Presenting Problems
Patient X is a 16 year old boy. The patient is afraid of attending an upcoming compulsory class camping trip. The patient is afraid of being in such a social situation that will require him to engage. He appears very shy, and hardly maintained any form of eye contact. The patient does not answer any question in class unless when prompted by a teacher, he refused to take part in any group activity unless when it was mandatory. The patient narrated an incident where he had to present a project in front of the whole class. His voice was weak, he stumbled around and choked a lot. He appeared deeply embarrassed by the incident such that he could not face his classmates after the presentation. Consequently, he would beat himself up wondering why he was so timid and scared, unlike his friends and classmates.
The patient has only a single friend that he interacts with, and is afraid of social events (Ryan & Warner, 2012). He does not know what to say to new people, and he believes that he makes conversation award for everyone else so he prefers to be alone. However, the worst part of his condition is the anticipatory anxiety. He constantly worries that he will not do well in any situation that will make him to speak in a public or to a stranger. He gets panic attacks at the thought of doing something in public.
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Relevant History
Patient X is the last born in a family of three boys, the patient admits that he is quite different from his older siblings who are more sociable. Patient comes from a middle- income family, and is quite close to his mother. However, he describes his mother as very critical, while his father is hardly involved in their lives.
While he was eleven, his family relocated to a new neighborhood. He left his childhood friends behind, and making new friends was quite problematic. His older siblings are a bit mature, hence they did not spend a lot of time with him. Eventually, he made friends with another shy age mate. The patient describes that adjusting to the new school was quite difficult, he did not make any new friends. His social life since eleven is not improving.
His academic performance is quite poor. Since he moved to the new school, patient has been failing most of his subjects. He is afraid of taking part in group works and any form of public speaking. Taking tests also scares him sometimes such that he spends a lot of his time worrying about the test instead of doing the test. His fear for authority figures also means that he cannot seek help from teachers. However, patient presents no medical condition that could be associated with social anxiety disorder.
Diagnosis
Social Anxiety Disorder (SAD) was accorded its own diagnostic category by the American Psychological Association in 1980 in DSM 3. However, DSM-5 has quite some changes regarding the diagnosis of SAD.
The process of DSM-5 differential diagnosis is guided by five steps. From the objective description, patient is suffering from some form of an anxiety disorder, and the first step is to rule out a malingering disorder. The second step is to rule out substance etiology, hence ruling out alcohol abuse and other substance disorders. In determining specific primary disorders, one has to refer to the specific DSM-5 criteria for each of the relevant disorders. DSM-5 provides the necessary guidance used to make a differential diagnosis between SAD and other anxiety conditions such as: panic disorder, schizoid personality disorder, performance anxiety and avoidant personality disorder.
DSM-5 has 10 distinct items in the diagnostic criteria for SAD. The first item is a marked fear of one or more social performance situations, and the fear is associated with feelings of embarrassment and humiliation (Hedman et al., 2013). The second item in the diagnostic criteria is that exposure of the feared situation will evoke anxiety.
From the objective description of the patient, it appears that the patient meets the criteria for generalized SAD, which is more dangerous than performance SAD. The patient seems to be afraid of social situations, rather than specific performances. Additionally, the anxiety is more comprehensive unlike in the cases of panic disorders which tend to occur in social situations and are accompanied by threatening physical symptoms. Agoraphobia is also ruled out because the anxiety is restricted to social situations, however the anxiety is not caused by the fear of lack of an escape in case of a panic attack in public. He is not delusional, hence he cannot be suffering from schizophrenia. However, avoidant personality disorder is almost similar to SAD, but it is a more advanced social phobia which is not presented by the patient as he opened up willingly about his condition.
Case Formulation
After interacting with the client, it becomes apparent that SAD is a more complex disorder than can disrupt all aspects of an individual’s life. SAD is a pronounced fear of social situations such that an individual is afraid to interact with a stranger or in public. As Hedman et al., (2013) puts it, several aspects of SAD are linked to the concept of shame, and such that an individual with SAD is afraid his actions will bring shame and guilt.
From the interaction with the patient, SAD can be traced a patient’s family history, social history, temperament and notable events in one’s childhood. The patient claimed that he had a critical mother who often rejected his ideas. The patient was not free to talk because his overbearing mother often criticized him. His older brothers were much older, hence they did not have anything in common.
Social situations also play an important role, when the patient moved to a new neighborhood, he had a hard time making new friends and his SAD became more pronounced. New social networks trigger anxiety, and people with SAD do worse with new environments (Ryan & Warner, 2012). Patient X described an embarrassing situation in his school, which seemed to have worsened his SAD. Temperament also plays an important role, such that shy and restrained individuals are at greater risk for developing SAD.
Lastly, SAD has its roots in adolescence. Adolescence is an extremely confusing time in an individual’s life, adolescence are more self-conscious and if the condition is not addressed at this stage, it can adversely affect their adulthood.
Treatment
The goal of SAD treatment is to reduce symptoms, hence psychotherapy is the best treatment method. Cognitive behavioral therapy (CBT) is commonly used to manage anxiety (Ryan & Warner, 2012). CBT therapy equip SAD patients with the skills for facing social situations, and skills for managing anxiety during such situations.
Ryan & Warner (2012) suggest a Social Anxiety in the School Setting (SASS) intervention. This is a suitable intervention for the patient X in that he seemed to be more afraid of social situations at schools. A SASS intervention is a 3-month in-school group sessions (45 minutes) to address anxiety and manage anxiety among students. The intervention also features additional four weekend social events such as bowling. A counselor is in charge of the program, however, parents and teachers are encouraged to attend so that they can learn skills on how to help students with SAD. SASS group intervention is the right intervention for the patient, the patient will learn that there are other students with similar symptoms and will help each other by sharing their experiences.
SASS intervention entails the following components: psychoeducation, realistic thinking, social skills straining, exposure and relapse prevention (Ryan & Warner, 2012). Each component has 5 sessions. Under psychoeducation, students are made to feel comfortable and asked to define their anxiety. The counselor can replace the word ‘anxiety’ with “discomfort’ to encourage openness. The second step of SASS intervention is realistic thinking which entails cognitive strategies for overcoming social anxiety such as identifying negative expectations.
The third component is social skills training. This component equips students with skills for starting and maintaining conversation, establishing friendships and being assertive (Ryan & Warner, 2012). Under social skills training, students will be given social assignments such as making new friends or role-playing with other students in the group to encourage them to practice social skills.
Under the fourth concept, students will be encouraged to face their fears. Students will develop a list of the things they are afraid of in a form of a “fear ladder.” Common items include answering a question in class, attending a party, making a new friend or tripping in front of a group. Students will practice how to handle such situations, and how to counter anxiety and negative thoughts before taking part in exposure experiments (Ryan & Warner, 2012).
Lastly, the intervention will include a lot of group exercises after each session and at the end of SASS intervention. Students will constantly practice realistic thinking, social skills and facing their fears until their SAD symptoms are drastically reduced.
References
Hedman, E., Ström, P., Stünkel, A., & Mörtberg, E. (2013). Shame and Guilt in Social Anxiety Disorder: Effects of Cognitive Behavior Therapy and Association with Social Anxiety and Depressive Symptoms. PLoS ONE, 8 (4). doi:10.1371/journal.pone.0061713
Ryan, J. L., & Warner, C. M. (2012). Treating Adolescents with Social Anxiety Disorder in Schools. Child and Adolescent Psychiatric Clinics of North America, 21 (1), 105-118. doi:10.1016/j.chc.2011.08.01
