C - Case Summary.docx

1.0 Justification of diagnosis According to my analysis of the case study one, Ali presented a very typical case of social anxiety disorder. Social anxiety disorder, which is also known as social phobia is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life (Jefferson, 2001). From my perspectives, Ali demonstrated strong anticipation and belief that he would not do well at social interactions and in social events became a self-fulfilling prophecy, and his belief came true in which he did not do well. Specifically, the more nervous and anxious he got over a situation, the more attention he paid to it and the more he could not perform well. Additionally, he is afraid of being judged and humiliated by others during the conversation. As a result, he often avoids the social and performance situations, and when a situation cannot be avoided, he experiences significant anxiety and distress. Although he recognized that his fear is excessive and unreasonable, he often feels powerless against the anxiety. Significantly, this was a very negative paradox or "vicious cycle" that people with social anxiety disorder get stuck in. Moreover, the pressure that comes about after the anxious event continued to fuel the fire. ‘I will never be able to hold a conversation with others,’ Ali would tell himself, consequently constantly reinforcing the fact that he saw himself as a failure and a loser.

2.0 Diagnosis criteria and symptoms Notably, Ali was diagnosed with social anxiety disorder as he was too afraid and shy for all the social arrangements. Specifically, he avoided almost all social responsibility and not to have to deal with any social situations. In work setting, when he needs to get the feedback from customers, he will be unable to get the words out, he stumbled around, choke up and blurts out the rest of the message and he afraid that the customers would not understand him.

He felt extremely embarrassing and humiliating afterwards. Consequently, he could not even hold a conversation with a customer without getting extremely anxious and giving himself away. This is because he was overly self-conscious and paid high self-attention after the activity. Also, he tends to interpret the neutral conversations with a negative outlook and remember more negative memories. While the fear of social interaction is recognized by Ali as excessive or unreasonable and overcoming it can be quite difficult. For these reasons, Ali was diagnosed under the diagnosis criteria A in social anxiety disorder which is a marked fear or anxiety about the social situations in which the individual is exposed to possible scrutiny by others (American Psychiatric Association, 2013). For example, social interaction including having a conversation, meeting unfamiliar people, being observed and performing in front of others (American Psychiatric Association, 2013). Furthermore, Ali showed the overwhelming fear of being judged by others in social situations. Specifically, he has negative thoughts such as: ‘why was he so timid and scared,’ ‘he simply must be crazy’ that put him under great pressure and defeated after his working hours. In accordance with the analysis of American Psychiatric Association (2013), Ali has met the diagnosis criteria B in which he fears that he will act in a way or show anxiety symptoms that will be negatively evaluated. For example, he fears that he will be humiliated, embarrassed and offends others when having a conversation with others. Also, Ali worries that he will show the anxiety symptoms, such as blushing, stumbling over one's words and staring, that will be negatively evaluated by others. Additionally, he is concerned that he will be judged as anxious, weak, stupid and unlikable. Due to this reason, he is working under high stress. In addition, Ali was very uneasy and worried when he had to attend social events. For this case, it reflects that Ali met the diagnosis criteria C in which the social situations almost always provoke fear or anxiety.

Markedly, as discussed by the American Psychiatric

Association (2013), an individual who becomes anxious only occasionally in social situations

would not be diagnosed with social anxiety disorder. However, the degree and type of fear and anxiety such as anticipatory anxiety and a panic attack may vary across different occasions (American Psychiatric Association, 2013). According to the American Psychiatric Association (2013), anticipatory anxiety may occur sometimes far in advance of upcoming situations. In this case, Ali felt the anticipatory anxiety ahead of time when he realized that he had to perform and do something in the public and even make phone calls from work. Apart from that, Ali was diagnosed under the diagnosis criteria D in which the social situations are avoided or endured with intense fear or anxiety (American Psychiatric Association, 2013).

Specifically, Ali will often avoid himself from the ‘fearful’ social

situations since his wife would handle all the social arrangements. As a result, he will not have to deal with any social situations. In addition, Ali showed a common symptom of social anxiety disorder in which he often overestimates the negative consequences of social situations. Likewise, he believes and felt worried that the silences that occurred in the conversation during the social events were his fault for being so backward and unconfident. Therefore, it reflects that he has met the diagnosis criteria E in which 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 (American Psychiatric Association, 2013). Moreover, in Ali’s case, the fear, anxiety, and avoidance are persistent and had causes clinically significant distress along with the impairment in social, occupational, as well as other important areas of functioning. Specifically, Ali could not even communicate and have a conversation with a customer during his working hours. Consequently, this may have an impact on his job performance. Additionally, his fear and uneasiness have caused a significant impact on his social functioning as he avoids and finds it is difficult to attend the social events. Furthermore, if there was a parent-teacher meeting to attend, Ali’s wife will go to it and even when the family ordered takeout food, it was his wife who made the call. Significantly,

according to the American Psychiatric Association (2013), Ali has met the criterion F and criterion G in social anxiety disorder. Additionally, in this case, the fear, anxiety and avoidance that presented by Ali are not attributable to the physiological effects of a substance such as a drug of abuse, a medication or another medical condition.

Meanwhile, his fear, anxiety, and avoidance are not better

explained by the symptoms of other mental disorders such as panic disorder, body dysmorphic disorder, or autism spectrum disorder. Therefore, in line with the analysis of the American Psychiatric Association (2013), diagnosis criteria H and diagnosis criteria I in social anxiety disorder is met. Under those circumstances, Ali was diagnosed with social anxiety disorder and the disorder have a significant impact on his life.

3.0 Possible causes for the disorder Research into the causes of social anxiety disorder is wide-ranging and encompassing multiple aspects from neuroscience to sociology (Jefferson, 2001). In fact, scientists have yet to identify the precise causes. However, studies suggest that genetics may play a role in combination with environmental factors (American Psychiatric Association, 2013; Stein & Stein, 2008). Specifically, according to the studies of Stein and Stein (2008), genetic and family factors may contribute to social anxiety disorder. In detail, as analysed by Gayatridevi and Vincent (2016), there is two to the threefold greater risk of having a social anxiety disorder if a first-degree relative is suffering from the disorder. Particularly, this could be caused by genetic factors or due to children acquiring social fears and avoidance through procedures of observational learning or parental psychosocial education (McLaughlin, Behar, & Borkovec, 2008). In other words, the genetic influence is subject to gene-environment interaction in which children with high behavioural inhibition are more vulnerable to the environmental

influences, such as socially anxious that modelling by parents (McLaughlin, Behar, & Borkovec, 2008). Moreover, studies have found that if a parent has any kind of anxiety disorder, a child will gain higher chances and more likely to develop an anxiety disorder or social phobia (McLaughlin, Behar, & Borkovec, 2008). Besides that, previous negative social experiences can be a trigger to social anxiety disorder, perhaps particularly for the individual who has higher sensitivity on the interpersonal relationship (Teachman & Allen, 2007). Notably, in line with the studies of Kummer and Harsanyi (2008), there are half of those diagnosed with social anxiety disorder claimed that a specific traumatic or humiliating social events appear to be related to the onset or worsening of the disorder. In addition, direct experiences such as observing and hearing about the socially negative experiences of others or verbal warnings of social problems and dangers may cause the development of a social anxiety disorder (Akinsola & Udoka, 2013). Markedly, longerterm effects of not fitting in, or being bullied, rejected or ignored may also cause the disorder. For this reason, as discussed by Akinsola and Udoka (2013), shy adolescents or avoidant adults have mentioned their unpleasant experiences with peers or childhood bullying or harassment. Apart from that, according to the analysis of the American Psychiatric Association (2013), temperamental is one of the factors of social anxiety disorder. Markedly, underlying traits that predispose individuals to social anxiety disorder include behavioural inhibition and fear of negative evaluation (American Psychiatric Association, 2013). In fact, individuals with anxiety states will have a high focus on and worry about the anxiety symptoms themselves and how they might appear to others (Fox & Pine, 2012). Due to this reason, they have developed a distorted mental representation of themselves and overestimates the likelihood and consequences of negative evaluation (Fox & Pine, 2012). Such cognitive models explain the role of negatively-biased memories of the past and the processes of rumination after an event as well as the fearful anticipation before it (Fox & Pine, 2012). Moreover, there are many

researchers investigating the neural basis of social anxiety disorder (Goldin, Manber, Hakimi, Canli, & Gross, 2009). As a matter of fact, the precise neural mechanisms have not found yet (Goldin et al., 2009). However, there is evidence relating to social anxiety disorder to the imbalance in some neurochemicals and hyperactivity in some brain areas (Martin, Ressler, Binder, & Nemeroff, 2009). Specifically, in accordance with the studies of Jefferson (2001), social anxiety disorder is associated with an imbalance of the brain chemical serotonin. Also, it has been found that individuals with social anxiety disorder have a hypersensitive amygdala, for example in relation to social threat cues such as angry or hostile faces (Davis, Neta, Kim, Moran, & Whalen, 2016).

4.0 Incidence and prevalence of the disorder In fact, social anxiety disorder was thought to be a relatively rare disorder when prevalence estimation was based on the examination of psychiatric clinic samples (Bandelow & Michaelis, 2015). Notably, according to the studies of Bandelow and Michaelis (2015), twelve-month prevalence rates as high as seven per cent have been reported for social anxiety disorder. Specifically, prevalence rates of social anxiety disorder are lowest in low-middle income countries and in the African and Eastern Mediterranean areas, and highest in highincome countries and in the Americas and the Western Pacific regions (World Health Organization, 2017). In each of the researches, the age of onset of social anxiety disorder was early and comorbidity with other mental disorders was high, and consequently, the impairment was remarkable (World Health Organization, 2017). Moreover, in accordance with the analysis of the World Health Organization (2017), the prevalence rates decrease with age. In general, females were found to have higher rates of social anxiety disorder than in males in the general population and the gender difference in prevalence is more pronounced in

adolescents and young adults (Brook & Schmidt, 2008). Markedly, as mentioned by Brook and Schmidt (2008), once the social anxiety disorder present, it is more probably to be persistent and debilitating. Furthermore, gender rates are equivalent or slightly higher for males in clinical samples, and it is believed that gender roles and social expectations play a crucial role in explaining the heightened help-seeking behaviour in male patients (Brook & Schmidt, 2008). Additionally, social anxiety disorder commonly begins in childhood or adolescence (Polo, Alegría, Chen, & Blanco, 2011). The mean age at onset of social anxiety disorder is ten to thirteen years old, although there is a considerable minority reported the onset between ages one and five years (Polo et al., 2011). Surprisingly, patients from the very early onset category describe the disorder as having been exist for as long as they can recall (Jefferson, 2001). However, as analysed by Jefferson (2001), the onset after twenty-five years old is rare and is typically preceded by panic disorder or major depression. Besides that, the disorder tends to be remarkably persistent among the individuals who are presenting to the clinical care (American Psychiatric Association, 2013).

In detail,

adolescents endorse a wider pattern of fear and avoidance when compared with younger children especially with the fear of dating (American Psychiatric Association, 2013). Conversely, older adults demonstrate social anxiety at lower levels but across a greater scope of situations, whereas younger adults express higher levels of social anxiety for specific circumstances (Colonnesi, Nikolić, de Vente, & Bögels, 2017). For this reason, in older adults, they may worry about their disability due to declining sensory functioning such as hearing and vision or functioning due to medical conditions, or cognitive impairment such as forgetting people's names (Colonnesi et al., 2017).

5.0 Prognosis for the client

In fact, social anxiety disorder is among the most common and disabling mental disorders. It can be persistent, and access to treatment is frequently delayed or avoided (Brady, Haynes, Hartwell, & Killeen, 2013). According to the analysis of Brady et al. (2013), about seventy per cent to eighty per cent of cases have a lifetime history of concurrent anxiety, depression, or substance abuse related disorders. Therefore, as discussed by Brady et al. (2013), effective intervention requires early detection, education, together with the delivery of pharmacotherapy as well as cognitive behavioural therapy (CBT). Moreover, long-term treatment is generally suggested due to the relapse potential (Bandelow, Michaelis, & Wedekind, 2017). Specifically, relapse may happen in thirty per cent to fifty per cent of patients after the medication discontinuation (Bandelow, Michaelis, & Wedekind, 2017). Conversely, relapse rates are reduced in those who have received components of CBT (Bandelow, Michaelis, & Wedekind, 2017). Markedly, treatment-resistant patients should be referred to a mental health professional with expertise in the management of anxiety disorders (Stein & Sareen, 2015). Also, as mentioned by Stein and Sareen (2015), ambivalence in accepting a psychiatric referral should be discussed with the patient, and they should be provided with accurate information and motivational enhancements. Significantly, a social anxiety disorder can be successfully treated, and if the treatments offered are highly effective (National Collaborating Centre for Mental Health, 2013). Likewise, repetition and reinforcement of rational concepts, strategies, and methods are the basic to reduce social anxiety disorder on a long-term basis (National Collaborating Centre for Mental Health, 2013). For this reason, people manage to overcome social anxiety disorder when they stick with cognitive strategies and practically apply them in their daily lives.

6.0 Assessment In general, assessment instruments can be used as strategies for the large-scale screening of social anxiety disorder and the characterization of the associated symptoms and damage (National Collaborating Centre for Mental Health, 2013). Markedly, a literature review of the instrument for social anxiety disorder evaluation pointed out about twenty-three available instruments with varying purposes, forms of application and extension (National Collaborating Centre for Mental Health). Specifically, as discussed by de Lima Osório, de Souza Crippa and Loureiro (2012), the Liebowitz Social Anxiety Scale (LSAS) and the Social Phobia Inventory (SPIN) were validated in samples of the general population and in a clinical social anxiety disorder sample involving cases. Likewise, standardized rating scales such as the Social Phobia Inventory can be used to screen social anxiety disorder and measure the severity of social phobia (de Lima Osório, de Souza Crippa & Loureiro, 2012). In detail, the LSAS is the self-rating scale most widely studied all over the world regarding its psychometric qualities (Caballo, Salazar, Arias, Hofmann, & Curtiss, 2018). According to the analysis of Schmits, Heeren and Quertemont (2014), it is the most frequently used in clinical assessments and has been validated for five languages, in addition to the English original. Besides that, the SPIN is a self-rating instrument which, like the LSAS, intends to evaluate the fear and avoidance symptoms (de Lima Osório, de Souza Crippa & Loureiro, 2012). In general, it is differing from the LSAS by assessing physiological symptoms, such as palpitation, blushing, tremor and transpiration, also associated with the disorder, by means of four specific items (Gren-Landell, Björklind, Tillfors, Furmark, Svedin, & Andersson, 2009). Notably, there is a reduced version of the SPIN which is known as the Mini-SPIN (MS), consisting of three items of the original scale (Gren-Landell et al., 2009). As discussed by Gren-Landell et al., (2009), it is an instrument of even shorter and more rapid application, with high discriminant power.

7.0 Treatment plan In fact, the most fundamental clinical point to emerge from studies of social anxiety disorder is the benefit of early diagnosis and treatment. However, research has provided evidence for the two forms of treatment available for social phobia including the specific form of psychotherapy and certain medications (Kaczkurkin & Foa, 2015; Wersebe, Sijbrandij, & Cuijpers, 2013). In detail, psychotherapy can be a beneficial part of the treatment for an anxious and phobic patient (Wersebe, Sijbrandij, & Cuijpers, 2013). According to the analysis of Tsitsas and Paschali (2014), cognitive behavioural therapy in which also called CBT can be highly effective for social anxiety disorder. Specifically, CBT has two main components which are cognitive and behavioural. In cases of social anxiety disorder, the cognitive component can help the patient question on how they can be so sure that others are continually watching and harshly judging them (Tsitsas & Paschali, 2014). On the contrary, the behavioural component was aimed to change their reactions towards the anxiety-inducing circumstances (Tsitsas & Paschali, 2014). Markedly, as discussed by Picardi and Gaetano (2014), the act of practising new thoughts through repetition when the individual notices unhelpful thoughts can allow new patterns of thinking to become automatic. In this case, Ali might work to change and replace the anxiety-inducing thought of ‘I make everyone else uncomfortable if I go to the party’ with these feelings ‘I am having right now is not rational. When the party is over, I will be glad that I went'. As such, CBT serves as a logical extension of cognitive therapy, whereby people have demonstrated the proof in the real world that their dysfunctional thought procedures are unrealistic (Picardi & Gaetano, 2014). Moreover, CBT has been improved by focusing treatment on the cognitive procedure such as behavioural experiment with attentional focus, video feedback experiments, addressing fears of negative evaluation and etcetera (Nilsson, 2012). Specifically, the purpose of these procedures is to let the patient learn from acting

differently and observing their own reactions (Nilsson, 2012). Notably, this has to be done with support and guidance and when the therapist and patient feel that they are ready (Nilsson, 2012). Besides that, exposure therapy can be one of the effective treatments for social anxiety patient (Gil, Carrillo, & Sanchez Meca, 2001). In general, according to the studies of Jefferson (2001), exposure needs to be repeated and lengthy to be effective. Likewise, the use of exposure in fantasy, presenting increasingly anxiety-provoking situations as unease dissipates at each level is considered as a form of systematic desensitization (Warnock-Parkes, Wild, Stott, Grey, Ehlers, & Clark, 2017). Also, the exposure in vivo involves gradual adaptation to anxiety-arousing

situations,

but

the

situations

are

actually

present

during

the

treatment. Consequently, in accordance with the investigations of Rowa and Antony (2005), a patient with continued exposure to the feared situations leads to anxiety reduction by habituation. In this case, Ali might be repeatedly asking customers for the feedbacks about their food and service until the process becomes comfortable. Apart from that, medication is sometimes used to relieve the symptoms of social anxiety, but it is not a cure. In general, medication is considered most helpful when used in addition to therapy and self-help techniques that address the root cause of the social anxiety disorder (Bystritsky, Khalsa, Cameron, & Schiffman, 2013). There are different types of medication are used in the treatment of social anxiety including selective serotonin reuptake inhibitors (SSRIs) and Benzodiazepines (Fink, Akimova, Spindelegger, Hahn, Lanzenberger, & Kasper, 2009). Notably, due to the high efficacy of selective serotonin reuptake inhibitors (SSRIs) and the favourable side effect profile, these compounds are mainly considered as first-line treatment in social anxiety disorder (Fink et al., 2009). However, doses of SSRIs for anxiety disorders could be higher than those used for depression but must be started at lower doses to minimize the short-term agitation sometimes experienced with these medications (Fink et al., 2009).

Markedly, the patient should be counselled that negative effects often diminish with time and that empirical switching to another SSRI may be necessary (Fink et al., 2009). Furthermore, a benzodiazepine anxiolytic can be another logical option to treat social anxiety disorder (Cassano, Rossi, & Pini, 2002). Specifically, positive sides of benzodiazepines include rapid onset, good tolerability, overdose safety, and flexibility of dosing (Cassano, Rossi, & Pini, 2002). Conversely, the disadvantages include side effects such as sedation, incoordination, and sexual dysfunction, discontinuation difficulties and etcetera (Cassano, Rossi, & Pini, 2002).

8.0 Conclusion In conclusion, social anxiety disorder is a highly prevalent psychiatric disorder with most underestimated effects on the functionality of individuals affected (Bandelow & Michaelis, 2015). Significantly, the consequences of social anxiety disorder on quality of life is enormous. For this reason, individuals with a social anxiety disorder, the fear and anxiety may lead to avoidance that can disrupt their life. Also, severe stress may influence their daily routine, work, school and other activities.

However, by learning coping strategies in

psychotherapy and taking medications can help the patients to gain confidence and improve their capability to communicate and interact with others. Significantly, dealing with the social anxiety disorder takes patience, courage to face fears and try new things, as well as the willingness to practice. Therefore, it takes a commitment to go forward rather than back away when feeling shy.