Social Anxiety Disorder in a 37 Year Old African American

Psychology Theory

Demographic Information

Mr. C, a 38-year-old married male recently contacted a faculty anxiety clinic seeking treatment. At the time he contacted the centre, he self-reported that he experiences social anxiety in different settings, for instance, when talking to strangers, speaking or writing in front of a group, and/or in hostile situations. Furthermore, Mr. C also reported that he often avoided settings such as the ones mentioned above because of social anxiety. Mr. C specifically pointed out that writing in front of a group of people was one of the worst experiences he had had to go through constantly due to the nature of his work (Weiss, Singh, & Hope, 2011).

Identifying Problem

According to his self-reports the client was born in Central America and immigrated to the U.S. (United States) when he was about 8 years old. Mr. C stated that he had had social anxiety since his childhood days before he moved to the United States. As a child he had moved from his rural village where most people spoke an indigenous language, to a city where the majority of the people conversed in Spanish. At that point in his life he started feeling anxious when interacting with them since he thought they would think of him differently if they knew he could not speak Spanish fluently. Mr. C continued in his report noting that from then up to now there are still a number of situations that make him anxious and that as an adult he had turned to drinking alcohol so as to cope with the condition. However, on a more positive note, he reported that he had recently become sober and purchased a self-help book to help deal with his social anxiety. He however noted that he felt that clinical therapy was the only way he could completely eliminate his negativity (Weiss, Singh, & Hope, 2011).

Source of referral

Referral to a specialist who could deal with the case was required and it was agreed that Mr. C should be sent to a mental health specialist. Different cases require different types of referral, at times it is best to send one to a community mental health interdisciplinary team. Such teams are usually made up of professionals from different disciplines who contribute towards better patient outcomes. The professionals included in a mental health team include: social workers, occupational therapists, clinical psychologists, psychiatric nurses and psychiatrists among other mental health specialists. Normally, one individual is appointed from the team to conduct a re-evaluation of the condition. The selected mental health specialist will usually inquire about previous interventions and their outcomes. The specialist may also inquire about the risk or contributory factors to the condition and the social support available to the patient. The specialist may then come up with his or her own intervention plan to deal with both the symptoms and the underlying causes of the disease effectively. His or her intervention plan may include a treatment not used before, either using clinical drugs or psychological interventions. Alternatively, Mr. C may be given a mixture of medication and psychological treatment or two different kinds of prescribed drugs (Generalized anxiety disorder in adults -- Treatment, 2014).

Treatment setting

A CaucAsian-American woman with a doctorate degree in clinical psychology will be dealing with this case. The white woman is a licensed clinical psychologist with expertise in treating different types of anxiety disorders will be supervising the treatment process. The psychological intervention will entail seventeen sessions which will concentrate on cognitive exposure and restricting and also psycho-education utilizing Hope and colleagues' (2000) Managing Social Anxiety: A Cognitive-Behavioral Approach manual. The sequence of treatment used from the work is presented in Table 1. Each of the seventeen sessions will be fifty minutes long. And there will only be a single session per week. Figure 1 for SASCI measures and corresponding treatment sessions will be used to evaluate the progress of the situation (Weiss, Singh, & Hope, 2011).

Diagnostic Evaluation

The symptoms that Mr. C reported were similar to those described under Social Anxiety Disorder (SAD) in the Anxiety Disorders Interview Schedule for DSM-IV. There were no additional diagnoses. Problematic symptoms included experiencing anxiety when talking to strange people, speaking or writing in front of a group, when reprimanding others or by being the centre of attention. A clinician's severity assessment was conducted using ADIS-IV and it was found that the patient had a severity of 5 out of a maximum possible score of eight, showing that his symptoms were between moderate and severe. Mr. C also noted that his condition cause him to difficulties at work and in education. One of the most problematic issues he had to face every day was writing in front of others since the work he did required it. Moreover, Mr. C noted that the condition limited the kind of jobs he could do since he was only comfortable in doing those that required very little interaction of with others. Mr. C also reported that he had enrolled in a computer literacy program but did not complete it out of the fear that he would end up having to speak in-front of the whole class if he was requested or wanted clarifications on an issue he did not understand (Weiss, Singh, & Hope, 2011).

Assessment

Fear of Negative Evaluation -- Brief Version (BFNE)

The BFNE is a twelve-item assessment tool that measures the degree to which someone thinks that the society views them unfavorably, a characteristic which is thought to be at the centre of social anxiety. The participant/client/respondent is asked to rate to what extent each item is characteristic of them. BFNE has a good reliability and its scores can be associated with measures of depression and loneliness. The measure was utilized in the 1st and 17th sessions (Weiss, Singh, & Hope, 2011).

Social Interaction Anxiety Scale (SIAS)

SIAS is a twenty-item measure of anxiety during social engagements. Respondents using the scale indicate, on a scale of 0 to 4, how characteristic of them each item is with 0 being equivalent to not true and 4 extremely true. People with social anxiety have consistently scored higher on social interaction anxiety scales compared to those who don't have the condition, providing proof of the validity of the scale, Moreover; SIAS has a more than average internal consistency. The measure was utilized in the 1st and 17th sessions (Weiss, Singh, & Hope, 2011; Hope, Heimberg & Turk, 2010).

Social Phobia Scale (SPS)

This is a twenty-item measure of anxiety when interacting with others or doing something in front of them. Respondents using the scale indicate, on a scale of 0 to 4, how characteristic of them each item is with 0 being equivalent to not true and 4 extremely true. Scores on the social phobia scale range from zero to eighty, and a score of 24 and above shows that the respondent suffers from social anxiety disorder. Quite a number of studies published reveal that the scale is good discriminator, divergent and convergent validity. Its internal consistency and re-test reliability were also found to be above average. The measure was utilized in the 1st and 17th sessions (Weiss, Singh, & Hope, 2011).

Social Anxiety Session Change Index (SASCI).

This is a 4-item measure that is usually utilized/administered a week before a session. The client is asked to report the extent they think they have changed since the sessions begun in terms of problems associated with SAD symptoms, their feelings towards the shame or embarrassment they felt in front of people, their avoidance of social interactions or engagements, and general anxiety towards such interactions. The client indicates on the measure using a seven-point scale (similar to the Likert scale) with the score of 1 indicating negative changes, 4 indicating no changes and 7 huge positive change. Studies have also proven that SASCI has a good sensitivity to change, discriminant validity and internal consistency. The index was administered after each session except the fourth one (Weiss, Singh, & Hope, 2011).

Fear and Avoidance Hierarchy

As part of the overall intervention, a special Fear and Avoidance Hierarchy was collaboratively developed during session four. Upon drawing a list of possible feared scenarios, Mr. C was asked to rate the degree of anxiety that each scenario elicited and how frequently he avoided such scenarios/situations. The degree or severity of anxiety was rated using ratings of the level of discomfort ranging from 0 to 100, with 0 indicating no anxiety and 100 extreme anxiety. Avoidance was similarly rated on a scale of 0 to 100 with zero indicating no avoidance and 100 indicating total avoidance. Fear and Avoidance ratings were measured in the 4th and 17 intervention sessions (Weiss, Singh, & Hope, 2011).

Cognitive restructuring sessions will concentrate on determining and changing negative thought processes. Advanced cognitive restructuring concentrated on changing core beliefs. All anxiety-exposure sessions were conducted in two ways: as an assignment in worksheets and within sessions by role-playing (Weiss, Singh, & Hope, 2011).

The mental status assessment in our present case is a structured evaluation of the cognitive and behavioral functioning of Mr. C. It entails the assessments of his higher cognitive abilities, mentality and insight, thought and perception, mood and affect, speech and motor activity, attentiveness, consciousness level, and general appearance and behavior. Of these many indicators of mental status, the most clinically relevant are constructional ability, memory, language, attentiveness and abstract reasoning. Unlike the other forms of assessments that Mr. C underwent, mental status evaluation is a more structured and systematic approach. Also since mental status evaluation is always a threatening evaluation for anyone to take and requires full cooperation from the client, it was thought best to leave that for the end of the entire examination process when the client could be more at ease and also at such a stage a certain degree of rapport could have already been created between the client and the examiner. The mental status evaluation of the client also reflects the sensitivity and accuracy of the whole medical history, from this perspective it is easy to see why psychologists wish that the mental status evaluations should be done before the rest of the measures are administered since it could act as a standard that could be used to determine the accuracy of the clinical evaluations. An effective clinician is he or she who assesses his or her client in an unstructured manner by observing the client during the normal physical and history assessments. The manner in which the patient reports the present condition will reflect a lot about his or her attitude, affect, attentiveness, behavior and appearance. A primary approach then would be to use some form of structure to measure these kinds of observations and to use them as clinically significant measures of behavior. When there are indications of a serious psychiatric condition, for example, deviant thinking or behavior, or irregularities in neurological tests or say difficulties in carrying out daily activities, then a formal dissection of specific cognitive abilities ought to be conducted close to the end of the examination of Mr. C. When it has been established that there is a need for special psychiatric evaluation, the patient, Mr. C, should be informed of the need and he should be told why the evaluation is being done so as to get his support and to prevent any resistance (Martin, n.d).

Risk Issues

In this case study involving Mr. C, SAD could have begun at any point of his life but it begun during his childhood. Being a man he is less vulnerable to the condition, in fact it has been found that women are 60% more likely to develop SAD compared to men. But he was still affected anyway. For him to have had the condition from a pretty young age he must have been exposed to risk factors very early in his life. One of the most common predisposing factors in social anxiety disorder is stress. A stressful life can increase one's risk of contracting the disease. Having a drug abuse problem or a significant medical problem can also cause anxiety disorder. GAD (generalized anxiety disorder) is defined as having extreme anxiety for no particular reason. ADAA (Anxiety and Depression Association of America) states that generalized anxiety disorder affects over 6,800,000 U.S. citizens every year. The diagnosis of GAD is regarded positive only when there is excessive anxiety about different situations lasting for at least 6 months. Someone with a mild prognosis of the condition can continue to function relatively normally. However, severe cases of the condition can have a huge impact on one's life. SAD (Social Anxiety Disorder) on the other hand has been defined as the fear and avoidance of social interactions or situations whereby one is the centre of attention. The fear of social situations can leave one feeling lonely and ashamed. Roughly 15,000,000 U.S. citizens suffer from SAD, according to the Anxiety and Depression Association of America. A related condition is PTSD (Post traumatic stress disorder) which develops after an individual has gone through a horrifying/traumatic experience. Symptoms can occur years later or immediately after the traumatic experience. Situations whereby witnesses could develop PTSD include: terror attacks, natural disasters and war. Episodes of stress/anxiety can occur with no warning. Another common anxiety disorder is known as OCD (obsessive compulsive disorder). Individuals with OCD have an excessive urge or compulsion to do some actions repeatedly. Some of the compulsions or urges that individuals with OCD have include constantly checking things, counting repeatedly and ritualistic hand-washing. Phobias have also been categorized as anxiety disorders. Common types of phobias include the fear of heights or the fear of tight spaces. Phobias develop within the client a strong drive to avoid the feared situation/item. Finally, the last anxiety disorder we will discuss for the purposes of this paper is panic disorder. Panic disorder causes extreme feelings of terror or anxiety. Physical indications include apnea, chest pain, and heart palpitations. These attacks usually occur repeatedly. Individuals suffering from different types of anxiety of disorders can have panic attacks (Krucik, 2014).

Psychological History

In this case it was reported that the client, Mr. C. was born in Central America and immigrated to the U.S. (United States) when he was about 8 years old. Mr. C stated that he had had social anxiety since his childhood days before he moved to the United States. As a child he had moved from his rural village where most people spoke an indigenous language, to a city where the majority of the people conversed in Spanish. At that point in his life he started feeling anxious when interacting with them since he thought they would think of him differently if they realized he could not speak Spanish fluently. Mr. C continued in his report noting that from then up to now he there are still a number of situations that make him anxious and that as an adult he had turned to drinking alcohol so as to cope with the condition. However, on a more positive note, he reported that he had recently become sober and purchased a self-help book to help deal with his social anxiety. He however noted that he felt that clinical therapy was the only way he could completely eliminate his condition (Weiss, Singh, & Hope, 2011).

The symptoms that Mr. C reported were similar to those described under Social Anxiety Disorder (SAD) in the Anxiety Disorders Interview Schedule for DSM-IV. There were no additional diagnoses. Problematic symptoms included experiencing anxiety when talking to strangers, speaking or writing in front of a group, when reprimanding others or by being the centre of attention. A clinician's severity assessment was conducted using ADIS-IV and it was found that the patient had a severity of 5 out of a maximum possible score of eight, showing that his symptoms were between moderate and severe. Mr. C also noted that his condition cause him to difficulties at work and in education. One of the most problematic issues he had to face every day was writing in front of others since the work he did required it. Moreover, Mr. C noted that the condition limited the kind of jobs he could do since he was only comfortable in doing those that had very little interaction of with others. Mr. C also reported that he had enrolled in a computer literacy program but did not complete it out of the fear that he would end up having to speak in-front of the whole class if he was requested or wanted clarifications on an issue he did not understand (Weiss, Singh, & Hope, 2011).

Mr. C has a social anxiety disorder. At age 38, the client has allowed and continues to allow the disorder to dictate his life leaving him both physical and emotionally exhausted. However, Mr. C is an intelligent and capable person, since he stopped drinking alcohol and sought help first from relevant literature and then from a specialty clinic. However, with minimal social support, he feels that he is all alone in this and has come to a point where he just wants to lead a normal life. Mr. C presented quite a typical case of generalized anxiety disorder/social phobia. His strong fear and expectation that he could not do well at social engagements or situations turn out to be a self-fulfilling prophecy. The greater the anxiety he felt over situations and the more he concentrated on his anxieties, the more he could not perform well. Thus, his affect, attitudes and beliefs needed to be changed. For individuals with social anxiety disorder, almost all kinds of social situations elicit some kind of anxiety/fear, including behavioral symptoms (for instance, avoiding social interactions/events), cognitive symptoms (for example, the fear of being judged or humiliated) and somatic symptoms (such as blushing, shaking or sweating). Owing to the severity of the anxiety levels, Mr. C has to often avoid social engagements or just perseveres through them. Even though in some social situations anxiety is normal, Mr. C's anxiety is disproportionate to the actual worst case scenario. Thus the anxieties leave him with problems in occupational, social and other crucial areas of normal functioning. Mr. C's case presentation of social anxiety disorder falls under 4 broad categories: (1) personality-related deficits (2) problems with physical appearance (3) inability to conceal symptoms of anxiety and (4) lack of social interaction or skills. He also believes he has no power to remedy these issues and thus tries to hide them via avoiding social interactions and utilizing deviant (safety) behaviors. Ironically, when he utilizes safety behaviors, the possibility of the avoided outcomes coming true actually increases (instead of decreasing) and thus reinforces his negative beliefs about his social interaction abilities (Chapman, Williams & Ryan, n.d).

Developmental history

In this particular case, Mr. C's fear and avoidance hierarchy is taken into account. As part of the overall intervention a special Fear and Avoidance Hierarchy was collaboratively developed during session four. Upon drawing up a list of possible feared scenarios, Mr. C was asked to rate the degree of anxiety that each scenario elicited and how frequently he avoided such scenarios/situations. The degree or severity of anxiety was rated using ratings of the level of discomfort ranging from 0 to 100, with 0 indicating no anxiety and 100 extreme anxiety. Avoidance was similarly rated on a scale of 0 to 100 with zero indicating no avoidance and 100 indicating total avoidance. Fear and Avoidance ratings were obtained in the 4th and 17 intervention sessions, Mr. C's case presented symptoms of SAD from childhood. He reported that being the centre of attention in social settings was particularly problematic. The client's beliefs about the visibility of his anxiety symptoms and the negative impacts of being perceived as anxious seemed to be flawed. His avoidance of social settings that would place him in the centre of attention probably exacerbated his symptoms since he never got to realize that the anxiety outcomes were highly unlikely. Logical flaws in Mr. C's cognitive thoughts were identified and counter/challenging thoughts and logical responses were developed. Mr. C's fear of being in front of groups was also noted and disputing questions were formulated against his automatic thoughts (Weiss, Singh, & Hope, 2011).

Medical/Health history, including any current medications

CBT (cognitive behavioral therapy) for the treatment of SAD has been proved to be effective in several randomized clinical trials. There is however a gap in research with regards to the efficacy of CBT interventions in patients with SAD. However, several professional associations have come up with guidelines and codes to improve treatment outcomes. In the case of Mr. C, the therapist tried to be more engaging by putting emphasis on the application of the intervention to the client's SAD. He went through an overview of the diagnosis process, explained the differences between excessive and normal social anxiety, described the elements of the intervention and its possible outcomes and also told the client what was expected of him during the treatment. Mr. C agreed that his social anxiety was extreme and he expressed eagerness to begin therapy. During this session (the first session after the intake session) Mr. C's SASCI score was 9 showing that his symptoms had improved between the two sessions. This was in line with his eagerness to begin treatment. With regards to Mr. C's medical history, both the long and short-term effects if his avoidance behaviors were discussed in addition to the reduction of anxiety that occurs when there is no avoidance, thus offering some data on how the functions of exposures were analyzed. Mr. C seemed to understand and embrace this rationale of treatment (Weiss, Singh, & Hope, 2011).

Mental health history

SAD is primarily characterized by a significant fear of judgment by others and it is a very common phobia. In its severe form it can significantly impair learning, income earning capabilities and social relationships (Weiss, Singh, & Hope, 2011). Mr. C contacted a faculty anxiety clinic seeking treatment. At the time he contacted the centre, he self-reported that he experiences social anxiety in different settings, for instance, when talking to unknown people, speaking or writing in front of a group, and/or when reprimanding others. Furthermore, Mr. C also reported that he often avoided settings such as the ones mentioned above because of social anxiety. Mr. C specifically pointed out that writing in front of a group of people was one of the worst experiences he had had to go through constantly due to the nature of his work (Weiss, Singh, & Hope, 2011).

Substance use history

The client reported that symptoms of SAD had continued until adulthood where he resorted to alcohol to cope with anxiety. He, however stated that he had become sober and had obtained a self-help book to help recover from his condition. He also stressed that he believed he needed therapy to completely recover from his condition (Weiss, Singh, & Hope, 2011).

History of other compulsive behaviors

In the case presented, since Mr. C felt he feared social interactions, he avoided them. Despite trying to reduce the number of times he avoided such situations, Mr. C still had some hidden avoidance behaviors, for instance, he did not talk much when engaged in conversation with his co-workers) and he felt that these behaviors also still affected how he lived his life. He however experienced confidence that with time he will reduce such behaviors to negligible levels through the skills he had learned (Weiss, Singh, & Hope, 2011).

Abuse/Trauma history

Mr. C stated that he had had social anxiety since his childhood days before he moved to the United States. As a child he had moved from his rural village where most people spoke an indigenous language, to a city where the majority of the people conversed in Spanish. At that point in his life he started feeling anxious when interacting with them since he thought they would think of him differently if they knew he could not speak Spanish fluently. Mr. C continued in his report noting that from then up to now there are still a number of situations that make him anxious and that as an adult he had turned to drinking alcohol so as to cope with the condition. However, on a more positive note, he reported that he had recently become sober and obtained a self-help book to help deal with his social anxiety (Weiss, Singh, & Hope, 2011).

Educational history

It is obvious that Mr. C does not have any formal education. That plus his social anxiety had caused him educational and occupational difficulties. He also had the fear of writing in front of people perhaps indicating that he had not developed in strong writing skills. The fact that Mr. C had joined a computer literacy class shows that he likely did not have a strong formal education background (Weiss, Singh, & Hope, 2011).

Vocational history

For any client to be awarded a clinical vocational allowance he or she must be formally diagnosed using the measures of anxiety. Most individuals receive disability allowances and other benefits when diagnosed with SAD in the form of clinical vocational allowance (Weiss, Singh, & Hope, 2011).

Legal history

Mr. C could qualify for SSDI (social security disability) benefits if he became unable to work because of his depression. However, similar to qualifying for medical vocational allowances, Mr. C must first meet set requirements, such as being formally diagnosed with the condition and he will have to find a lawyer and gather the right documents to file a claim to get SSDI.

Diagnostic Impression

DSM-IV-TR Diagnosis and rationale

The symptoms that Mr. C reported were similar to those described under Social Anxiety Disorder (SAD) in the Anxiety Disorders Interview Schedule for DSM-IV. There were no additional diagnoses. Problematic symptoms included experiencing anxiety when talking to strangers, speaking or writing in front of a group, when reprimanding others or by being the centre of attention. A clinician's severity assessment was conducted using ADIS-IV and it was found that the patient had a severity of 5 out of a maximum possible score of eight, showing that his symptoms were between moderate and severe. Mr. C also noted that his condition cause him to difficulties at work and in education. One of the most problematic issues he had to face every day was writing in front of others since the work he did required it. Moreover, Mr. C noted that the condition limited the kind of jobs he could do since he was only comfortable in doing those that had very little interaction of with others. Mr. C also reported that he had enrolled in a computer literacy program but did not complete it out of the fear that he would end up having to speak in-front of the whole class if he was requested or wanted clarifications on an issue he did not understand (Weiss, Singh, & Hope, 2011).

DSM 5 Diagnosis

The symptoms presented strongly point to a case of SAD (social anxiety disorder) as defined by DSM-5 in addition to other variables that influence the manifestation of these symptoms, for instance, etiological and demographic factors. Besides, cross-cultural differences in the prevalence of the condition were used to show the significance of culture when it came to treating people from diverse backgrounds. Mr. C's case also shows cultural variable at play and interacting with the symptoms of SAD. This knowledge was integrated within the CBT (Cognitive Behavioral Therapy) intervention for patients from ethnic minorities (Chapman, Williams & Ryan, n.d).

E. Case Conceptualization

Mr. C reported having too much social anxiety ever since his infancy. He pointed out that that being monitored in social circumstances (for instance speaking in front of a crowd, writing in front of other individuals) was specifically difficult. His beliefs regarding the vividness of his anxiety symptoms as well as the terrible repercussions of being viewed as anxious seemed to be distorted. The consequent evasion of a number of social circumstances in which Mr. C would turn out as the center of attention possibly served to sustain his SAD symptoms since he was never aware that the feared results were not likely (Weiss, Singh, & Hope, 2011).

Consideration of cultural influences

The cultural background of Mr. C affected his treatment in several ways. Firstly, it influenced the approach assumed toward cognitive restricting. Reporting of automatic thoughts is the initial step in cognitive restructuring. Normally, the client is asked by the therapist to name the automatic thoughts which aggravate anxiety as an initial step to the alteration of the thoughts. For those clients whose main language is not similar to the language through which the therapy is being carried out, the real meaning of the thoughts of the client could be lost in translation, hence making the cognitive work less helpful. Mr. C stated that as a kid he learnt Spanish, related with friends and family majorly in Spanish, and even thought in Spanish. Therefore, early during therapy the therapist suggested that he complete his cognitive homework in Spanish. Mr. C reported that he was scared that the therapist perceived that he was not capable of completing his homework in English since he was not fluent in English, a possible expression of his social anxiety. Treatment continued in English just until the bond was stronger amidst the client and the therapist reinitiated the idea. The client seemed excited and completed the rest of his homework in Spanish. The client stated that he saw it meaningful and seemed to be better capable to dispute his automatic thoughts in Spanish and the thoughts seemed to be more emotionally burdened. His SUDS ratings seemed to reduce more rapidly with the utilization of a Spanish rational response (Weiss, Singh, & Hope, 2011).