Psych 233: Abnormal Psychology

Anxiety Disorders
Panic Disorders, Phobias and Generalized Anxiety Disorder

Tyrone Reden Sy & Daniella Morga

ATENEO DE MANILA UNIVERSTY

GENERALIZED ANXIETY DISORDER (I CANT STOP MY HEAD) ................................................................. 3 BRIEF THEORETICAL BACKGROUND ............................................................................................ 3 SOCIAL ANXIETY DISORDER ................................................................................................................ 13 BRIEF THEORETICAL BACKGROUND .......................................................................................... 13 ILLUSTRATIVE CASE STUDY ....................................................................................................... 14 CASE DISCUSSION ..................................................................................................................... 14 TREATMENT .............................................................................................................................. 15 SPECIFIC PHOBIAS ............................................................................................................................. 16 CASE STUDY: VOMIT PHOBIA .................................................................................................... 17 CASE DISCUSSION ..................................................................................................................... 18 TREATMENT .............................................................................................................................. 18 PANIC DISORDER (WITH AGORAPHOBIA) .............................................................................................. 18 BRIEF THEORETICAL BACKGROUND .......................................................................................... 18 ILLUSTRATIVE CASE STUDY ....................................................................................................... 19 CASE DISCUSSION ..................................................................................................................... 20 TREATMENT .............................................................................................................................. 21 References .................................................................................................................................... 22

GENERALIZED ANXIETY DISORDER (I CANT STOP MY HEAD)

I always thought I was just a worrier. Id feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. Id worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldnt let something go. Jason, diagnosed with GAD

BRIEF THEORETICAL BACKGROUND

While it is common for people to worry about objects or concerns of daily life from time to time, people with Generalized Anxiety Disorder (GAD) do so uncontrollably to the point that their worry impedes them in their daily functioning. Indeed, Kring et al. (2013) notes that the central feature of GAD is worry, and those with GAD usually chronically worry about a lot of things, some of them usually minor and mundane. GAD is a new diagnosis, being previously classified under the label of anxiety neurosis before 1980 (Tyrer & Baldwin, 2006). Previously, the DSM IV TR (APA, 2000) enumerated the following as symptomatic of GAD: the essential feature of Generalized Anxiety Disorder is excessive anxiety and worry (apprehensive expectation), occurring more days than not for a period of at least6 months, about a number of events or activities (Criterion A). The individual finds itdifficult to control the worry (Criterion B). The anxiety and worry are accompaniedby at least three additional symptoms from a list that includes restlessness, being easilyfatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep (only one additional symptom is required in children) (Criterion C). The focus of theanxiety and worry is not confined to features of another Axis I disorder such as havinga Panic Attack (as in Panic Disorder), being embarrassed in public (as in SocialPhobia), being contaminated (as in Obsessive-Compulsive Disorder), being awayfrom home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder),or having a serious illness (as in Hypochondriasis), and the anxiety and worrydo not occur exclusively during Posttraumatic Stress Disorder (Criterion D) (p. 472). However, the DSM 5 (APA, 2013) added some changes to the diagnostic criteria for GAD namely, that the excessive anxiety and worry be present at least 50% of days in at least two life domains, worry is sustained for at least three months (previously from 6 months) and that the worry

and anxiety are associated with marked avoidance of situations in which negative outcomes could occur, marked time and effort preparing for situations that might have a negative outcome (Kring et al., 2013).

ILLUSTRATIVE CASE STUDY

Attached is the psychological evaluation report of Angelita, a 45 year old female, who presented for psychological evaluation at the Section of Psychology, Philippine General Hospital. Angelitas presenting symptoms and behavioral manifestations seem to be typical of a person with Generalized Anxiety Disorder.

CASE REPORT: ANGELITA

SECTION OF PSYCHOLOGY Department of Rehabilitation Medicine Philippine General Hospital Taft Avenue, Manila 5548400 loc 2421

PSYCHOLOGICAL EVALUATION REPORT

DATE OF EVALUATION: September 7, 2011

IDENTIFYING INFORMATION:
Name of Client: Sex: Date of Birth: Chronological Age: Present home address: Educational Attainment: Referring physician: Diagnosis/Working Impression: Angelita Female July 26, 1966 45 years, 1 month, 11 days Imus, Cavite College Graduate, BS Commerce (1991) Mylene Rose Benigno, M.D. Osteoarthritis of the Right Knee; R/O Generalized Anxiety Disorder; R/O Hypochondriasis

REASON FOR REFERRAL Angelita was referred for psychometric evaluation to rule out the presence of generalized anxiety disorder and hypochondriasis. The results of this evaluation can also be used as reference to determine her fitness for employment and to determine future psychotherapeutic interventions to enhance her well-being.

PERSONAL BACKGROUND Family History Angelita is the second to the youngest of the eleven children of Pablo and Mercedes (both deceased). At present, she is married to Susano (51), a former OFW from Qatar and presently unemployed since 2008. A housewife, Angelita seems to experience some distress because of the financial difficulties their family is currently experiencing. Susano and Angelita have three children: Shekainah (14), Stephen John (12) and Samuel James (10). Presently, Angelitas in-laws are financially supporting their family. Domestic Environment Angelita shared that during her childhood, her parents did not employ corporal punishments on her nor any of her siblings. Once or twice, Angelitas father would spank or shout at her and her siblings and their mother would comfort them afterwards. At present, the client explained that her relationship with her husband is somewhat harmonious. Significant Health History Recently, Angelita complains of osteoarthritis (pain and discomfort) of the right knee. She has been confined after her tonsillectomy in 1998, and contracts allergic rheinitis occasionally. Last June 2011, she has been to a psychiatrist after complaining that she was lagingkinakabog, laging tense. She shared that during times of emotional unpreparedness and stressful situations, she would experience palpitations, dyspnea, trembling and incessant crying. There have also been times during class discussions and oral presentations that she would not be able to think clearly (mental block) or to speak coherently and audibly (garalgal angboses). She had been prescribed Alprazolam and Venlafaxine since. However, Angelita shared that on certain occasions where she needs to be alert (e.g. household chores), she would not take these medicines because they make her feel sleepy. Aside from wearing reading glasses, Angelita shared that she has no major difficulties in her eyesight and hearing although she would stammer when under distressful situations. Her appetite is relatively elevated (she has to restrain herself from eating) and she currently experiences some sleep disturbance because of intrusive thoughts relating to their financial difficulties. Social, Emotional and Behavioral History Angelita has no notable mannerisms. She shared that whenever she is denied of what she wants or does not get what she wants, she would often get disappointed but after some time of thinking and analyzing, she would let go of these frustrations. Angelita describes herself as a person who is maligalig (tense or agitated), workaholic, impulsive, socially reserved and melancholic. The client shared that after her mother and father died when she was in Grade 6 and 2 year High School, respectively, she felt neglected and uncared for by her siblings. This is why she sought for a boyfriend on the hope that this could satisfy her need for love from her family. However, when her boyfriend left her for another woman, Angelita sank in a state of depression to the point that she had thoughts of suicide and death.
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Angelita shared that while she appears to be very talkative, friendly and sociable on the outside, at the end of each day she would get lonely and cry. According to her, she fears rejection and somehow gets hurt easily by criticisms or rebuttal to the extent that she would resort to evading interaction with others so that she may not offend (or get hurt). She also seems to express some apprehension in her inability to restrain herself from sharing her personal life to other people she just met. She also seems to be frustrated at herself for not being able to overcome her weaknesses and insecurities which include her inability to speak in English fluently because of her regional dialect (kapampangan). The client also shared that her decision to marry her present partner seems somewhat impulsive. She claims that nakapag-asawasiyang di niyamahal and this resulted to her present regrets of not being able to work (and wasting her education) because of child-rearing responsibilities. She also shared that in the past few months, she had been disappointed by a lot of people who owed her money, and felt that they took advantage of her back when they still had the financial-capacity because her husband was still in Qatar. Angelita seems to express some fears about the safety of her children, and the kind of death that she would have if ever she will pass away. Educational and Work History After working in a factory for two years, Angelita went back to school and finished a degree in Commerce from the Baguio College Foundation in 1991. After which, she took a job as an accounting clerk at Del Monte but resigned 6 months later because she wanted to work abroad. However, she was not accepted after knowing that she was pregnant with her second child. In August of last year (2010), Angelita enrolled in an English-proficiency course at the Imus Institute and Computer-skills training at the Cavite Computer Center because she wanted to work as a Call Center agent. However, the client shared that she wanted to work but is unable to pass job interviews because she would often tremble uncontrollably. At present, Angelita wants to overcome her uncontrolled anxieties and physiological responses so that she could work. BEHAVIORAL OBSERVATIONS Physical Appearance and Clothing Angelita has an average height, weight and physique for her age and has fair complexion. Her facial features are proportionate to his body whereas her hair and over-all appearance was tidy, proper and well-groomed. There were no peculiarities in her walking ability or posture. Speech Behavior Angelita spoke in an audible volume and at a relatively fast speaking rate. There were also no noticeable distortions in her pronunciation. The patient primarily spoke in Filipino and can fully understand and speak English. During the evaluation, Angelita responded to every question that the clinician asked of her attentively and sensibly.

Quality of Communication Angelitas vocabulary and grammar skills were suggestive of normal intellectual functioning. She showed affects that were appropriate to verbal content and displayed emotions such as happiness, agitation, sadness and anxiety. Thought content revealed no evidence of delusions, paranoia or suicidal/homicidal ideation. Flight of ideas, clang associations and perceptual disorders were absent.Angelitas level of insights about herself, loved ones and other people seem to be intact. Movement/Activity Throughout the evaluation, Angelita remained seated and maintained eye contact and attention towards the clinician. She emotionally appeared agitated and tense especially when she is not able to answer questions asked of her. Over-all, Angelitas attitude during the evaluation was open and cooperative. No imminent dangers were evident. CURRENT EMOTIONAL STATE Depression Level Angelita seems to show no overt signs and behavioral manifestations of depression at the time of psychological evaluation. She also does not seem to show any signs of lethargy or fatigue. She also seems to be able to concentrate in detailing vital information needed by the clinician. Anxiety Level Angelita seemed relatively agitated and apprehensive in her actions and behaviors during the evaluation. She seems to be able to keep her agitation under control when she is asked. Premorbid personality Angelita shared that it was only recently that the people around her noticed her relative agitation and nervousness. She contends though that even before she was really a very nervous person. Coping Style Angelita seems to cope with her difficulties and anxieties positively and actively. Perception of Disability Angelita perceives her difficulties and present anxieties negatively because she sees them as hindrances for her to be able to work and function normallyin social settings. Self-esteem and Level of Motivation Angelita has low to average levels of self-esteem despite her present difficulties. At present, she verbalizes her intent and dedication to renew her mind and to overcome her anxieties.

Patients Plans Angelita plans to find an occupation which could sustain their familys financial needs. She also aims to know and resolve the underlying tensions for her nervousness. Social Support System Her family relationships seem harmonious although the client has only a few networks outside the home. Her strong belief in God is also one of her coping mechanisms to accept the things she cannot change.

Patients Expectations Given her social support system, her abilities and her determination and perseverance, with some external assistance, Angelitas planned activities seem to be realistic and attainable. TESTS ADMINISTERED 1. 2. 3. 4. Slosson Intelligence Test Revised (SIT-R) Test of Non-Verbal Intelligence 2nd Edition (TONI-2) Minnesota Multiphasic Personality Inventory 2 (MMPI-2) Draw-a-Person Test (DAP)

TEST RESULTS AND INTERPRETATION

Slosson Intelligence Test Revised (SIT-R) Raw Score 26 TONI-2 Quotient 94 Percentile 34% Rating Average

In the SIT-R, Angelitas true standard score is 98 and her IQ exceeds 45% of the general population. This being the case, it can be said that Angelita has relatively normal verbal intelligence or intelligence learned from exposure to ones environment, culture and life experiences. This suggests she has adequate capacities to learn and recall information, to reason quantitatively and to apply these abilities in solving problems and dealing effectively with the environment. Test of Non-Verbal Intelligence 2nd Edition (TONI-2) Raw Score 130 True Standard Score 98 Percentile 45% Classification Average

The results of Angelitas TONI-2 are concurrent with the findings of her SIT-R. For her age, Angelita possesses normal intelligence especially in concepts involving abstract reasoning. Her performance in TONI-2 would imply that she has adequate abilities to solve problems and form decisions, to engage in analysis of information presented to her and to think critically. She may also possess some significant potential in processing and remembering abstract and complex information. Taking into consideration the clients performance in the TONI-2 and SIT-R, it can be said that the clients orientation, memory and attention are intact during the psychological examination.

Minnesota Multiphasic Personality Inventory II (MMPI-II) Measures of inconsistent responding indicate that Angelitas MMPI profile is valid although characterized by some minor inconsistencies. Despite her elevated scores on the Lie scale, other measures of infrequent responding indicate that the client accurately described her mental health status in taking the test. Angelitas scores indicate that she is presently experiencing a great amount of psychological turmoil (fear, anxiety, tension, depression). At the time of evaluation, her relatively elevated scores in various clinical scales indicate that she is highly anxious, apprehensive, unhappy and cynical. Somatic complaints may occur as a result of these elevated scores. Intruding thoughtscould also be present and thus she may have some difficulty in concentrating. She may also have low energy levels and unique beliefs. Angelita may also have a tendency to over-control her emotions and maysomewhat feel inferior and uneasy in social situations. She may be excessively sensitive and responsive to the opinions of others and feel misunderstood and unloved. The client is highly introverted, having some tendencies to avoid social situations and interpersonal relationships whenever possible. In dealing with her psychological problems, Angelita tends to internalize and tends to be conventional and cautious. Draw-a-Person Test (DAP) Angelitas drawings are suggestive of feelings of weakness, inadequacy, futility and depression. They are also indicative of the clients need for emotional support when under stress and her tendency to head for flight from a frustrating environment. They also imply the clients refusal to listen to the criticism of others and her detached interactions with them. The features of her drawing indicate that the client has a tendency to avoid unpleasant situations, and some free flow of basic drives and impulses with inadequate controls. Over-all, the strokes of her drawing implies determination and fearfulness although the location of her drawn figure is indicative of the need to maintain careful control in freely expressing feelings or emotions. DIAGNOSTIC IMPRESSIONS Based on Angelitas self-reports and shared experiences, her psychological test results and the clinicians personal observations, Angelita qualifies for a clinical diagnosis of Generalized Anxiety Disorder. For the past six months, she has experienced excessive and uncontrollable anxiety and worry about a number of events. Furthermore, her worry and apprehension was accompanied by at least three physiological symptoms that included agitation, disturbed sleep and difficulty concentrating. Also, her anxiety does not occur within the context of other disorders such as a Panic Disorder nor Social Phobia because the client experiences anxiety and apprehension even without fear of an upcoming panic attack or social situations in which others will evaluate her. In her apprehension, Angelita also experiences distress and difficulty in controlling her worries to the extent that it has impaired her from communicating effectively and working productively. Finally, the disturbance that the client is presently experiencing is not due to the direct physiological effects of a substance. On the other hand, Angelita does not qualify for a clinical diagnosis of Hypochondriasis. Although the clients score in the hypochondriasis scale of the MMPI is moderately elevated, her somatic complaints are a result of her highly elevated scores in other clinical scales such as depression and anxiety. These somatic complaints could be viewed as a kind of coping mechanism

in dealing with her psychological tensions resulting from their financial difficulties including her unemployment. Given the results of her intelligence test, it can be said that Angelita is capable of engaging in productive work. However, it is recommended that her working environment be free from as much pressure and tension as possible (e.g. clerical or secretarial work). Also, she would need to undergo psychotherapy so that she may be taught relaxation and stress management techniques in order for her to be able to effectively manage her agitation and anxiety. RECOMMENDATIONS Angelitais recommended to: Continue medications prescribed by her psychiatrist. Be taught stress management and relaxation techniques. Undergo desensitization, imaginal flooding and behavior rehearsal psychotherapy in order for her to be able to manage her anxiety and agitation in unfamiliar social situations. Undergo gestalt therapy as a way of integrating previous emotional issues she has faced.

For her work environment: It is recommended that Angelita find an occupation whose working environment has minimal pressure and work tension (e.g. clerical or secretarial work). Research more on generalized anxiety disorder, depression and/or suicide to further enhance their knowledge of interacting and helping their co-worker. Make Angelita feel that she is accepted, loved and understood for who she is, her conditions, limitations and abilities. For her family and friends: Be on the lookout for possible behavioral and cognitive symptoms of depression and suicidal tendencies in Angelita. Research more on generalized anxiety disorder, depression and/or suicide to further enhance their knowledge of interacting and helping their loved one. Make Angelita feel that she is accepted, loved and understood for who she is, her conditions, limitations and abilities. Thank you for referring Angelitato us. It has been a pleasure working with her. If there are any concerns regarding the evaluation, please do not hesitate to call us at 5548400 Loc. 2421.

Prepared by: _______________________ Tyrone Reden L. Sy

Clinical Psychology Intern

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THERAPY PLAN GOAL # 1: To reduce the clients anxiety and apprehension to manageable levels that will enable her to express herself better. Number and Duration of Sessions 2 - hour sessions (Relaxation techniques and mental imagery) Specific Behavioral Objectives 1) Make the client relax and tension-free for a period of 30 minutes to 1-hour. 1) The client progresses up to the second highest anxiety-provoking scene or stimuli in her list of anxiety hierarchies in imaginal flooding. 1) The client is able to remain calm, and able to appropriately respond to at least 75% of the social situations which she has listed as anxietyprovoking. Methods/Strategies Teach client relaxation techniques and breathing exercises Evaluation/Assessment Method to be used Behavioral observation; self-reports of client; take-home exercises; journal; assignment: list anxiety hierarchies Behavioral observation; self-reports of client; journal writing; takehome practice; assignment: list of social situations which had been highly anxiety-provoking Behavioral observation; self-reports of client; journal writing; takehome practice;

2 - hour sessions (Systematic desensitization and imaginal flooding)

Systematic desensitization and imaginal flooding

2 - hour sessions (Behavior Rehearsal)

Behavior rehearsal and simulation; social skills training

GOAL # 2: To enable the client to face unfinished businesses in her past and integrate her experiences into one coherent whole. Number and Duration of Sessions One 2 - hour session (Gestalt Therapy) Specific Behavioral Objectives 1) Make the client realize the baggage she still carries inside of her (and the effects of these in her present life) as well as those aspects of herself that she is unaware of or denying. Methods/Strategies Internal dialogue exercise and emptychair technique Evaluation/Assessment Method to be used Behavioral observation; self-reports of client; take-home advices

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DISCUSSION
As Kring et al (2013) has stated, the central feature of GAD is worry. This is particularly applicable in the case of Angelita who constantly worries about a lot of things. For one, she reported being particularly worried about the present financial concerns of their family and this has generalized to other aspects of their domestic life. Angelita has expressed some agitation about the health of her children, as well as their academic welfare. She seems to be worried that if she doesnt have an active part in her childrens studies, then they will automatically fail. She also seems to be apprehensive about the kind of death that she will have if ever she will pass away. Angelita has been experiencing these worries and anxieties for the past three months and these have been associated with other physiological symptoms such as restlessness, difficulty concentrating and sleep disturbance.

Most importantly, Angelita has been avoiding situations in which negative outcomes could occur. For example, while she wanted to talk to her acupuncture therapist to assert for better treatment, she hesitated doing so out of fear that she will be unable to get her message across clearly because her mind will just go blank (mental block) and will not be able to speak coherently (garalgal ang boses). The same goes with her psychiatrist.

Biologically-speaking, how and why Angelita has acquired GAD could have been a malfunction of her GABA system (Kring et al, 2013). There could also be some abnormalities in her serotonergic and noradrenergic neurotransmission (Tyrer & Baldwin, 2006). However, a better explanation would be that of Borkovec & Newman (1998, as cited in Kring et al, 2013) who said that people with GAD worry in order to distract/relieve themselves from overwhelming emotions brought about by early experiences of trauma. This is very much applicable to Angelita. At a young age, Angelita suffered many traumatic experiences from the death of her parents, from being left by her boyfriend for another woman, and from being cheated on by people who owed her some money. From Borkovecs perspective, then, it would seem that all these free-floating anxiety as Freud originally described GAD, is a result of unresolved and unfathomable emotionally-charged experiences. Hence, Angelita worries in order to avoid facing these emotions.

TREATMENT
As Angelitas therapist, the original goals of my therapeutic plan were two-fold: (1) to equip her with the necessary relaxation techniques and skills to manage her anxiety, worry and

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physiological agitation; and (2) help her face her unresolved emotional baggages through catharsis and cognitive reframing. These kinds of treatment have been proven to be more effective than nondirective treatment or no treatment at all (Kring et al, 2013). However, because of the clients financial limitations and time constraints, therapy sessions were limited to addressing goal 1. For eight weeks, the client underwent therapy for 1 to hours per session. Each session began with brief processing of the clients experience for the past week through minimal CBT/RET to establish rapport. Relaxation techniques such as deep breathing exercises, progressive muscle relaxation and guided mental imagery were done and taught to the client. Succeeding sessions also involved a review and reinforcement of previously learned techniques. Likewise, since the client reported some difficulty asserting her needs to persons in authority or even to other people, behavior rehearsal was also done within the therapy sessions. I also tried to invite family members however, they refused to come with the client.

SOCIAL ANXIETY DISORDER

When I would walk into a room full of people,Id turn red and it would feel like everybodys eyes were on me. I was embarrassed to stand off in a corner by myself,but I couldnt think of anything to say to anybody. It was humiliating.I felt so clumsy, I couldnt wait to get out.

BRIEF THEORETICAL BACKGROUND

Social anxiety disorder (SAD) is one of the most common among all mental health disorders (Shorey & Stuart, 2012). According to Kring, Johnson, Davison and Neale (2012), social anxiety

disorder is a persistent, unrealistically intense fear of social situations that might involve being scrutinized by, or even just exposed to, unfamiliar people.
This disorder is also and previously called social phobia in the DSM-IV-TR. The shift from the previous label to social anxiety is due to its more pervasive resulting problems which interferes more with a persons normal activities (Kring et al., 2012). According to the Diagnostic and Statistical

Manual of Mental Health Disorders (DSM-IV-TR, American Psychiatric Association, 2000) individuals
suffering from this syndrome are afraid of negative evaluation by others and typically worry that they are perceived as inadequate, weak or dumb. They also experience intense anxiety during social or performance situations, where the level of fear is unreasonable or excessive. As such the

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individual either suffers through the situation with intense anxiety or avoids situations entirely; this results in impairment on the persons life. The proposed DSM-5 Criteria for Social Anxiety Disorder specifically lists the following: marked and disproportionate fear and consistently triggered by exposure to potential social scrutiny, exposure to the trigger leads to intense anxiety about being evaluated negatively, trigger situations are avoided or else endured with intense anxiety and symptoms persist for at least 6 months (Kring et al., 2012). While the DSM-IV-TR specified that the person recognizes the fear is unrealistic, under DSM-5, this is not mentioned (Kring et al., 2012). Also, not included in the criteria in DSM-5 is the inclusion of the duration criterion for those under age 18, which was in DSM IV-TR (Kring et al., 2012).

ILLUSTRATIVE CASE STUDY

This case study is lifted from the journal article of Shorey and Stuart (2012). Henry is a 26 year old male of Caucasian decent that was referred to a psychological unit of a university due to anxiety symptoms. The patient reported living alone while working as a cashier in a retail company on a part-time basis, as he studies full-time at the local university. Henry presented with symptoms of social anxiety disorder. He reports being fearful that others would judge him negatively in social situations. He becomes anxious when a teacher asks him questions and when thinking of having to speak in public. He also mentioned that he is more anxious when he is around women. He added that he is anxious about his writing and that other people would see his hand writing and considers it bad and illegible. He said that this fear was increasingly affecting his life negatively. Within the two years after Henry was discharged in the army that he reported having intense increase in his social anxiety. While Henry did not directly mention that he avoids social situations, he did mention that he interacted rarely with his peers, and chooses not to speak in class.

CASE DISCUSSION
Henry reports a history of punitive and restrictive parenting. He remembers his father as severely judgmental of him while demanding perfection and strict adherence to his standards. He also remembers being disallowed to express emotions or complaints. As Festa and Ginsburg (2011) suggested, this type of parenting termed parental overcontrol is related to higher levels of social anxiety in children and adolescents, and ultimately in adults. Parental overcontrol limits the chances of a child to try and explore the world, situations and learn and develop new skills (Festa &

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Ginsburg, 2011). This limitation decreases the childs ability to develop social competencies that results to anxious and avoidant children, and then adults (Festa & Ginsburg, 2011). In instances that Henry would fall short from his fathers expectations, which happens to all children, his fathers prevention of voicing emotions as well as his negative reactions and expressions may have appeared to Henry as signs of rejection. This feeling of rejection would also have led Henry to believe that other people, especially his peers, reject him (Festa & Ginsburg, 2011). It may not have been helpful for Henry also, that as a child, he and his family moved and transferred homes multiple times, and even moved countries. Being uprooted many times may have lessened Henrys chances of forming friendships as a child. Festa and Ginsburg (2011) mentioned that children who can find people they can talk and connect to and share experiences with worry less about what outsiders think of them and would feel socially accepted, thus, lowering their levels of social anxiety. Henry has a level of awareness that the negative treatment and words he heard and absorbed from his father and their home environment may have influenced the way he views and talks to himself, his view of the world, and especially how other people may perceive him. He imbibed the habit of evaluating himself and being overly critical of how he behaves with other people. His social anxiety disorder appears to have been the result of the combination of his upbringing and home environment, gender and cultural pressures that imposes strict rules on expression and behavior, and negative beliefs. Feeling incompetent in his social skills, and fearingcritical evaluation from others in social situations became a vicious cycle for him, which led him to experience intense feelings of anxiety that pushed him to avoid social encounters. On the other end, Henry feels the desire and need to connect with other people as he wishes to meet more people, make new friends, and have a romantic relationship. This burning desire to move towards one direction, while being pulled back by fear further increases Henrys anxiety and causes him emotional pain.

TREATMENT
Social anxiety disorder is a condition that does not have a cure. However, through therapy, a person may be able to manage the condition and live a functioning, productive and meaningful life. Having a solid motivational base - his desire to meet new people, make friends and eventually have a romantic relationship - treatment outlook for Henry is hopeful.

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The treatment would be an adaptation of Mindfulness-based Cognitive Behavioral Therapy (CBT) and will be a progression starting from alliance formation, psycho-education about his condition, self-report and awareness of his own symptoms and experience, learning tools and tips for self-monitoring activities and strategies, learning relaxation techniques through mindfulnessmeditation, and cognitive reframing and progressive exposures. Mindfulness-based CBT may help Henry reduce somatic symptoms of his social anxiety, as may also help with the cognitive reframing of his negative beliefs, by being present in the moment, avoiding cascading destructive critical thoughts and blocking over focus on external cues (Sharma, Mao, & Sudhir, 2012). The duration of the treatment would be around 23 (to 25) sessions over a period of four to six weeks. Treatment goals are in line with Henrys goal, which is to develop relationships and connect with people. Progression from one step to another will depend on Henrys confidence level and readiness to proceed, with the guidance and support of the therapist, especially during the progressive exposure part of the treatment.

SPECIFIC PHOBIAS
Ginko is a 32-year-old woman who presented with a history of fear of cockroaches that had begun during adolescence. This fear impacted markedly on her life. She continuously anticipated the possibility that cockroaches would come in to her home; and she often avoided places where there were likely to be cockroaches. When cockroaches were present, her anxiety was noticeably increased and included panic attacks. Over the years, she felt increasingly demoralized by her circumstances.

Brief Theoretical Background

The DSM IV-TR specifies the following as symptomatic of Specific Phobias (formerly Simple Phobia): the essential feature of Specific Phobia is marked and persistent fear of clearly discernible, circumscribed objects or situations (Criterion A). Exposure to the phobicstimulus almost invariably provokes an immediate anxiety response (Criterion B).This response may take the form of a situationally bound or situationally predisposedPanic Attack (see p. 430). Although adolescents and adults with this disorder recognizethat their fear is excessive or unreasonable (Criterion C), this may not be the casewith children. Most often, the phobic stimulus is avoided, although it is sometimes endured with dread (Criterion D). The diagnosis is appropriate only if the avoidance, fear, or anxious anticipation of encountering the phobic stimulus interferes significantlywith the person's daily

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routine, occupational functioning, or social life, or if the person is markedly distressed about having the phobia (Criterion E). In individualsunder age 18 years, symptoms must have persisted for at least 6 months beforeSpecific Phobia is diagnosed (Criterion F). The anxiety, Panic Attacks, or phobic avoidance are not better accounted for by another mental disorder (e.g.,

ObsessiveCompulsiveDisorder, Posttraumatic Stress Disorder, Separation Anxiety Disorder,Social Phobia, Panic Disorder With Agoraphobia, or Agoraphobia Without History ofPanic Disorder) (Criterion G). (p. 443). The DSM IV-TR then goes on to enumerate the following as subtypes of specific phobia: (1) animal type; (2) natural environment type; (3) blood-injection-injury type; (4) situational type; and (5) other type.

According to Kring et al (2013), it is likely that two key changes in DSM 5 regarding specific phobias would include (1) a specification of the duration criteria for adults and (2) that the person would need not perceive fear as unrealistic.

CASE STUDY: VOMIT PHOBIA

Veale and Lambrou (2006) studied the specific phobia of vomiting (also known as emetophobia). They found that vomit phobics did not discriminate between fear of vomiting whether they were alone or in public situations. They also feared that they or others will vomit however, the frequency of vomiting was not significantly greater in individuals with vomit phobia compared to the control group of the study. Vomit phobics also reported feeling nauseous almost every day or every other day and that the sensation lasts longer than in the panic disorder group. Those with vomit phobia were also found to higher scores in the Beck Anxiety Inventory than those with panic disorder. For vomit phobics, the seven perceived cause of nausea included: (i) anxiety; (ii) irritable bowel syndrome;(iii) migraine; (iv) gastric/duodenal ulcer; (v) chemotherapy; (vi) middle ear disease/balance disorder; (vii) brain tumour. Vomit phobics were more likely to report looking for an escape route, tryingto keep tight control of their behavior, taking medication, reading, sucking antacids/mints, and moving very slowly. The study concluded that there seems to be an overlap in the cognitive processes and behaviors with panic disorder as well as obsessive compulsive disorder (fear of contamination) and social anxiety.

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CASE DISCUSSION
The behaviorist perspective notes that phobias are conditioned responses that develops after a threatening experience and is sustained by avoidant behavior (Kring et al, 2012). It can be said that the same mechanism applies to the perpetuation of vomit phobia. Avoidant behaviors (and even the act of vomiting itself) provide relief that reinforces vomit phobia through negative reinforcement.

TREATMENT
As with other specific phobias, Veale and Lambrou (2006) recommended the use of imaginal exposure to vomiting and role plays of the self-vomiting so as to help the client reduce the awfulness of vomiting and thereby drop their avoidance, excessive vigilance towards vomiting and safety seeking behaviors. As vomit phobia has similar characteristics with panic disorder, the authors also recommend that therapists explore with their client the meaning or imagery associated with losing control and to practice losing control.

PANIC DISORDER (WITH AGORAPHOBIA)

For me,a panic attack is almost a violent experience. I feel disconnected from reality. I feel like I'm losing control in a very extreme way. My heart pounds really hard, I feel like I cant get my breath, and theres an overwhelming feeling that things are crashing in on me.

BRIEF THEORETICAL BACKGROUND

Panic disorder is a condition characterized by recurring severe panic attacks (Marazziti, Carlini, & DellOsso, 2012). According to Kring et al. (2012), a panic attack is a sudden attack of

intense apprehension, terror, and feelings of impending doom, accompanied by at least four other symptomsthat typically last for about 10 to 15 minutes. However, attacks may be as short as one
to five minutes and as long as 30 minutes, coming and going for a period of hours with varying intensity and varying symptoms (Marazziti, Carlini, & DellOsso, 2012). These attacks happen during occasions that may not seem related with each other (Kring et al., 2012). These attacks may be triggered by specific and clear causes (cued) or may be set off randomly (uncued) (Kring et al., 2012). Marazziti, Carlini, and DellOsso (2012) specified the common symptoms of a panic attack as including rapid heartbeat, perspiration, dizziness, dyspnea, trembling, uncontrollable fear and hyperventilation. Further, other symptoms listed were sweating, shortness of breath, sensation of choking, chest pain, nausea, numbness or tingling, chills or hot flashes, and some sense of altered reality. Other symptoms include a feeling of being outside ones body (depersonalization) and a

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feeling of the worlds not being real (derealization) (Kring et al., 2012). Additionally, a person experiencing a panic attack may have thoughts of impending doom and has a strong desire of escaping from the situation. A persons experience is made worse by ongoing worries about developing other attacks and eventually dying, which increases the likelihood of feeling more fear.

The criteria for Panic Disorder as identified by DSM-5 are recurrent, uncued panic attacks, at least 1 month of concern about the possibility of more attacks, worry about the consequences of an attack, or maladaptive behavioral changes because of the attacks. Previously, Agoraphobia was included as a diagnosis under Panic Disorder however, the DSM 5 has pushed for its diagnosis as a separate disorder because numerous studies have shown that panic disorder and agoraphobia may occur independent of each other (Kring et al, 2012). The DSM 5 proposes the following criteria for Agoraphobia as a separate diagnosis: Disproportionate and markedfear or anxiety about at least2 situations where it would bedifficult to escape or receivehelp in the event of incapacitationor panic-like symptoms,such as being outside of thehome alone; traveling on publictransportation; being in openspaces such as parking lots andmarketplaces; being in shops,theaters, or cinemas; or standingin line or being in a crowd. These situations consistentlyprovoke fear or anxiety. These situations are avoided,require the presence of a companion,or are endured withintense fear or anxiety. Symptoms last at least 6 months (Kring et al, 2012, p. 180).

ILLUSTRATIVE CASE STUDY

This case study is lifted from the book Case Studies in Abnormal Psychology by Oltmanns, Martin, Neale and Davison (2012).. Dennis Holt was a 31 year old salesman (no ethnicity or descent indicated). He is divorced but has a fiance named Elaine. He has experienced several panic attacks during the past 10 years but did not seek psychological treatment immediately. He appeared confident with his tall posture, neatly trimmed hair, and friendly smile. Dennis was referred to a psychological clinic after an incident while he was doing his Christmas shopping with his fiance in a mall. Even though Dennis was usually uneasy in large crowds, he was preoccupied with the Christmas rush and the motivation to buy gifts to mind. Suddenly, Dennis felt very sick, his hands began to tremble and his vision became blurred. He felt weak and started gasping for air as he felt heavy pressure on his chest, as if he was being

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smothered. He felt terrified, but was unsure why. He swiftly ran out of the store and entered their car, opened the window, lay down and closed his eyes. His dizziness and shortness of breath continued for around 10 more minutes. Denniss condition appears to be a combination of panic disorder, agoraphobia and generalized anxiety disorder.

CASE DISCUSSION
Dennis does not remember having panic attacks in his childhood. He was a shy child, but he had friends and was a member of his high school drama club. His father, though, was a difficult person, often demanding perfection and unrealistic expectations of him. Even as an adult, his father never missed an opportunity to show disapproval and disappointment. This type of parenting may have had a effect on Dennis self-constructs and his sense of control (Festa & Ginsburg, 2011). He may have developed a negative view of himself as a person, as well as his future. He may have also felt that no matter what he does, nothing is good enough.

Dennis remembers choking during tests in college where his hands would sweat and his breathing would become rapid and shallow, his mouth becoming dry. It was also during his college years when he developed gastrointestinal problems, interchanging between constipation, cramping and diarrhea. These experiences and symptoms may have been rooted in his father; from the psycho-physiological stress of his fear of not measuring up to his fathers expectations that were transferred to him. Dennis became an anxious and tense person, frequently having headaches, muscle tension and insomnia. He became self-conscious, and preoccupied with what others think of him and generally fearful and overly cautious. The panic attack in the mall was not the first for Dennis as an adult. Hes had these attacks since he was 24 years old. The first attack happened during a dinner theatre where Dennis was selfconscious about eating in public and did not really like the company. He suffered from gastrointestinal problems and was worried he might have an attack during that dinner and will have to use the restroom and explain the problem to his company. Perhaps a slight discomfort in his stomach during dinner caused Dennis to respond and think catastrophically. In a couple of minutes, he started to feel like he was choking and having a heart attack. Six months later, another attack happened while driver during rush hour. The panic attacks made Dennis cautious of the things he

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does and places he goes to. It impacted his social life considerably and eventually caused his first marriage to end. Dennis situation may have been a result of cognitive and behavioral responses that interacted with and made worse by his sensitivity to stress. His first panic attack happened during a stressful activity for Dennis, and the experience in turn, traumatized him. He became fearful of many different situations that he thinks will cause an attack and avoided them, again perhaps due to how he thinks of himself, about whats going to happen to him and what other people will think of him, rooted in his relationship with his father. Dennis negative beliefs about what is going on with him worsens his condition, as consequently thinks and fears that he will die as soon as he feels some new or different bodily sensation or senses cues from his environment (Kring et al., 2012).

TREATMENT
Panic attacks may have its roots in the persons past and its effect on the persons unconscious(Kring et al., 2012). As such, a combination of psychodynamic and cognitive behavioral therapy would be used. In line with Dennis objective to manage his panic attacks, the treatment goals would be to identify the triggers, emotions and meanings surrounding the panic attacks (Kring et al., 2012) with the hopes that Dennis will face, fight and defeat his demons. After such phase of the treatment, the next goal would be focused on the present and to aim achieve his objective. The therapy would progress from alliance formation, psycho-education about his condition, psychotherapy, self-report and awareness of his own symptoms and experience, learning tools and tips for self-monitoring activities and strategies, learning relaxation techniques, and cognitive reframing and progressive exposures. Part of the cognitive treatment would be identifying triggers and starting points of attacks, and learning how to challenge the catastrophized thoughts that follow (Kring et al., 2012). With the progressive exposures, Dennis would be exposed, in progressive quantities, to triggers and starting points and sensations that lead to the attack (Kring et al., 2012). These exercises would demonstrate to Dennis the realistic outcome, instead of what he negatively visualized. These would also empower Dennis as it would make him realize that he has the power to control his emotions and reactions as well as his thoughts. The duration of the treatment would be around 23 (to 25) sessions over a period of four to six weeks. Dennis has had successes in his life particularly with his job as a salesman. The strength and will to achieve his current success can also be his strength to finally overcome and manage his

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condition. With the support and encouragement of his fiance Elaine, his friends and co-workers, Dennis can reach his goal, manage his condition and live a functioning and fulfilling life.

References

Festa, C. C.& Ginsburg, G. S. (2011). Parental and peer predictors of social anxiety in youth. Child

Psychiatry & Human Development,42(3), 291-306. doi:10.1007/s10578-011-0215-8

Kring, A. M., Johnson, S. L., Davison, G., & Neale, J. (2012). Abnormal Psychology (12th ed.). Hoboken, NJ: John Wiley & Sons, Inc. Marazziti, D., Carlini, M., & DellOsso, L. (2012). Treatment strategies of obsessive-compulsive disorder and panic disorder/agoraphobia. Current topics in medicinal chemistry, 12(4), 23853. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22204483 Oltmanns, T. F., Martin, M. T., Neale, J. M., & Davison, G. C. (2012). Panic disorder with agoraphobia. Case Studies in Abnormal Psychology (9th ed.) pp 17 27. Hoboken, NJ: John Wiley & Sons, Inc. Schutters, S. J., Dominguez, M. G., Knappe, S. S., Lieb, R. R., van Os, J. J., Schruers, K. J., &Wittchen, H. U. (2012). The association between social phobia, social anxiety cognitions and paranoid symptoms. ActaPsychiatricaScandinavica, 125(3), 213-227. doi:10.1111/j.1600-

0447.2011.01787.x Sharma, M. P., Mao, A., & Sudhir, P. M. (2012). Mindfulness-based cognitive behavior therapy in patients with anxiety disorders: A case series. Indian Journal of Psychological Medicine, 34(3), 263-269. doi:10.4103/0253-7176.106026 Shorey, R. C. & Stuart, G. L. (2012). Manualized Cognitive-Behavioral Treatment of Social Anxiety Disorder: A Case Study. Clinical case studies, 11(1), 3547. doi:10.1177/1534650112438462 Tyrer, P. & Baldwin, D. (2006). Generalised Anxiety Disorder. The Lancet2156 - 66 Veale, D. & Lambrou, C. (2006). The Psychopathology of Vomit Phobia. Behavioural and Cognitive

Psychotherapy, (34), 139 - 150.

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