NEW FORMAT

ABNORMAL PSYCHOLOGY
Psychological Report
Name: Alex
Age: N/A
Gender: Male

Diagnosis: Social Anxiety Disorder (Social Phobia) DSM-5 300.23 (F40.10)

Reason for clients Visit:

Alex is a very shy person. As the father in the family, Alex is not able to perform his role
in the family because he was very shy. There are times that he is hurting himself for
getting extremely anxious and giving himself away.

Problem/ Symptoms:

He was very anxious about socializing with other people. He always thinks that he might
get embarrassed when he is talking to other people. At times when he felt he simply had
to go to these social events, Alex was very ill-at-ease, never knew what to say, and felt
the silences that occurred in conversation were his fault for being so backward.  He
knew he made everyone else uncomfortable and ill-at-ease. The worst part of all was
the anticipatory anxiety Alex felt ahead of time – when he knew he had to perform, do
something in public, or even make phone calls from work.  The more time he had to
worry and stew about these situations, the more anxious, fearful and uncomfortable he
felt.

Psychosocial and Environmental Problem Areas:

Psychosocial in all day, every day, life is like this. Fear. Apprehension. Avoidance.
Pain. Anxiety about what you said. Fear that you said something wrong. Worry about
others' disapproval. Afraid of rejection, of not fitting in. Anxious to enter a conversation,
afraid you'll have nothing to talk about. Hiding what's wrong with you deep inside,
putting up a defensive wall to protect your "secret". You are undergoing the daily,
chronic trouble of living with this mental disorder we call social anxiety disorder. protect
your "secret".  You are undergoing the daily, chronic trouble of living with this mental
disorder we call social anxiety disorder.
I. CASE OVERVIEW

In the case of Alex this severe shyness causes him personal distress and
impairment of functioning in one or more domains, such as interpersonal or
occupational functioning. He is a “backward” person. He is typically the individual
who fears that if he displays his anxiety, he will experience social rejection.
Despite of this anxiety that Alex is experiencing still he is lucky because his wife
Sandy is really understanding. Alex eventually had to go for treatment because
he started having problems at work.

II. DSM-5 DIAGNOSIS

The diagnostic criteria of Social Anxiety Disorder (Social Phobia) DSM-5

300.23 (F40.10) as applied to Alex’ case is reflective of the essential feature of
social anxiety disorder is a marked, or intense, fear or anxiety of social situations
in which the individual may be scrutinized by others. In children the fear or
anxiety must occur in peer settings and not just during interactions with adults
(Criterion A). When exposed to such social situations, the individual fears that he
or she will be negatively evaluated. The individual is concerned that he or she will
be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable.
The individual fears that he or she will act or appear in a certain way or show
anxiety symptoms, such as blushing, trembling, sweating, stumbling over one's
words, or staring, that will be negatively evaluated by others (Criterion B). Some
individuals fear offending others or being rejected as a result. Fear of offending
others—for example, by a gaze or by showing anxiety symptoms—may be the
predominant fear in individuals from cultures with strong collectivistic
orientations. An individual with fear of trembling of the hands may avoid drinking,
eating, writing, or pointing in public; an individual with fear of sweating may avoid
shaking hands or eating spicy foods; and an individual with fear of blushing may
avoid public performance, bright lights, or discussion about intimate topics. Some
individuals fear and avoid urinating in public restrooms when other individuals are
present (i.e., paruresis, or "shy bladder syndrome"). The social situations almost
always provoke fear or anxiety (Criterion C). Thus, an individual who becomes
anxious only occasionally in the social situation(s) would not be diagnosed with
social anxiety disorder. However, the degree and type of fear and anxiety may
vary (e.g., anticipatory anxiety, a panic attack) across different occasions. The
anticipatory anxiety may occur sometimes far in advance of upcoming situations
(e.g., worrying every day for weeks before attending a social event, repeating a
speech for days in advance). In children, the fear or anxiety may be expressed
by crying, tantrums, freezing, clinging, or shrinking in social situations. The
individual will often avoid the feared social situations. Alternatively, the situations
are endured with intense fear or anxiety (Criterion D). Avoidance can be
extensive (e.g., not going to parties, refusing school) or subtle (e.g.,
overpreparing the text of a speech, diverting attention to others, limiting eye
contact). 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). Sometimes, the anxiety may not be judged to be excessive,
because it is related to an actual danger (e.g., being bullied or tormented by
others). However, individuals with social anxiety disorder often overestimates the
negative consequences of social situations, and thus the judgment of being out
of proportion is made by the clinician. The individual's sociocultural context needs
to be taken into account when this judgment is being made. For example, in
certain cultures, behavior that might otherwise appear socially anxious may be
considered appropriate in social situations (e.g., might be seen as a sign of
respect). The duration of the disturbance is typically at least 6 months (Criterion
F). This duration threshold helps distinguish the disorder from transient social
fears that are common, particularly among children and in the community.
However, the duration criterion should be used as a general guide, with
allowance for some degree of flexibility. The fear, anxiety, and avoidance must
interfere significantly with the individual's normal routine, occupational or
academic functioning, or social activities or relationships, or must cause clinically
significant distress or impairment in social, occupational, or other important areas
of functioning (Criterion G). For example, an individual who is afraid to speak in
public would not receive a diagnosis of social anxiety disorder if this activity is not
routinely encountered on the job or in classroom work, and if the individual is not
significantly distressed about it. However, if the individual avoids, or is passed
over for, the job or education he or she really wants because of social anxiety
symptoms. Criterion G is met. (DSM-5 American Psychiatric
Association, p. 204).”

(Note: You only put the criteria that the client meets. If the client did not meet the
criteria, you don’t have to mention it here. What’s more important is that the
client’s symptoms meet the requirement for Criteria A, which is mentioned before
the Criteria are enumerated. For example, the DSM-5 may mention that you
need five or more symptoms, etc.))
A. Marked fear or anxiety about one or more social situations in which the
individual is exposed to possible scrutiny by others. Examples include
social interactions (e.g., having a conversation, meeting unfamiliar
people), being observed (e.g., eating or drinking), and performing in
front of others (e.g., giving a speech).

At times when he felt he simply had to go to these social events, Alex was very
ill-at-ease, never knew what to say, and felt the silences that occurred in
conversation were his fault for being so backward.  He knew he made everyone
else uncomfortable and ill-at-ease. The worst part of all was the anticipatory
anxiety Alex felt ahead of time – when he knew he had to perform, do something
in public, or even make phone calls from work.  The more time he had to worry
and stew about these situations, the more anxious, fearful and uncomfortable he
felt.

B. The individual fears that he or she will act in a way or show anxiety
symptoms that will be negatively evaluated (i.e., will be humiliating or
embarrassing: will lead to rejection or offend others).

At our first meeting, Alex was very shy and averted his eyes from me, but he did
shake hands, respond, and smile a genuine smile.

C. The fear, anxiety, or avoidance is persistent, typically lasting for 6

months or more.

He could trace his shyness to his teenage years. Alex mentioned suffering with
this kind of anxiety for as long as he can remember.  When he was at school, he
was “backward” and didn’t know what to say.

D. The social situations almost always provoke fear or anxiety.

 Alex was also too shy to order pizza because he was too afraid and shy to do it.

E. The fear, anxiety, or avoidance causes clinically significant distress or

impairment in social, occupational, or other important areas of
functioning.

Years earlier, Alex had worked at a branch of 7 Eleven, where he knew the
owner and felt a part of the family.  The business was slow and manageable and
he never found himself on display in front of lines of people.
 F. The fear, anxiety, or avoidance is not better explained by the symptoms
of another mental disorder, such as panic disorder, body dysmorphic
disorder, or autism spectrum disorder.

"When I have to call people up to tell them that their order is in," he said, "I know
my voice is going to be weak and break, and I will be unable to get my words out.
I’ll stumble around and choke up.... then I’ll blurt out the rest of my message so
fast I’m afraid they won’t understand me.  Sometimes I have to repeat myself and
that is excruciatingly embarrassing." Alex felt great humiliation and
embarrassment about this afterwards: he couldn’t even make a telephone call to
a stranger without getting extremely anxious and giving himself away.  That was
pretty bad!  Then he would beat himself up.  What was wrong with him?  Why
was he so timid and scared?  No one else seemed to be like he was.  He simply
must be crazy!  After a day full of this pressure, anxiety and negative thinking,
Jim would leave work feeling fatigued, tired, and defeated.

III. DSM-5 DESCRIPTION OF THE DISORDER

DSM-5, “Social anxiety disorder is a marked, or intense, fear or anxiety of social

situations in which the individual may be scrutinized by others. The fear, anxiety,
or avoidance is persistent, typically lasting 6 or more months." Page 203.

A. PREVALENCE/DEVELOPMENTAL COURSE/ETIOLOGY/RISK AND

PROGNOSTIC FACTORS/CULTURE RELATED DIAGNOSTIC
ISSUES/GENDER RELATED DIAGNOSTIC ISSUES

PREVALENCE

The 12-month prevalence estimate of social anxiety disorder for the United
States is approximately 7%. Lower 12-month prevalence estimates are seen in
much of the world using the same diagnostic instrument, clustering around 0.5%-
2.0%; median prevalence in Europe is 2.3%. The 12-month prevalence rates in
children and adolescents are comparable to those in adults. Prevalence rates
decrease with age. The 12-month prevalence for older adults ranges from 2% to
5%. (DSM-5 “These individuals may be shy or withdrawn, and they may be less
open in conversations and disclose little about themselves. They may seek
employment in jobs that do not require social contact, although this is not the
case for individuals with social anxiety disorder, performance only. They may live
at home longer. Men may be delayed in marrying and having a family, whereas
women who would want to work outside the home may live a life as homemaker
and mother”, (In Alex’ case he is not able to find a stable job because he is
always fear of interacting to different people and that he enabled his wife Sandy
to take charge of family responsibilities). In general, higher rates of social anxiety
disorder are found in females than in males in the general population (with odds
ratios ranging from 1.5 to 2.2), and the gender difference in prevalence is more
pronounced in adolescents and young adults. Gender rates are equivalent or
slightly higher for males in clinical samples, and it is assumed that gender roles
and social expectations play a significant role in explaining the heightened help-
seeking behavior in male patients. (Alex is a male adult, he is married and have
three children)

RISK AND PROGNOSTIC FACTORS

Temperamental. Underlying traits that predispose individuals to social anxiety

disorder include behavioral inhibition and fear of negative evaluation.

Environmental. There is no causative role of increased rates of childhood

maltreatment or other early-onset psychosocial adversity in the development of
social anxiety disorder. However, childhood maltreatment and adversity are risk
factors for social anxiety disorder.

Genetic and physiological. Traits predisposing individuals to social anxiety

disorder, such as behavioral inhibition, are strongly 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. Also, social anxiety disorder is heritable
(but performance-only anxiety less so). 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.

(In Alex’ case TEMPERAMENTAL is the prognostic factor that affects his
condition)

CULTURE-RELATED DIAGNOSTIC

The syndrome of taijin kyofusho (e.g., in Japan and Korea) is often characterized
by social evaluative concerns, fulfilling criteria for social anxiety disorder, that are
associated with the fear that the individual makes other people uncomfortable
(e.g., "My gaze upsets people so they look away and avoid me"), a fear that is at
times experienced with delusional intensity. This symptom may also be found in
non-Asian settings. (Alex’ case is not as worse as syndrome of Taijin Kyofusho
 because Alex is a calm person and not paranoid) Other presentations of taijin
kyofusho may fulfill criteria for body dysmorphic disorder or delusional disorder.
Immigrant status is associated with significantly lower rates of social anxiety
disorder in both Latino and non-Latino white groups. Prevalence rates of social
anxiety disorder may not be in line with self-reported social anxiety levels in the
same culture—that is, societies with strong collectivistic orientations may report
high levels of social anxiety but low prevalence of social anxiety disorder. (Here
in the Philippines when someone is shy, we have these teasing remarks like in
Bisaya “oy aysig ulaw-ulaw diha mura man pud kag cute” some are not
respecting the persons who are suffering from this kind of anxiety just like Alex,
he always avoids conversations with people around him because it is very
tensional for him to talk and socialize)

GENDER RELATED DIAGNOSTIC

Females with social anxiety disorder report a greater number of social fears and
comorbid depressive, bipolar, and anxiety disorders, whereas males are more
likely to fear dating (Alex had no dating records when he met Sandy he
immediately got married), have oppositional defiant disorder or conduct disorder,
and use alcohol and illicit drugs to relieve symptoms of the disorder. Paruresis is
more common in males.

B. FUNCTIONAL CONSEQUENCES OF THE DISORDER

Social anxiety disorder is associated with elevated rates of school dropout and
with decreased well-being, employment, workplace productivity, socioeconomic
status, and quality of life. (He is not able to find stable job because most of job
opportunities require social interaction in recruitment.) Social anxiety disorder is
also associated with being single, unmarried, or divorced and with not having
children, particularly among men. In older adults, there may be impairment in
caregiving duties and volunteer activities. Social anxiety disorder also impedes
leisure activities. (Alex can’t feel enjoyment and belongingness when attending
gatherings/events) Despite the extent of distress and social impairment
associated with social anxiety disorder, only about half of individuals with the
disorder in Western societies ever seek treatment, and they tend to do so only
after 15-20 years of experiencing symptoms. (In Alex’ case he did not seek any
treatment when he was mid 20’s because he was able to get married, also he
was hired in 7/11 store that was owned by his friend) Not being employed is a
strong predictor for the persistence of social anxiety disorder.
C. DIFFERENTIAL DIAGNOSIS
Generalized anxiety disorder. Social worries are common in generalized anxiety
disorder, but the focus is more on the nature of ongoing relationships rather than
on fear of negative evaluation. Individuals with generalized anxiety disorder,
particularly children, may have excessive worries about the quality of their social
performance, but these worries also pertain to nonsocial performance and when
the individual is not being evaluated by others. In social anxiety disorder, the
worries focus on social performance and others' evaluation.

Normative shyness. Shyness (i.e., social reticence) is a common personality

trait and is not by itself pathological. In some societies, shyness is even
evaluated positively. However, when there is a significant adverse impact on
social, occupational, and other important areas of functioning, a diagnosis of
social anxiety disorder should be considered, and when full diagnostic criteria for
social anxiety disorder are met, the disorder should be diagnosed. Only a
minority (12%) of self-identified shy individuals in the United States have
symptoms that meet diagnostic criteria for social anxiety disorder.

Specific phobias. Individuals with specific phobias may fear embarrassment or

humiliation (e.g., embarrassment about fainting when they have their blood
drawn), but they do not generally fear negative evaluation in other social
situations.
Selective mutism. Individuals with selective mutism may fail to speak because
of fear of negative evaluation, but they do not fear negative evaluation in social
situations where no speaking is required (e.g., nonverbal play).
Agoraphobia. Individuals with agoraphobia may fear and avoid social situations
(e.g., going to a movie) because escape might be difficult or help might not be
available in the event of incapacitation or panic-like symptoms, whereas
individuals with social anxiety disorder are most fearful of scrutiny by others.
Moreover, individuals with social anxiety disorder
Personality disorders. Given its frequent onset in childhood and its persistence
into and through adulthood, social anxiety disorder may resemble a personality
disorder. The most apparent overlap is with avoidant personality disorder.
Individuals with avoidant personality disorder have a broader avoidance pattern
than those with social anxiety disorder. Nonetheless, social anxiety disorder is
typically more comorbid with avoidant personality disorder than with other
personality disorders, and avoidant personality disorder is more comorbid with
social anxiety disorder than with other anxiety disorders.
Other mental disorders. Social fears and discomfort can occur as part of
schizophrenia but other evidence for psychotic symptoms is usually present. In
individuals with an eating disorder, it is important to determine that fear of
 negative evaluation about eating disorder symptoms or behaviors (e.g., purging
and vomiting) is not the sole source of social anxiety before applying a diagnosis
of social anxiety disorder. Similarly, obsessive-compulsive disorder may be
associated with social anxiety, but the additional diagnosis of social anxiety
disorder is used only when social fears and avoidance are independent of the
foci of the obsessions and compulsions.

My diagnosis Social Anxiety Disorder is the most appropriate because it’s very
obvious that Alex’ have the feelings of self-consciousness or fear that people will
judge him negatively. He has the fear of social situations that may made him feel so
intense that it seems beyond his control. The fear that may get in the way of going to
work or doing everyday things.

IV. THEORETICAL ANALYSIS OF THE CASE

Social anxiety disorder is generally treated with psychotherapy (sometimes called

“talk therapy”), medication, or both. It is not a hopeless case. Better speak with a
health care provider about the best treatment for you if you have this kind of
mental disorder.

According to the self-presentation theory of social anxiety (Leary & Kowalski,

1995), people feel socially anxious when they wish to make a good impression
on others but doubt their ability to do so. People with excessive social anxiety are
likely to view themselves as having more flaws or deficits, compared to those
who rarely feel social anxiety (Clark & Wells, 1995); thus, for SAD sufferers,
social interactions may seem like dangerous places where flaws can be
observed and scrutinized (Moscovitch, 2009).

Vohs, K. D., Baumeister, R. F., & Ciarocco, N. J. (2005). Self-regulation and self-
presentation: Regulatory resource depletion impairs impression management
and effortful self-presentation depletes regulatory resources. Journal of
Personality and Social Psychology, 88, 632–657. doi:10.1037/0022-
3514.88.4.632

V. EVIDENCE BASED TREATMENTS FOR THIS DISORDER

CBT (Cognitive Behavioral Therapy) with an emphasis on exposure can reduce

symptoms of social phobia. Exposure therapy is a CBT method that is used to
treat anxiety disorders. Exposure therapy focuses on confronting the fears
underlying an anxiety disorder to help people engage in activities they have been
avoiding. Exposure therapy involves gradually placing oneself in anxiety
provoking situations, and associating the feared stimulus with a response of
relaxation or indifference. This is also known as systematic desensitization, and
is a very effective evidence-based treatment of phobia, including social phobia.
(NIMH, 2014).

NIH. (2014) What is Social Phobia (Social Anxiety Disorder) NIH. Retrieved
February 28, 2014 from http://www.nimh.nih.gov/health/topics/social-phobia-
social-anxiety-disorder/index.shtml