Social Anxiety Disorder: Case Study and Treatment Plan

Presenting Concerns

The client 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 that time, a friend advised her to seek counseling; however, she never did. Since then, she has been avoiding certain types of social situations, has gravitated toward jobs with as little social contact as possible, and fears that her anxiety may be impacting her academic performance and her ability to secure a viable internship. She loves "diving into my work" and becoming absorbed in her academics, but when it comes to attending classes, she feels stressed and has been missing more classes than ever before. After not showing up to classes for two weeks—and an incident involving alcohol poisoning during that same period—her family intervened and contacted the mental health center.

The level of distress the client experiences 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. She has walked out of social situations and feels humiliated "often." She attributes the additional stress to her workload at school and to the increasingly social nature of her upper-division courses. She has been experiencing panic attacks with greater intensity and frequency over the past several months, although she has suffered from them on and off for ten years. She claims, "I never knew anything was wrong until now."

The client often takes two hours to get ready for class, claiming that she tries "everything in my closet" before she feels presentable enough to go out in public. Being late for class has also been a problem, but because her grades and work are among the best in her cohort, her professors have not complained.

Background and Developmental History

When the client was ten years old, she began to feel excessively self-conscious at school. The onset coincided with her first menstrual period; she recalls being paranoid all day that everyone knew, running to the bathroom between every class, and being certain she had blood on her clothes. During this same period, she became more withdrawn than she had been before. She had always been on the quiet side, but by age twelve she had few friends and rarely attended parties. Her parents believed she was simply a studious child and did not intervene.

Throughout high school, incidents she now recognizes as panic attacks began to occur with relative frequency. Symptoms included increased heart rate, a sense of impending doom, changes in breathing, sweating, and occasional shaking. These symptoms arose immediately before social engagements, during social events, and during conflict or confrontation. When she first started college, she delved into her studies but continued to experience anxiety symptoms and therefore avoided social engagements. She does not belong to any clubs, and her only friends live in her dormitory hallway.

The client admits that although she completes all her work on time and earns strong grades, she rarely participates in class. She mentions how grateful she is that professors do not "call on you" or "single you out" as they did in high school. She recalls hiding in the bathroom and even under a table at school to avoid being called on. In her senior year of high school, however, she was required to make up for a lack of credits by taking debate classes—a course she had previously avoided because of the intense teamwork it demanded. She has also remained distant from legal academic societies despite strong encouragement from her advisors.

Her parents divorced when she was eight years old. She has two stepsiblings. Apart from work-study programs to offset financial aid loans, she has never held a steady job. In high school she was a capable athlete who gravitated toward track and field rather than team sports such as basketball. She recalls always wanting to stay in the outfield during softball games so that she would "never have to field a ball." She now recognizes that her aversion to team sports was rooted in a broader discomfort with teamwork: "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 project at school." Her recent coursework in debate has made her academic environment considerably more socially demanding than it had been in previous years.

Diagnosis and Multiaxial Assessment

The client's symptoms are classic indicators of social anxiety disorder. The precipitating incident of alcohol abuse suggests that her social anxiety had never been professionally addressed and, left untreated, could escalate into serious substance abuse. Although comorbidity was considered, there are no concurrent indicators of depression. A differential diagnosis process ruled out substance abuse, as the recent incident appears to be isolated and was itself the catalyst for the client's concern. She does not present with symptoms of agoraphobia or generalized anxiety disorder; social situations are clearly the primary source of her distress. She has performed well academically but has few close friends, avoids parties, and dreads both attending classes and the prospect of future employment that might require sustained social contact.

Axis I: 300.23 — The principal disorder is social anxiety disorder, formerly termed social phobia. Terminology and diagnostic criteria have shifted, more closely aligning the disorder with the anxiety disorders than with the phobias. This shift is partly due to emerging neurophysiological research and partly to its manifest symptoms. In the DSM-5, the nomenclature has changed from that of the DSM-IV, which still used the term social phobia. The primary diagnostic criteria also changed, particularly regarding the degree of insight the client has about her condition. The client meets sufficient criteria, including the duration of symptoms and their type. The primary diagnostic challenge was determining whether her symptoms indicated generalized anxiety disorder rather than social anxiety disorder. Ruling out generalized anxiety disorder required an intake assessment that included questions about her perceptions across a range of situations. One updated criterion for social anxiety disorder is the level of awareness a client has about the irrationality of the fear (Bogels et al., 2001). The client has demonstrated this awareness and recognizes that her social anxiety is a problem. Notably, she experiences no performance anxiety on tests, essays, or when running track and field, but does experience distress in classes requiring group or team projects.

Axis II: No personality disorders have been indicated. The client does not appear to have Avoidant Personality Disorder.

Axis III: The client has no known medical issues.

Axis IV: Psychosocial stressors include the intensely social environment of her current coursework, the demands of her senior-year schedule, and uncertainty about life after graduation.

Axis V: The client performs well academically, and her highest level of functioning occurs on days when she faces few social obligations. She does not object to one-on-one interactions and states she prefers a few close friendships to many acquaintances. On the Global Assessment of Functioning (GAF) Scale, she has rated between 50 and 70, placing her symptoms generally in the mild-to-moderate range (Burke, n.d.).

References

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Anxiety and Depression Association of America. (2014). Social anxiety disorder. Retrieved from http://www.adaa.org/understanding-anxiety/social-anxiety-disorder

Bogels, S. M., Alden, L., et al. (2010). Social anxiety disorder. Depression and Anxiety, 27, 169–189.

Burke, B. (n.d.). Abnormal psychology. Retrieved from http://faculty.fortlewis.edu/burke_b/Abnormal/Abnormalmultiaxial.htm

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