Social anxiety disorder: symptoms, causes, and treatment

NURSING

Nursing: Social Anxiety Disorder

Initials: M.I.

Age: 45 years

Race: African American

Gender: Female

Chief Complaint (CC)

The patient came to the clinic and reported that she fears any strangers or even acquaintances that she has met at her workplace and has been experiencing it for the past year. It is the exact time when she moved here in the country, and belonging to a social minority; she has faced some racial discrimination. She could not stop crying and told her that it was routine whenever she felt low, even at home. Also, she felt racial discrimination could be why she has developed a fear of people and avoids mingling with them, other than her family at home and her two to three close friends at the workplace.

Demographic Data

Some of the patient’s demographic data features have been given above age, race, ethnicity, and gender. Further, the patient is married and has three children. She has completed her Master’s in Nursing Studies and works as FT Nurse. She does not drink but smokes 20 packs per year (PPY).

Medications and Allergies

The patient has no allergies specified (NKDA), but she is on Lisinopril (10 mg) daily.

Risk Factors

Some of the risk factors of her condition are the temperament changing when exposed to people who are especially stranger to her and even some of those who are acquaintances at the office. There is always a presence of fear that she is being looked at or people are talking about her and fear of being ridiculed, which causes sudden changes in her mood. Though her boss is familiar with some of her symptoms, when she has to give presentations at the office, her symptoms are triggered just from its thought.

History of Present Illness (HPI)

As she belonged to an African American family, some of her family members had stress and mild depression symptoms. Since she had moved to the present area within the U.S., racism here is serious and has affected her gravely. It had started to affect her work and family life, too, as she is afraid of going out in the neighborhood. When she was a child, her sister narrated that once in school, when she was ten years old, her teacher scolded her badly for not performing well in a test. She started feeling fearful of all of her teachers and showed lesser participation. She was even frightened when some of her school assignments included giving presentations in front of the class and was uncomfortable standing before several children. She had a small group of friends from the beginning of her school days and did not get along well with boys.

Past Medical History (PMHX)

Surgeries: None

Hospitalization: None

Family History: None specified

Vaccination: Had been regular in keeping up with the vaccination schedule.

Social history: The patient has her own house with her husband and three children. Her mother passed from coronary artery disease (CAD), but the father is still alive. Grandmother had no such signs, but grandfather had stress since they faced financial difficulties after 50 years.

Developmental history: Sister had not told developmental difficulties other than some symptoms of fearfulness during her second and third pregnancy.

Objective Data

General appearance: The patient looked healthy; she mentioned she gained 20 lbs in the past year. Recently, she felt determined to lose her weight as being overnight increased her worries. She was wearing clean clothes, and the first two buttons were not done since the second button of the shirt was absent. She looked weary and tired, and her eyes looked puffed up due to persistent crying.

LOC: She seemed in some distant state of mind, for example, when a person looks at something and appears to be deep thoughts.

Vital Signs:

Temperature: 98.6 HR: 65 RR: 18 BP: 110/68 HT/WT: 66\"/220 BMI:X

HEENT: The patient frequently complained about headaches and Post Natal Depression (PND), particularly after her third pregnancy.

Eyes showed a little redness due to constant crying

Ears, nose, and throat appeared fine.

PULM: Clear to all bases, A/P symmetrical

CV: RRR, S1 S2 no click, rub, gallop

GI/GU: The patient’s abdomen was soft, non-tender, and no masses were observed. G.U. was deferred as well.

EXT: There was no clubbing, cyanosis or edema, palp DP/PT bilat 2+/2+

Psych: Orientation/consciousness: X4

Attention, memory, and intellect: They showed healthy signs of fulfilling the requirement of a sound conversation.

Speech/thought: The patient did not shout as she looked afraid of being in the clinical environment. The main reason is being fearful of strangers and not wanting to engage in normal conversations.

Affect/mood (observed): The patient was frightened and was constantly scared as she was clinging to her chair in a backward position and spiral inwards. She once or twice trembled when talking about her workplace experiences, and at the same time, her voice was found experiencing difficulty voicing out words.

Thought processes: The patient exhibited numerous thought processes such as black and white thinking, mental filtering, and overgeneralization (Cuncic, 2021).

Thought content: Most of her thoughts comprised self-blaming since she believed that there was always something wrong with her that she was afraid of people. If one situation occurred at one point, it is most probable for her to happen again. She generalized all types of people in the same way and tried to perceive situations negatively. Moreover, she distinguishes things in two extremes, and there is no middle way of her thoughts.

Reliability/Insight/Judgment: She is present most of the time during her conversation, but she seems distant occasionally. She appeared intensely anxious about social situations and worries excessively days before an event have happened.

Suicidal ideation/ Homicidal ideation (SI/HI): There have been no such indications from herself and her sister until now.

ROS Subjective Data

Following are some of the factors of subjective data that the patient told about herself:

PULM: she has some form of new non-productive cough, although she had denied wheezing

CV: The patient has mentioned Hx of cardiac murmur and NSVT, though she has denied C.P. or recent palpitations

GI/GU: The patient had denied any N/V/D/constipation, blood in urine, or stool.

EXT: The patient did not mention any pain, tingling, or numbness in the upper or lower extremities. There is also a denial of edema.

Psych: There are strong signs of remote hx of over-eating, especially binge eating while under stress.

Final Treatment Plan

Primary Diagnosis

The patient’s primary diagnosis is a social anxiety disorder. The DSM 5 and ICD 10 code for this disorder is F40.10 (ICD10 Data.com, 2021).

Pathophysiology and pharmacology

Social anxiety disorder is a mental and social disorder in which the person is afraid of facing social situations and people (Rose & Tadi, 2021). The individual feels ashamed and embarrassed when confronting people. Being exposed to people or social situations and gathering instill fear and anxiety in such people. They feel that they might be judged negatively by people around them, and adversely, social experiences start infiltrating their minds.

People who experience such disorders have shown faster heart rate, which is perceived as a response to the autonomic nervous system, and changes in neurological functioning when exposed to social situations (Rose & Tadi, 2021). The pathogenesis of social anxiety disorder also reveals that the distortions in neurotransmitter systems are caused by altered levels of serotonin, dopamine, and glutamate. When brain imaging of people suffering from a social anxiety disorder is obtained, it is discovered that greater activity in paralimbic and limbic regions is present.

There have been several medications and interventions proposed to treat social anxiety disorder. Research has suggested irreversible monoamine oxidase inhibitors (MAOIs), beta?blockers, reversible monoamine oxidase A (RIMAs), and high potency benzodiazepine (Williams et al., 2017). Further studies in subsequent years mentioned positive outcomes from the use of serotonin reuptake inhibitors (SSRIs), and other newer agents such as GW876008 (NCT00397722), buspirone, the noradrenergic and specific serotonergic anti-depressants like mirtazapine, olanzapine which is a new generation medication, selected dosage of noradrenaline reuptake inhibitor (NARI) atomoxetine and the similar vigilance in prescribing the serotonin antagonist and reuptake inhibitor (SARI) nefazodone, etc. (Williams et al., 2017). Later, certain anticonvulsants/gamma-aminobutyric acids (GABA) were also valued for the same purpose (Williams et al., 2017). Behavioral therapies have proven to be most effective since changes in attitudes are the real instigators for giving positive outcomes in the health conditions of anxiety patients.

Diagnostic Testing

No lab tests were run for the patient to detect her social anxiety disorder, though physical examination and discussion about the symptoms were made. Certain checkboxes were ticked or unticked mentioned in the previous section that helped in concluding the condition. After reviewing the current situation, observation during the clinical session, and self-reported data, the checklist of DSM 5 diagnosis supported in clearly identifying the disorder.

Psychiatric tests could be used for testing social anxiety disorder, for which the Generalized Anxiety Disorder 7-item (GAD-7) is advised (Sapra et al., 2020). The sensitivity index indicates 72% sensitivity on GAD 7 scale, 80% specificity, and 3.6 positive likelihood ratios to determine if the patient has a social anxiety disorder. Also, the score of 0-4 signifies minimal anxiety, a score of 5-9 implies mild anxiety, a score of 10-14 signifies moderate anxiety, and a score greater than 15 is severe anxiety.

Medications

According to the national guidelines and taking approval from Food and Drug Administration (FDA), the treatment of social anxiety disorder could be done by prescribing medicines like Paxil, Zoloft, and Effexor X.R. (Higuera, 2018). The patient could start with a low dosage of these medicines, preferably Zoloft (1 tablet daily). If effectiveness is not observed, the dosage could be increased, considering her family history of CAD and previous hypertension medications (Lisinopril, 10mg).

Interventions

The primary clinical intervention, as suggested by National Institute for Health and Care Excellence (NICE), for treating social anxiety disorder is cognitive-behavioral therapy (CBT) since it is chiefly based on Clark and Wells model or Heimberg model (National Institute for Health and Care Excellence, 2013). It involves certain relaxing and breathing exercises and techniques conducive to eliminating the symptoms of this disorder and helping the patient relieve himself of negative thoughts. The neuroanatomical irregularities in the social anxiety disorder are normalized with CBT, which various and recurrent research studies have corroborated with evidence support (Williams et al., 2017). It is validated that CBT has proved more useful in treating social anxiety disorder than psychodynamic and other similar psychosocial therapies (Rose & Tadi, 2021).

Education

The patient could be educated with social skills training that encompasses the verbal and nonverbal skills required to communicate effectively in social situations (Olivares-Olivares, Ortiz-Gonzalez & Olivares, 2019). Improvement in interaction with others is believed to improve with this training involving activities like role-playing and rehearsals with other participants. Besides, some preventions strategies are suggested by the physicians like keeping a journal and writing down what the patient feels, continuing a healthy lifestyle with a balanced diet and some exercise, meeting other people gradually, having a good night sleep so that the thought process is refined, and abstaining from alcohol or drug abuse so that addiction should not worsen the social anxiety symptoms (Felman, 2020).

Labs

No lab tests are required to detect social anxiety disorder other than surveys or questionnaires. The patient could self-analyze her condition and match those responses with the standardized criteria presented by American Psychiatric Association (APA).

Follow-Ups

Follow up checkup for the patient is suggested every two months or whenever the need arises based on the worsening of symptoms. The actions required at the follow-up would be the inclusion of a Quality of Life (QoL) questionnaire based on the Flanagan conceptual model that has five domains and fifteen questions to be surveyed about the physical, mental and social wellbeing of the patient (Celestine, 2021).

Referrals

The referrals for this patient could include outpatient counseling when in need.

Full 5-Point Plan

A full five-point plan for this patient is suggested as follows:

· Based on the techniques used in cognitive behavioral therapy, the patient could be provided a goal or agenda-setting for the behavioral changes and elimination of negative thoughts (Stiles-Shields, Ho & Mohr, 2016).