¶ … Andrea M. is a 21-year-old female in her fourth year of college with aspirations to become a civil rights attorney. She was first recommended to seek treatment when she experienced her first panic attack three years ago. At the time, a friend advised her to seek counseling. However, Andrea never did seek counseling at that time. Andrea has since been avoiding certain types of social situations, has gravitated towards jobs with as little social contact as possible, and fears that her anxiety may be impacting her performance in school and her ability to find viable work as an intern this summer. She loves "diving into my work" and becoming absorbed in her academics, but when it comes to attending classes, Andrea feels stressed and has been missing more classes than she has ever before. After not showing up to classes for two weeks, and an incident involving alcohol poisoning during that same time period, her family intervened and called the mental health center. Presenting Concerns

The level of distress Andrea feels is high, as she has been experiencing more frequent and severe panic attacks lately. She has never fainted, but she has "been in tears" on more than one occasion. Andrea has walked out of social situations, and feels humiliated "often." She attributes the additional stress to her workload at school, and to the change in the nature of her classes. Andrea has been experiencing panic attacks with greater intensity and frequency over the past several months, although she has suffered from them off and on for ten years. She claims, "I never knew anything was wrong until now." Andrea often takes two hours to get ready for class, claiming that she tries "everything in my closet" before she feels she is ready to be presentable in public. Being late for class has also been a problem for her, but because her grades and work are among the best in her class, her professors have never complained.

Background of Problem

When Andrea was ten years old, she remembers starting to feel excessively self-conscious in school. It was right after she got her first period, and she remembers being paranoid all day that everyone in school knew. She ran to the bathroom between every class and was certain she had blood on her clothes. During this same time, Andrea became more withdrawn than she had before. She had always been on the quiet side, but by the time she was twelve, Andrea had few friends and rarely attended parties. Her parents believed she was simply a studious girl and left her alone. Throughout high school, incidences of what she now recognizes as panic attacks started to occur with relative frequency. Increased heart rate, a sense of impending doom, changes in her breathing, sweating, and occasionally, shaking were some of the symptoms. These symptoms would arise immediately prior to impending engagements, during social events, and during conflict or confrontation scenarios. When Andrea first started college, she delved into her studies but still experienced the symptoms of anxiety so avoided social engagements. She does not belong to any clubs, and her only friends live in her hallway in the dormitory. Andrea admits that although she completes all her work on time and has good grades, she rarely participates in class. She mentions how grateful she is that professors don't "call on you" or "single you out" like they did when she was in high school. In the past, Andrea remembers hiding in the bathroom and even hiding under the table in school to avoid being called on. However, in her senior year Andrea had to make up for the lack of credits in debate classes. She had avoided taking debate because of the intense teamwork the class represented. Andrea has also remain distant from the academic societies in the legal field, in spite of the strong encouragement of her academic advisors to do so.

Developmental, Family, Social, and Work History

Andrea's parents divorced when she was eight years old. She has two step siblings. Besides work-study programs to pay off her financial aid loans, Andrea has never had a steady job. In high school, Andrea was a good athlete. She wanted to play basketball, but gravitated instead toward track and field because it did not require the rigors of teamwork. Andrea remembers in elementary school, playing softball and always wanting to remain in the outfield so that "I never had to field a ball." She since avoided team sports because she thought she did not like them, but now admits it is because she does not like teamwork in general. "I have always liked working independently, but until now did not realize how extreme my aversion to teamwork had become. Now I freak out when there is a team...

Her precipitating event of alcohol abuse is a sign that her problem with social anxiety had never before been addressed in a professional manner, and that left untended, could erupt into serious substance abuse issues. Although comorbidity may be present, it seems that there are no concurrent issues like depression. A differential diagnosis process has ruled out substance abuse, as the recent incident was an isolated event and is in fact what caused Andrea great concern. Andrea does not seem to have the symptoms of agoraphobia or generalized anxiety, and it does look as if social situations are the primary cause of stress for Andrea. Andrea has done well in school but she has few close friends, avoids parties, and dreads going to classes and having to find work in the future because "it might involve being around people all day."
Axis I: 300.23 The principle disorder is social anxiety disorder, which used to be called social phobia. Terminology and diagnostic criteria have shifted, so that the disorder is more closely linked with the anxiety disorders than the phobias. This is in part due to emerging research in the neurophysiology of the disorder, but also to its manifest symptoms. In the DSM-V, the nomenclature has clearly shifted from that in the DSM-IV, which still used the term social phobia. The primary diagnostic criteria also changed, particularly regarding the type of awareness the client has about having social anxiety. Andrea meets sufficient criteria, including the length of time she has experienced symptoms and the types of symptoms experienced. The primary challenge in diagnosing Andrea is determining whether her symptoms are not indicative of a generalized anxiety disorder. Ruling out generalized anxiety disorder required an intake assessment including questions related to her perceptions of different situations. One of the new criteria for diagnosing patients with social anxiety is the level of awareness one has about the irrationality of the fear of social situations (Bogels, et al., 2001). Andrea has demonstrated awareness and recognizes that her social anxiety is a problem, and the only disproportionate fear or anxiety is experienced in social situations. A clear example is the fact that Andrea does not feel performance anxiety on tests, essays, or when running track and field. However, Andrea does have trouble in any classes requiring team or group projects.

Axis II: No personality disorders have been indicated. Andrea does not seem to have Avoidant Personality Disorder.

Axis III: Andrea has no medical issues.

Axis IV: Psychosocial stressors in Andreas life include the intensely social situations in college, and the pending demands of her work schedule in her senior year. Also, Andrea is facing what to do after graduation.

Axis V: Andrea does well in school, and her highest level of functioning can be seen on days in which she experiences little stress due to the lack of social obligations. She does not mind one-on-one interactions, and in fact states that she prefers to have a few close friends than to have many acquaintances. On a Global Assessment of Functioning (GAF) Scale, Andrea has rated between a 50 and a 70, with her symptoms generally ranging in the mild to moderate zone (Burke, n.d.)..

Case conceptualization, etiological considerations, theoretical conceptualization and perspectives

Theoretical perspectives that account for etiology and symptoms of social anxiety disorder include those that emphasize biological or neurological factors, those that stress temperamental and personality factors, behavioral variables, and also cognitive variables (Hoffman & DiBartolo, 2010). As Hoffman & DiBartolo (2010) points out, these multiple perspectives do not need to be viewed in isolation of one another. In fact, social anxiety is likely to be multimodal, and requires a "real world" combination of various theoretical viewpoints (Hoffman & DiBartolo, 2010, p. xxii).

Biological and neurological research reveals dysfunctional cortisol regulation, hyper-reactivity in the limbic system, hyperactivity in the paralimbic system, abnormalities in the amygdala, and hypoactivation in frontal cortex regions associated with emotions and cognitions in persons diagnosed with social anxiety disorder (Phan & Klumpp, 2010). There may also be a genetic component to the disease, as Stein & Gelerntner…