The client purchased a house in Derby, Connecticut, significantly reducing daily travel time compared to his previous commute from Waterbury (which took approximately $40\,m$ vs. the current $20\,m$ drive to the clinic).

  • The client continues his employment at the cathedral in Bridgeport, Connecticut, where he received a salary raise approximately $2\,\text{years}$ ago.

• Home Renovations and Finances:

  • The Derby property was previously owned by an elderly individual who passed away after neglecting maintenance for an extended period.

  • Major home repairs are required, including a failing water heater tank estimated at $3{,}000\,\text{dollars}$ to replace.

  • The client renovated the basement out-of-pocket using savings without taking loans, converting the space into a music studio for significant other.

• Musical Engagements:

  • The client performs as a musician with the band Disco Cactus approximately $10\,\text{times}$ per year due to members living in different locations.

  • The band was booked to perform at a major convention in Washington, D.C., playing before an audience of approximately $2{,}000\,\text{people}$.

Performance Anxiety and Obsessive-Compulsive Tendencies

• Diagnostic History & Symptoms:

  • A prior therapist recorded "anxiety with OCD tendencies" in clinical notes, though no formal diagnosis or comprehensive explanation was provided at the time.

  • The client experiences ritualistic mental habits, high anxiety, and severe distress prior to live musical performances.

• Etiology and History of Anxiety:

  • Performance anxiety originated around $2009$ to $2012$ after college graduation when the client joined the touring concert production Video Games Live (a show performing video game soundtracks with screen visuals, comparable to Hans Zimmer orchestral events).

  • The tour manager behaved deceptively, lying to staff to take higher pay while issuing pay cuts to workers.

  • The tour schedule was extremely demanding: nightly flights to new countries, immediate customs clearance, and same-day stage performances without hotel rest or sleep.

  • The extreme physical demands combined with an unhealthy personal relationship triggered severe performance anxiety.

  • Recent escalation occurred during a major concert with the New Haven Symphony Orchestra, an event prepared over $1$ to $2\,\text{years}$. Prior to the show, the client restricted food intake out of extreme fear of food poisoning, consuming only safe foods like plain bread and performing in an exhausted state.

• Symptomatic Triggers and Manifestations:

  • Symptoms subside during periods without travel or scheduled performances.

  • Anxiety is absent regarding technical musical mistakes (e.g., missing notes), but fixates entirely on perfectionism, health maintenance, and preventing catastrophic physical failure (such as fainting on stage).

  • Highly psychosomatic: fixating on dizziness induces actual lightheadedness, which the client manages through internal self-talk ("this is all in my head").

Pre-Performance Rituals and Physical Limitations

• Sleep Control Rituals:

  • Fixation on achieving an exact number of sleep hours prior to an $8\text{:}00\,\text{PM}$ performance.

  • Attempts to sleep in until $9\text{:}00\,\text{AM}$ or $10\text{:}00\,\text{AM}$ to stay awake later into the evening, though travel and pre-show nervousness regularly disrupt these plans.

• Gastrointestinal Rituals & Retrograde Cricopharyngeus Dysfunction (R-CPD):

  • The client and his sister share a physical medical condition characterized by the inability to burp (Retrograde Cricopharyngeus Dysfunction).

  • Ingested air becomes trapped in the esophagus, producing audible gurgling sounds, severe discomfort, and abdominal bloating.

  • Because the client is a vocalist and wind instrument player, bloating directly impedes performance capacity.

  • Pre-performance dietary rules include:

  • Strict elimination of carbonated beverages (soda).

  • Mandated protein consumption prior to $1\text{:}00\,\text{PM}$.

  • Requiring a $3\,\text{hour}$ digestive buffer between a daytime nap and stage time.

• Psychological Impact:

  • Schedule disruptions create intense frustration and heightened anxiety.

  • Driven by a hyper-goal-oriented mindset, the client regularly sacrifices personal comfort and physical well-being to execute performance goals.

Financial Dynamics and Relationship Strain with Significant Other

• Significant Other's Background and ADHD:

  • Significant other has ADHD, exhibiting impulsive spending and executive dysfunction.

  • Significant other received no financial education during childhood due to a broken home environment and an abusive father who abandoned him for an entire summer during elementary school.

  • The client received structured financial education from his parents, works as a freelancer managing fluctuating income via regular spreadsheets, and avoids debt entirely.

• Financial Disclosures and Interventions:

  • Approximately one year prior, the client discovered significant other had almost $0\,\text{dollars}$ in his bank account, undisclosed credit card debt exceeding $3{,}000\,\text{dollars}$ with high APR, an $8{,}000\,\text{dollar}$ car loan balance, an existing $3\text{-year}$ IRS tax repayment plan, and a new $5{,}000\,\text{dollar}$ tax bill.

  • Significant other mistakenly believed he could attach the new $5{,}000\,\text{dollar}$ tax balance onto his existing IRS agreement without notifying the IRS, risking loan default and heavy penalties.

  • The client paid off the $3{,}000\,\text{dollars}$ credit card balance and provided checks covering the tax deficit, totaling approximately $7{,}000\,\text{dollars}$ in financial aid.

  • Significant other paid off his $8{,}000\,\text{dollar}$ car loan balance in a single payment using a large music royalty disbursement, eliminating a $500\,\text{dollar}$ per month payment.

  • Significant other currently holds $12{,}000\,\text{dollars}$ in a dedicated savings account for upcoming tax liabilities.

• Communication Disagreements & Shared Structure:

  • Friction occurred when a delayed $1{,}900\,\text{dollar}$ royalty payment caused significant other to make a monthly IRS payment late without communicating the delay to the client.

  • After a restaurant discussion where significant other reacted defensively out of shame and embarrassment, he apologized, recognized the trust breach, and made the payment immediately on his phone.

  • The client and significant other conduct weekly financial check-ins every Monday.

  • The client covers the house mortgage in full; utility, internet, and grocery costs are split, with significant other overseeing grocery budgeting.

Clinical Recommendations and Action Plan

• Relationship Dynamics & Boundaries:

  • Gladys Sanchez validated the client's anxiety as a reaction to financial unpredictability and recommended communicating non-judgmentally to relieve internal pressure while maintaining essential boundaries.

• Healthcare Navigation for Significant Other:

  • Significant other previously found Adderall highly beneficial for ADHD management while living in Arizona but lacks local psychiatric care in Connecticut.

  • Significant other attempted applying for Connecticut's state health program (Husky/Medicaid) after missing open enrollment, receiving mixed official communication (phone denial vs. receiving a welcome letter in the mail).

• Medical and Clinical Referrals:

  • Gladys Sanchez provided a direct referral for an affiliated psychiatric nurse practitioner qualified to evaluate and prescribe ADHD medications via telehealth:

  • Provider Name: Jane

  • Credentials: Psychiatric Advanced Practice Registered Nurse (APRN)

  • Contact Telephone: $203\text{-}410\text{-}4382$

  • Service Structure: Virtual monthly check-ins for diagnosis verification and medication management.

• Therapist Contact Information & Scheduling:

  • Clinician: Gladys Sanchez

  • Contact Telephone: $203\text{-}919\text{-}0376$

  • Next Scheduled Session: Next Wednesday at $2\text{:}00\,\text{PM}$ (available in-person or via telehealth on Doxy).