1. What diagnosis does the client have? You must state what you see in the case study that is leading you to believe the client has a particular diagnosis. Diagnosis: Social Anxiety Disorder (Social Phobia) (F40.10) According to the DSM-5 (2013), the characteristic symptoms of social anxiety disorder are marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others. When exposed to such social situations, the individual fears that he or she will be negatively evaluated and become concerned that he or she will be judged as anxious, boring, or unlikable.
Marked fear or anxiety about one or more social situations occurs in social interactions, when observed by others, and performing in front of others. For Leon’s case, he is a 45-year-old man who has felt constantly depressed since the first grade of school, without a period of normal mood for more than a few days at a time. His depression has been accompanied by lethargy; little or no interest or pleasure in anything; trouble concentrating, and feelings of inadequacy, pessimism, and resentfulness.
His only periods of normal mood occur when he is home alone, listening to music or watching television. In general, the individual with social anxiety disorder fears that he or she will show anxiety symptoms that will be negatively evaluated by others (Criterion B). For example, Leon never had a best friend, as he grew up. He suffered when oral classroom participation was expected. As a teenager, he was terrified of girls, and to this day he has never gone on a date or even asked a girl for a date. This bothers him, although he is so often depressed that he feels he has little energy or interest in dating.
Leon had trouble finding a job because he was unable to answer questions in interviews. He worked at a few jobs for which only a written test was required. He passed a civil service examination at age 24 and was offered a job in the post office on the evening shift. He enjoyed this job, as it involved little contact with others. He was offered several promotions but refused them because he feared the social pressures. Although he currently supervises a number of employees, he still finds it difficult to give instructions, even to people he has known for years. He has no friends and avoids all invitations to socialize with co-workers. During the past several years, he has tried several courses of psychotherapy to help him overcome his “shyness” and depression.
These social situations almost always provoke fear or anxiety (Criterion C). Thus, an individual who becomes anxious only occasionally in a social situation(s) would not be diagnosed with social anxiety disorder. However, the degree and type of fear and anxiety may vary across different occasions. For example, Leon cannot ever remember feeling comfortable socially. Since he was young, he felt overwhelming anxiety at children’s social functions, such as birthday parties, which he either avoided or, if he went, attended in total silence.
He could answer questions in class only if he wrote down the answers in advance; even then, he frequently mumbled and could not get the answer out. He met new children with his eyes lowered, fearing their scrutiny, expecting to feel humiliated and embarrassed; he was convinced that everyone around him thought he was “dumb” or a “jerk.” The fear or anxiety is judged to be out of proportion to the actual risk of being negatively evaluated or to the consequences of such negative evaluation (Criterion E). As we can see in Leon’s case, individuals with social anxiety disorder often overestimate the negative consequences of social situations. The individual’s sociocultural context needs to be taken into account when this judgment is being made.
The duration of the fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more (Criterion F). For example, Leon’s symptom thoughts and feelings of anxiety persist and are chronic; it started even before kindergarten. If Leon was asked to speak in front of a group of his parents’ friends, his mind would “go blank.” This duration threshold helps distinguish the disorder from transient social fears that are common, particularly among children and in the community. Leon has never experienced sudden anxiety or a panic attack in social situations or at other times. Rather, his anxiety gradually builds to a constant high level in anticipation of social situations.
2. If they completed an assessment with this client, what biological, family and cultural considerations of their background would they need to see to justify the diagnosis? In Leon’s case, he has never experienced any psychotic symptoms. Interestingly, biological or family history is not an important risk factor to diagnose social anxiety disorder because family and relatives of individuals with behavioral inhibition are culturally and genetically influenced.
The genetic influence is subject to gene-environment interaction; that is, children with high behavioral inhibition are more susceptible to environmental influences, such as socially anxious modeling by parents. First-degree relatives have a two to six times greater chance of having social anxiety disorder, and liability to the disorder involves the interplay of disorder-specific (e.g., fear of negative evaluation) and nonspecific (e.g., neuroticism) genetic factors. Age and gender also cannot be directly related to diagnostic issues either in Leon’s case. Median age at onset of social anxiety disorder in the US is 13 years, and 75% of individuals have an age at onset between 8 and 15 years.
Although females with social anxiety disorder report a greater number of social fears and comorbid depressive, bipolar, and anxiety disorders, male patients are struggling with the difficulties. An interesting cultural fact of Leon’s case is that despite the emotional difficulties such as the social anxiety disorder, Leon did not have focus problems at school, his academics appeared to be strong. Although he suffered when oral classroom participation was expected, his school grades were good. He attended college and did well for a while, then dropped out as his grades slipped. He could not meet most of his academic milestones within normal limits, because he still remained very self-conscious and “terrified” of meeting strangers.
3. Are there any ethical considerations? For example, are there concerns related to offering medication versus talk therapy? Even in the presentation of symptoms, or which treatment options they select? Social anxiety can be successfully treated today as well as the other anxiety disorders. It is a fully treatable condition and can be overcome with effective therapy, work, and patience. The important thing is in seeking help for this problem, i.e. searching for a specialist — someone who understands this problem well and knows how to treat it, social anxiety treatment must include an active behavioral therapy group, where members can work on their anxiety hierarchies in the group, and later, in real-life situations with other group members.
Appropriate active, structured, Cognitive-Behavioral Therapy (CBT) can be the best solution to this problem. CBT for social anxiety has been markedly successful. Current studies have concluded that this type of therapy is the only way to change the neural pathways in the brain permanently. These studies indicate that, after the completion of social anxiety-specific CBT, people with social anxiety disorder are changed.
They now live a life that is no longer controlled by fear and anxiety. Appropriate therapy is markedly successful in changing people’s thoughts, beliefs, feelings, and behavior. The person with social anxiety disorder must be compliant and do what is necessary to overcome this disorder. Group therapy also can be helpful. National Institutes of Mental Health-funded studies report a very high success rate using cognitive therapy with a behavioral therapy group. Both are essential to alleviating anxiety symptoms associated with social anxiety disorder.
The interesting fact on social anxiety is that medication is useful for many, but not all, people with social anxiety disorder. Medications can only temporarily change brain chemistry and can be useful in some cases. For social anxiety, research indicates use of the anti-anxiety agents, and perhaps certain antidepressants in conjunction with CBT have proven most beneficial. Medication without the use of active, structured cognitive-behavioral therapy has no long-term benefits. Only CBT can change the neural pathway associations in the brain permanently. The therapy used must fit the way the human brain is structured.
