Symptoms of Social Anxiety Disorder

Question:

Develop and Describe a Cognitive Behavioral Therapy (CBT) formulation and treatment plan for a Case Study.

The client in the case study is called James. He is a thin guy without any mentioned physical or mental disorder. However behavioural issues had been depicted by the client himself. He lives a happy family life with his wife and three children. They have financial stability as both are working. James work in a music company and his wife acts as registered nurse. Both have been in a stable relationship from the time of school and maintain a comfortable life in each other’s presence. However, most of the work in maintaining a proper social life is conducted by James’s wife as he is not comfortable in socialising with people. He states that he lacks the courage to communicate with someone new in his daily life. He faces anxiety when any responsibilities on him regarding communication of performing any social duties arise. Her wife is very helpful and therefore she does all the social duties of the family without pressuring him or blaming him. He was working in small locally owned music store where few members worked previously and he developed bonding with them. He was comfortable with the slow pace of work and the warm relationships shared by all. However the company has been now taken over by national music Chain Company and work culture has changed. The fast paced work culture had become difficult for him to handle as it has exposed him to a wide number of customers with whom he needs to talk properly. From the childhood, his behaviour had not affected him much as he had been able to establish his career and a married life. However coming to this age, the problems of his shyness and inability talk at social level had aroused tension in him as he fears to lose his financial strength and also fears the embarrassments he has to go onwards from now on.

From the evaluation of the symptoms of the patients, the client is diagnosed to be suffering from social anxiety disorder. Dating back to childhood, it can be stated that he had suffered from selective mutism which is one of the forms of social anxiety disorders. As a phobia or communication, a child or an adult with this disorder in front of an individual person or a group of people is unable to speak properly although he has idea about what needs to be spoken to them (Lischenring et al., 2013). In simple words, they are fully capable of speaking but cannot speak in certain situations as they fear or become anxious before initiating the speech. It usually begins form the age of 2.7 to 4.1 years of age which is long before the mean age of social anxiety disorder arises. It gradually becomes apparent when the child enters a communal environment outside the family home for first time (Goldin et al., 2014). If not treated, it continues even to adulthood disrupting the development of quality life. Researchers over the years have identified the main causes of the disorder. Different trauma in childhood, minimal brain dysfunction or neuropsychological social cue processing disorder may be a cause. However no such cases are reported for him (Lischenring et al., 2013). The main causes which align with James ‘upbringing is particular parent profile and parent-child relationship. As both the members have been reserved and his father was shy, he had adopted the traits in his cognitive development as researchers state that children pick up traits and characters form parents in their early life as they spend most of the time with them during their cognitive phase of development (Goldin et al., 2014. Until these days, his wife had done most of the work on the social front and therefore his symptoms of social anxiety disorder did not affect his life. He also could not make friends due to his issues of shyness and anxiety to speak to new people. However these are now affecting his professional life and he needs to handle the symptoms effectively. He has always escaped the situations of social communication as his wife had been proactive and considerate of his issues. However in the professional front, he needs to communicate with customers effectively to maintain sales and customer satisfaction. Therefore he has come to consultation centre. The different triggers which have been identified for the client are being introduced to other people (Handling new customers and also making new friends), having to say something in a formal as well as public situation (Like arranging and hosting social gathering), meeting people in authority (like in case of handling parent-teachers meeting in school for his children). Other triggers include feeling insecure and out of place in social situations and also getting embarrassed easily. Moreover others noticed were not  meeting eyes and also making phone calls and others. All these need to be handled effectively to make him overcome the barriers.

Causes and Triggers of Social Anxiety Disorder

Evidence based journals are of the opinion that cognitive development therapy has proved to be exceptionally beneficial for handling social anxiety disorders. After the completion of this therapy, people have been seen to suffer no longer from fear and anxiety before social communications. Appropriate therapy has been found to be successful in modifying people’s thoughts, feelings, behaviour as well as beliefs (Craske et al., 2014). While developing the treatment plan, the expert should be helping the client to identify the anxious thoughts which are contributing to the mute behaviour. He should be introducing strategies which would help him to be aware of his thoughts (Kocovskil et al. 2013). The strategies should be including recognizing his body symptoms of anxiety and identifying and challenging maladaptive beliefs. Moreover a coping plan would be developed which would help him to tackle his levels of distress (Mansson et al., 2015). Feelings of embarrassment, thinking himself to be incapable, feeling insecure are mainly results of anxiety and feelings of worry and these should be made to understand to the client.

James would be taught new information through encouragement about his social skills, his inner powers, his capability to socialise well and empowering him with positive thoughts. James need to taken in what is taught to him by practicing them in homes and other social circles by means of continuous repetition. He would then be registering the new learning in his brain over and over again until it becomes automatic and habitual (Barlow et al., 2016). When James would have learnt properly, he would be able to think, act and feel differently. However this would take persistence, patience as well as practice. However the expert should mainly pay importance to the fact that the client remains adhered with the fact and make it a habit in his life to attain successful modifications of the behaviour.

The treatment plan which should be followed by the expert for treatment of the client would be according to the Heimberg model. This would mainly comprise of 15 sessions with 60 minutes duration for each session. It would also comprise of 90 minutes of 1 session for the exposure. This treatment would require 4 months and would incorporate several important phases. The first phase is called the ‘education about social anxiety’. However, before that the expert should be sure that he has the ability to integrate the main elements of the interventions like exposure as well as cognitive restructuring (Bogels et al., 2014). He should make sure that he implements treatment in a manner which would not only be structured but also responsive to the needs of the client. In the first few sessions, the client needs to develop the ability to conceptualise his own social anxiety in the context of the model involving the primacy of cognition as well as negative consequences of avoidance and habituation. This would be completed in first two to three sessions of 60 minutes.  The nest would be the ‘establishing the hierarchy of feared situations”. Here the client would develop the ability to help the client in constructing the hierarchy of feared and avoided social situations. With the help of the expert, he would rank them accordingly to establish the rate of degree or fear associated with it (Hedman et al., 2014).

Cognitive Development Therapy for Social Anxiety Disorder

This would require 3 more sessions. The third phase would be the self monitoring phase where the client would be developing the ability to self monitor their anxiety and mood and thereby trying to troubleshoot any potential barriers. He should be doing this in his homework and it would require 2 sessions to confirm his adherence with the treatment model. The fourth is the step called ‘cognitive restructuring’ which would require the expert to offer him illustrative examples stating the fact that they are not the events which are creating anxiety but are the interpretations of the events which are doing so. Experts should also appraise the validity of the client’s thoughts rather than considering them as wrong (Dagoo et al., 2014). He would also help the clients to make connections between the emotions, behavioural and physiological reactions and help him to challenge the automatic thoughts. The fifth step would be exposure of the client to real life situations and debriefing after exposure ensuring that all the perceptions of the clients have been explored and thereby providing feedback. This would require 2 sessions of 90 minutes. The last three of four therapies would mainly address the core beliefs which would help them to maintain their social anxiety properly in nature. One more 90 minutes session would be important to assure the overall progress of the effect of the treatments and to make further treatment based measures and discuss the issue of relapse (ElAlaqui et al., 2015). This also helps James to employ skills which he has learned, after treatment ends.

References:

Barlow, D. H., Allen, L. B., & Choate, M. L. (2016). Toward a Unified Treatment for Emotional Disorders–Republished Article. Behavior therapy, 47(6), 838-853.

Bögels, S. M., Wijts, P., Oort, F. J., & Sallaerts, S. J. (2014). Psychodynamic psychotherapy versus cognitive behavior therapy for social anxiety disorder: an efficacy and partial effectiveness trial. Depression and anxiety, 31(5), 363-373.

Craske, M. G., Niles, A. N., Burklund, L. J., Wolitzky-Taylor, K. B., Vilardaga, J. C. P., Arch, J. J., … & Lieberman, M. D. (2014). Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators. Journal of consulting and clinical psychology, 82(6), 1034.

Dagöö, J., Asplund, R. P., Bsenko, H. A., Hjerling, S., Holmberg, A., Westh, S., … & Andersson, G. (2014). Cognitive behavior therapy versus interpersonal psychotherapy for social anxiety disorder delivered via smartphone and computer: A randomized controlled trial. Journal of anxiety disorders, 28(4), 410-417.

El Alaoui, S., Hedman, E., Kaldo, V., Hesser, H., Kraepelien, M., Andersson, E., … & Lindefors, N. (2015). Effectiveness of Internet-based cognitive–behavior therapy for social anxiety disorder in clinical psychiatry. Journal of consulting and clinical psychology, 83(5), 902

Goldin, P. R., Ziv, M., Jazaieri, H., Hahn, K., Heimberg, R., & Gross, J. J. (2013). Impact of cognitive behavioral therapy for social anxiety disorder on the neural dynamics of cognitive reappraisal of negative self-beliefs: randomized clinical trial. JAMA psychiatry, 70(10), 1048-1056.

Goldin, P. R., Ziv, M., Jazaieri, H., Weeks, J., Heimberg, R. G., & Gross, J. J. (2014). Impact of cognitive-behavioral therapy for social anxiety disorder on the neural bases of emotional reactivity to and regulation of social evaluation. Behaviour research and therapy, 62, 97-106.

Hedman, E., El Alaoui, S., Lindefors, N., Andersson, E., Rück, C., Ghaderi, A., … & Ljótsson, B. (2014). Clinical effectiveness and cost-effectiveness of Internet-vs. group-based cognitive behavior therapy for social anxiety disorder: 4-year follow-up of a randomized trial. Behaviour research and therapy, 59, 20-29.

Kocovski, N. L., Fleming, J. E., Hawley, L. L., Huta, V., & Antony, M. M. (2013). Mindfulness and acceptance-based group therapy versus traditional cognitive behavioral group therapy for social anxiety disorder: A randomized controlled trial. Behaviour research and therapy, 51(12), 889-898.

Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., … & Ritter, V. (2013). Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial. American Journal of Psychiatry, 170(7), 759-767.

Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., … & Ritter, V. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, 171(10), 1074-1082.

Månsson, K. N., Frick, A., Boraxbekk, C. J., Marquand, A. F., Williams, S. C. R., Carlbring, P., … & Furmark, T. (2015). Predicting long-term outcome of Internet-delivered cognitive behavior therapy for social anxiety disorder using fMRI and support vector machine learning. Translational psychiatry, 5(3), e530.