CASE 7

Case Report

Social Anxiety Disorder:

Anxiety disorders are the most pervasive class of mental disorders, with a 12-month

prevalence in the community of about 18%. People with social anxiety disorder have fear and

avoid the scrutiny of others. The concern in such situations is that the individual will say or do

something that will result in embarrassment or humiliation. These concerns can be so

pronounced that the individual shuns most interpersonal encounters, or endures such situations

only with intense discomfort. Once largely neglected by the medical community, social anxiety

disorder came to the attention of the general medical community a decade ago, and is now

garnering increased attention and recognition as a widespread, impairing, but treatable condition

(Kessler et al., 2005).

Individuals with social anxiety disorder are typically shy when meeting new people,

quiet in groups, and withdrawn in unfamiliar social settings. When they interact with others, they

might or might not show overt evidence of discomfort (e.g., blushing, not making eye contact),

but invariably experience intense emotional or physical symptoms, or both (e.g., fear, heart

racing, sweating, trembling, trouble concentrating). They crave the company of others, but shun

social situations for fear of being found out as unlikable, stupid, or boring (Stein, 1996).

Accordingly, they avoid speaking in public, expressing opinions, or even fraternizing with peers;

in some situations, this can lead to such individuals being mistakenly labelled as snobs. People

with social anxiety disorder are typified by low self-esteem and high self-criticism, and as

detailed below, often have depressive symptoms. Believed to account for about half of cases in

the community, and most individuals seeking treatment for social anxiety disorder,
generalizedsocial anxiety disorder is also the most disabling form of the disorder. Although

people with generalized social anxiety disorder can fear and avoid specific performance

situations such as public speaking, their social fears and avoidance extend far beyond that

relatively common sphere of concern (Schneier, 2006).

Setting:

Case was taken from Rawal Hospital Khanapul Islamabad.

Demographic Details:

Name: MA
Age: 20 years
Gender: Female
Qualification: F.A
Socioeconomic Status: High
Religion: Islam
Number of siblings 6
Subject’s birth order 6th
Father Alive/Dead Alive
Mother Alive/Dead Alive
Father’s age and profession 55 and Doctor
Mother’s age and profession 50 and doctor
Dependent/Independent Dependent
Marital status Unmarried
Family Structure Nuclear
Head of Family Father
Earning Members 3
Residence Islamabad

Source of Referral:

Client was self-referred.

Presenting complaints:

The client reported;

Mujhy bhar jana aur logon say milna nahi pasand, khas tor pr wahan jahan zada log hon, mjy
baat karny me dar lagta hai k kuch ghalat na bol dun. Mujhy aesa lagta hai log mjh pr comment
kar rahy hain, mujhy ghabraht hoti hai, paseena ata hai, Saans ukhar jati hai, chehra laal ho jata
hai, kanpny lagti hu, aesy lagta hai k myny kch ghalat kar dia hai, or sab ko mjh pr gussa ay ga
sab mjh pr hansen gain, mery kapron pr, meri baton pr hansen gain. Isi waja say meny FA k bad
admission hi nahi lia. Purany sb doston say bat bhi nahi karti na milti hun or gar sy bahar bhi
nahi jati.

History of present illness:

Miss MA was cheerfully getting a charge out of her life, but the issue raised when she
was rejected by her adore. Concurring to client, she needed to wed with him; she is of see that
she didn’t merit all that mess in her life. As per client’s depiction he criticized on her (client)
looks and physical appearance, which makes the client down hearted and after that she never met
her college companions as well. This was one of major reason for client’s this condition.

Past psychiatric history:

Client reported that he has no previous psychiatric history in past.

Past medical history:

Client had not faced any significant medical issue in past.

Family History:

The client belongs to a high socio economic class. Both the client’s parents were doctors
and earning proficient. The client had 5 sisters who were all doctors by profession and 4 of them
married to doctors as well. The client is unmarried and lives in a nuclear family. Client is
youngest in her siblings, and being overprotective by her parents. The client is very emotionally
attached with her mother but conflict arise a few months back when client faced such problem in
her life. There was one case of depression in the maternal side of the client’s family. There were
no genetic or inheritance based medical problems in the client’s family.

Personal History:

Miss MA was born without any inherited problem and had a normal birth without any
pre and post-delivery complications. She had enjoyed entire millstones at appropriate ages and
never suffered from any kind of physical, emotional and mental trauma throughout her
childhood. Her childhood was a never-ending source of pleasurable excitement. She is FA pass
with distinctions in various subjects and an overall gold medal. She is very hard working and
wishes to achieve big goals in life but is hopeless due to her conditions and limitations. She had
good relationships with her teachers and other class mates throughout her school and college life.
She was involved with a guy, when she was going through her collage period. She wanted to
marry with that guy, but the things didn’t work according to plan. She was badly criticized by
him in front of her friends. After that incident Miss MA never moved on. The client feels down
hearted and complaints of restrictions imposed on her by her father.

Pre-morbid Personality:

The client was hard working and had big ambitions. The client has a natural talent
for arts and drawing. She was an extrovert throughout her life except past few months. She is
youngest of all siblings and was loved by everyone in family so the life was very happy and
satisfying for her.

Mental Status Examination:

The client was making very less eye contact. She talked at an ordinary rate, with brief
intervals. Her volume was low. She was agreeable and replied each address clearly. She had a
good orientation of time.

Assessment:
The client was assessed through following psychological tests:

 HTP (House Tree Person)

 RISB (Rotter Incomplete Sentence Blank)
 TAT (Thematic Apperception Test)
 BGT (Bender Gestalt Test)
 SPM (Standard Progressive Matrices)
House Tree Person (HTP):

House: The house speaks to sense of belonging, nurturance and steadiness of a person, the figure

drawn by the client reveal signs of anxious behavior shown through shading in house, small

house, and shaded roof, whereas little entryway demonstrates a sign of socially insufficient

behavior. Drawing figure at right side of page demonstrates that individual is not social, while

need of subtle elements appear indications of sadness and depression in client.

Tree: The tree drawn appears the mental age of 30 a long time. Shaded tree beat portrays her
stresses approximately future. Overwhelming lines appear her anxiety, though no leaves on tree
show that client is feeling fruitless/barren. Shaded roots illustrate inconveniences in past.

Person: Individual is more coordinate representation of self. Large eyes and head extension
appears signs of anxious behavior. Erasures moreover demonstrate signs of anxiety, whereas
mouth emphasis shows depression. Long neck, minor shoulders and little trunk illustrate
sentiments of inferiority. Shaded hands are a sign of anxiety, whereas overlooked legs appear a
sign of debilitation.

Rotter’s Incomplete Sentence Test (RISB):The subject score on RISB was 146, which

is high above the cut off score i.e. 135, which depict that subject might have maladjustment

towards her environment. Client was not well adjusted, have social problems. Concern about

possible future failure indicate that she have high level of anxiety which is responsible for her

mentally disturb condition.

TAT (Thematic Apperception Test): Stories of client showed that she had need of

hopefulness and peace. Her parental, contempt and family members are seen as supportive and

helpful. She want social approval, individual identity and loneliness. She want happy gathering

around her. She want to get out of disturbed routine.

BGT (Bender Gestalt Test):The patient completed all the images which were shown to

her. The patient took time of 14 minutes to complete the test. The patient attempt only 2 errors in

BGT which indicate absence of brain impairment.

SPM (Standard Progressive Matrices):The clients score on SPM was 25 and her

percentile was 95th which shows that her reasoning ability and ability of intellectual functioning

is very good. She did not get confuse at any level.

Diagnosis:

Social anxiety disorder 300.23(F40.10)

Theoretical Orientation: One of the main theories about social anxiety asserts that social

anxiety is related to overestimating the negative aspects of social interactions, and

underestimating the positive aspects. Individuals with social anxiety tend to overestimate the

threat of social interactions, the likelihood of negative outcomes, and the consequences of

negative outcomes. Individuals with social anxiety also tend to underestimate their ability to

handle social interactions (Huppert et al, 2003).

Another theory about social anxiety is that patterns of thoughts and beliefs play an important role

in social anxiety, and targeting these thoughts and beliefs can be a helpful way to treat it. These

patterns of thinking tend to lead them to avoid social interactions.

According to the cognitive theory, individuals with social anxiety tend to:

– Over estimate the level of threat in social situations. (For example, “This person is going to be

judging me.”)

– Under estimate their ability to handle social situations. (For example, “I’m going to say

something stupid.”)

– Expect negative outcomes from interactions in social environments. (For example, “He is

going to think I’m stupid.”)

– Over estimate the consequences of these negative outcomes. (For example, “He’s probably

going to tell everyone at the office how stupid I am, and then I’ll probably be fired.”)

Because of these beliefs and expectations, social interactions are often avoided. Focus of

attention during social interactions when individuals with social anxiety are in social

interactions, they tend to focus more on how they are being perceived by other people (for

example, “My handshake was too weak. She’s going to think I have no confidence….”), rather

than on the interaction itself.

-This focus on one’s own performance can be very distracting, and can get in the way of having

a positive with someone else.

-This attention can also lead one to only pay attention to the negative aspects of how they are

interacting with others.

-Because of this focus, individuals with social anxiety tend to remember past interactions as

worse than they really were.

This pattern can lead to more avoidance of social interactions (Huppert et al, 2003).
Number of sessions:

Total number of sessions: 7

First session was conducted with the client at Rawal hospital and initial intake was done in

which client shared her problems. Consent was taken from the client and was ensured that all the

information will be kept confidential. In introductory session basic history was taken from the

patient for rapport building.

Client reported that she was 20 years old and resident of Islamabad. Her birth order

was last among siblings and she was unmarried. She lived in nuclear family system and her

parents were alive.

Client reported that she was cheerfully getting a charge out of her life, but the issue raised when

she was rejected by her adore. Concurring to client, she needed to wed with him. She is of see

that she didn’t merit all that mess in her life. As per client’s depiction he criticized on her (client)

looks and physical appearance, which makes the client down hearted and after that she never met

her college companions as well. This was one of major reason for client’s this condition.

The client was hard working and had big ambitions. The client has a natural talent for
arts and drawing. She was an extrovert throughout her life except past few months. She is
youngest of all siblings and was loved by everyone in family so the life was very happy and
satisfying for her.

During 2nd session, after greetings detail history was taken from the patient. The client
belongs to a high socio economic class. Both the client’s parents were doctors and earning
proficient. The client had 5 sisters who were all doctors by profession and 4 of them married to
doctors as well. The client is unmarried and lives in a nuclear family. Client is youngest in her
siblings, and being overprotective by her parents. The client is very emotionally attached with
her mother but conflict arise a few months back when client faced such problem in her life.
There was one case of depression in the maternal side of the client’s family. There were no
genetic or inheritance based medical problems in the client’s family.

She was born without any inherited problem and had a normal birth without any pre
and post-delivery complications. She had enjoyed entire millstones at appropriate ages and never
suffered from any kind of physical, emotional and mental trauma throughout her childhood. Her
childhood was a never-ending source of pleasurable excitement. She is FA pass with distinctions
in various subjects and an overall gold medal. She is very hard working and wishes to achieve
big goals in life but is hopeless due to her conditions and limitations. She had good relationships
with her teachers and other class mates throughout her school and college life. She was involved
with a guy, when she was going through her college period. She wanted to marry with that guy,
but the things didn’t work according to plan. She was badly criticized by him in front of her
friends. After that incident Miss MA never moved on. The client feels down hearted and
complaints of restrictions imposed on her by her father.

During 3rd session, different psychological tests were administered based on identifying

problems. Behavioral observations were also done during test administration. Client was asked to

draw house, tree and person for HTP interpretation and after that Rotter Incomplete Blank Test

was given to the client.

In 4th session different TAT cards were shown to the clients and instructions were given

to write a story about each picture on the cards. After that Bender Gestalt Test and Standard

Progressive Matrices were completed by the client.

Progression of the therapy:

In 5th session, therapeutic suggestions were given to the client. Cognitive behavioral therapy

was used with the patient. Therapy addresses negative patterns and distortions in the way we

look at the world and ourselves. It involves two main components:

Cognitive therapy examines how negative thoughts or cognitions, contribute to anxiety.

Behavior therapy examines how you behave and react in situations that trigger anxiety.

Patient was guided that not the external events but our thoughts affect the way we feel. In other

words, it’s not the situation that determines how you feel, but your perception of the situation.

Therapist explained the therapy through example of party invitation. Patient was asked to

imagine that you have just been invited to a big party. Consider three different ways of thinking

about the invitation, and how those thoughts would affect your emotions.

Thought #1: The party sounds like a lot of fun. I love to be going out and meeting new people.
Emotions: Happy, excited
Thought #2:Parties aren’t enjoyable. It’s good to stay at home and watch a movie.
Emotions: Neutral
Thought #3:I never know what to say or do at parties. I’ll make a fool of myself if I go.
Emotions: Anxious, sad
In this example, same event can lead to completely different emotions in different

people. It all depends on our individual expectations, attitudes, and beliefs. We have to identify

and correct the negative thoughts and beliefs. If you change the way you think, you can change

the way you feel.

In 6th session, further therapeutic techniques were applied. Exposure therapy was used with the

patient. Client was asked to imagine the anxious situation during the session and she was

encouraged to practice flooding in real life. Initially, client hesitated to imagine the most anxious

situation but therapist instructed her to relax and feel calm and then therapy was started again.

Last session was of termination when client and therapist both felt that goal has achieved.

Fellow up sessions were recommended to the client.

Therapist/Client Orientation Dynamics:

No issue of transference and counter transference happened in the whole process of

psychotherapy.

Prognosis:

The prognosis seems favorable as there are more chances to get better as her family is supportive

towards her. She is also willing to get better and want counseling so she can get out of her

problems.

Termination:

After achieving psychotherapeutic goals set up by the client and therapist in the start,

psychotherapy was terminated. During 7th session, progression of the therapy was checked and

client told the therapist that she is relieving from problematic behaviors. She told that she has

learned to overcome her problems. Her signs and symptoms are getting low in frequency.

References

Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, et al. (2007) Use of mental

health services for anxiety, mood, and substance disorders in 17 countries in the WHO world

mental health surveys. The Lancet 370: 841–850.

Hidalgo RB, Tupler LA, Davidson JRT (2007) An effect-size analysis of pharmacologic

treatments for generalized anxiety disorder. J Psychopharmacol 21:864—872

Boswell, J. F., Thompson‐Hollands, J., Farchione, T. J., & Barlow, D. H. (2013). Intolerance of

uncertainty: A common factor in the treatment of emotional disorders. Journal of clinical

psychology, 69(6), 630-645.

Newman, M. G., Llera, S. J., Erickson, T. M., Przeworski, A., &Castonguay, L. G. (2013).

Worry and generalized anxiety disorder: a review and theoretical synthesis of evidence on

nature, etiology, mechanisms, and treatment. Annual review of clinical psychology, 9, 275-297.

Swain, J., Hancock, K., Hainsworth, C., & Bowman, J. (2013). Acceptance and commitment

therapy in the treatment of anxiety: a systematic review. Clinical psychology review, 33(8), 965-

978.