Social Anxiety Disorder - Essay Example

Social Anxiety Social anxiety disorder is quite a common ailment that afflicts quite a few people. The case under study in this report is that of 33 year old Mr. A, who suffers from a fairly severe form of social anxiety which makes him reluctant to interact with people. He has suffered from this nervousness and anxiety at meeting people ever since he was a young boy. There is a history of alcoholism in the family and Mr. A’s completion of the AUDIT questionnaire elicited a response which shows that he is at a “high risk, harmful” level for the development of an alcohol use disorder. Social anxiety disorder has been described as an anxiety disorder in which a person has “an excessive and unreasonable fear of social situations”, which produces “intense nervousness and self consciousness” that arise from the fear of being closely watched, judged and criticized by others (Heimburg, 1995:3). Mr. A appears to be a characteristic example of social phobia as detailed by Butler and Wells (in Heimburg, 1995: 312), wherein the condition may have developed out of an early shyness which was exacerbated during the entry into adolescence and the increased level of interpersonal demands. Since no treatment was sought at this stage, it has moved on into secondary problems like low self confidence, low self esteem, social isolation and depression. Mr. A’s prior low levels of social interaction may have contributed to a lack of knowledge and ability to solve problems and the social anxiety associated with all personal interactions may have made it hard for him to approach clinical personnel for treatment. The 36-item-Short-Form-health-Survey was developed in the United States and has been used in population surveys around the world. It has been shown to be valid measure of general population health and contains two summary measures – the mental health (MH) scale and the mental component summary (MCS) and has been found to be a good test in screening for depressive and anxiety disorders. In a test carried out by Silveira et al (2005), the predictive validity of the SF-36 MH and MCS cut off scores was supported in screening for depressive disorder, but not for anxiety disorder in older Swedish women. It is however, a commonly used instrument to measure general health. In Mr. A’s case, he has been administered the Brief Fear of Negative Evaluation self-report and he scored the highest possible score, i.e, 60, suggesting that if the SFHS is administered to him, he could well score at disturbingly high levels. In a study carried out by Luo et al (2004) on the health related quality of life of Asians in Singapore to assess social anxiety, 119 patients attending a hospital psychiatric clinic completed the SF-36 Survey, the Beck Anxiety Inventory and the General Health Questionnaire. The SF3 score reduction derived from the population norms, quantified as the number of standard deviations falling below the mean value was compared with similar data on Singaporeans in general suffering from various other medical conditions as well as Americans suffering from panic disorder. The factors affecting the health related quality of life were measured using stepwise linear regression models. The findings in this study showed that the SF-36 score reduction value in these subjects with values from 0.3 to 1.4 SD were about seven times greater as compared to other Singaporeans suffering from thyroid cancer or lupus. As compared to Americans however, the values obtained were the same, i.e., 0.5 to 1.7 SD. Some of the external factors that were found to contributed to panic disorder in this study were the presence of chronic medical conditions, being married or increasing age. The study then concluded that Singaporeans with social anxiety disorders experienced a measurable decrease in the health related quality of life and the anxiety was affected by both clinical and socio-demographic factors. Leibowitz et al (1985) also arrived at a similar finding, where their study showed that patients with the social anxiety disorder generally underperformed educationally , they have a lower probability of marrying because of the social phobia they suffer from and when they do marry, they find it difficult to adjust with the spouse. Additionally, they also found that such patients suffered from a lower economic status and a higher probability of losing their jobs. Schneier (2003) has provided an assessment of the current extent of knowledge about social anxiety disorder, i.e, it is common, it is under diagnosed, it is impairing, but above all, it is treatable. Furthermore, Scheiner et al (1994) have also pointed out that individuals with social anxiety disorders are frequent users of the health care system, and their social phobias can be considerably worsened if they are also associated with other kinds of mental disorders. They point out that individuals who have social anxiety phobias may also try to adapt their life styles and working habits in such a manner that they can accommodate those symptoms. This may also be noted in the case of Mr. A, who has chosen the profession of computer programmer in order to avoid much social contact with others. Social phobia is not an easy condition to treat, although it is not overly difficult to describe or recognize it. Some individuals who suffer from social anxiety disorder may resort to the use of alcohol or drugs in order to reduce their fear and enable them to cope in social situations. In carrying out an initial assessment of a patient and arriving at a preliminary formulation, it may be necessary to explore both general and more specific aspects of the problem. In general, there are two approaches that have been applied in the treatment of social anxiety disorder, i.e., the pharmacological approach and the cognitive approach. Butler and Wells (in Heimburg, 1995:310) have argued that the most productive model on the basis of which a clinical application may be made in the case of social anxiety disorder is the cognitive model. The cognitive behavioural therapy approach has been found to be beneficial in treating this condition, especially in treating generalized social anxiety, because this clinical approach focuses on the patient’s thought processes and belief systems (Beck, 1995). As Butler and Wells state, cognitions play a central part in the definition of social phobia as well as in its secondary aspects. Some clinicians tend to apply well established, traditional psychological methods such as exposure, relaxation and anxiety management to deal with the symptoms of nervousness and stress, which in some instances can be very successful. However, applying the cognitive approach would be extremely useful, not only in cases where the patient is resistant to such treatments, but in actually improving outcomes through the application of such methods (Heimburg, 1995:311). In the treatment of social phobia, Butler (1985) recommends the use of exposure, by engaging the patient in thinking rationally about how to interact better with people, while using brief, unguarded opportunities that arise to seek that exposure until there is a gradual increase in such exposure to social situations and contacts with people. Some of the difficulties in using this approach which Butler has identified include (a) precisely specifying graduated and repeatable tasks (b) the problem of how to prolong exposure to the social situations (c) ensuring the engagement of the subject during exposure and (d) dealing with the cognitive aspects associated with phobia. Butler recommends the addition of anxiety management as a part of the program regime in exposure; in this study the anxiety management consisted of a combination of relaxation, distraction and brief, individualized cognitive procedures. The addition of the cognitive procedures appeared to be quite beneficial because outcomes improved five fold as compared to the use of only distraction or relaxation, which brought about only a two fold increase. In examining the various means for the treatment of severe social phobia, Mattick (1988) reported that the best predictor of a long term favourable prognosis in the case of social phobia was to change the cognitive component of social anxiety, i.e., help patients recognize that their automatic perception of negative evaluation and criticism from others might not necessarily be true. Some of the techniques used in this study to improve treatment outcomes for social anxiety included training by self instruction and application of the cognitive behavioural theory. Every patient’s cognitive perceptions are different and if the therapist is to achieve a successful outcome, it is important that s/he does not automatically classify the patient’s thoughts and fears as irrational. If the therapist approaches the problem with the idea of merely replacing the patient’s existing set of cognitive beliefs with another, this may not achieve a long term change. Rather the effort of the therapist should be to listen to the patient’s internal dialogue and clarify it without giving the impression that is a right and a wrong set of cognitive beliefs (Bower, 2003). The attempt made in applying a cognitive approach is to “modify both the dysfunctional thoughts and beliefs that underlie distress”.(Heimberg, 1995:319). The cognitive approach attempts to treat the root cause of the problem of social anxiety, i.e., the fear of being judged negatively, because individuals suffering from social anxiety tend to evaluate their own behaviour negatively. Heimburg (1995:323) sets out a table recording the automatic negative assumptions that an individual might make in setting out to deal with a social situation that arises, and the intensity of these negative perceptions contribute to the levels of anxiety experienced. Patients can thus be helped by encouraging them to prepare self-reporting tables where they list their own negative perceptions of their behaviour and then list alternative reasons for such behaviour which may be quite acceptable socially. For example, if an individual cries in public and fears that others will perceive him or her as weak, the alternative explanation could be that crying is quite natural at airports. By consistently providing the patient with such alternative cognitive scenarios which develop naturally out of the patient’s own explication and articulation of inner fears and thoughts, there is a slow progression in the way a patient thinks, which could become more positive as treatment improves along and achieve sustained positive outcomes which would endure into the long term. The pharmacological approach applied different kinds of drugs to treat the general symptoms of the disorder, i.e, the anxiety, tension and nervousness associated with the condition. Guest et al (2005) carried out a study to examine the cost effectiveness of two drugs used in the treatment of generalized anxiety disorder in the UK – Venlafaxine XL and diazepam. They have cited other studies which have been carried out that support the efficacy of pharmacological treatments such as venlafaxine and benzodiazepenes such as diazepam. These studies show that individuals suffering from generalized anxiety disorder tend to respond quickly to diazepam, usually within a one week period of administration of the drug. In the UK however, benzodiazepenes such as diazepam can be taken continuously for a maximum period of four weeks. The use of diazepam has been associated with side effects such as sedation, impairment of psychomotor functions and in some cases, with hyper-excitement. Venlafaxien XL, marketed as Efexor XL has been authorized for use in the UK, at a dose of 75mg per day, to treat a range of disorders where depression is one of the symptoms, including depression associated with anxiety. In order to build further on the work of earlier researchers as detailed above in the use of these two pharmacological interventions for anxiety and depression, Guest et al (2005) carried out a multinational, double blind, placebo controlled study. The criteria for inclusion of participants in the study were as follows: (a) over 18 years of age (b) met the criteria in the DSM-IV for patients suffering from generalized anxiety and depression (c) had an HAM-A (Hamilton Rating Scale for Anxiety) score of 20, with scores of 2 or more for the variables anxious mood and tension. If the patients had a major depressive disorder, they were excluded from the study. The patients were selected on a randomised basis to receive either 75 mg venlafaxine XL one time daily or 5 mg dose of diazepam three times daily. A third group received a placebo for eight weeks. After a four week period, on the basis of a CGS (Clinical Global Score) all the patients who responded to the Venlafaxine were treated on the same basis for four weeks more while those who responded favourably to Diazepam were treated with a placebo for the further four week period. Patients who did not respond to treatment were not given any further medication, but those who responded were treated for a total period of six months. The findings in this study showed that starting treatment for patients suffering from generalized anxiety disorder with Venlafaxine increased the probability of being in remission within 6 months by 83% from 16.8% to 30.7%. Simultaneously, the expected probability of a relapse at six months was decreased by 79% from 16.9% to 3.5%. The costs for using each of the two drugs was also examined and worked out to estimates of £353 for Venlafaxine as compared to £311 for diazepam. The authors thereby concluded that commencing treatment for patients with venlafaxine XL is clinically, a more cost effective option. Conclusions: On the basis of the above, it may thus be seen that each of the treatment options offers some benefits. Treatment means such as relaxation or distractions may be effective in some cases where the patient suffers only slightly, but for patients more severely afflicted, the degree of efficacy may be limited. Using pharmacological drugs may also be useful in treating the depression and anxiety associated with social anxiety disorder. Some drugs are more effective from a cost based point of view; for instance Venlafaxine may be more effective to bring about a positive prognosis in treating depression and is also cost effective compared to diapezam. The advantage associated with diapezam however, is the speed with which it produces relief for the symptoms and it could be useful in treating patients who are severe victims of depression and providing them some initial relief of symptoms before moving on to other treatment methods. The most effective treatment method in dealing with social anxiety however, appears to be the application of a cognitive approach, because it tackles the root cause of the disease, i.e, the negative perceptions about oneself which a patient of social anxiety disorder feels. Applying the treatment method of exposure is based upon the belief that through graduated exposure to the situations that make the individual tense, there is a level of immunity that builds up so that the patient becomes more and more hardened as time passes and becomes less sensitive and self critical. The problems associated with this treatment method however, are that it is difficult to devise the kind of situations where the patient’s levels of exposure can be gradually built up. Exposure may however, be useful when combined with other programs such as anxiety management, including relaxation and small cognitive exercises to provide a different kind of conditioning that is positive rather than negative. The cognitive theory approach focuses on tackling the root cause of the problem, i./e., the negative and self critical assumptions that function as a stumbling block in improved social interactions. This is a more time consuming process, but may involve extensive therapy, wherein the patient’s patterns of internal thought is determined and then systematically and slowly changed through a series of mental exercises. This appears to be the approach that would suit Mr. A the most, because the attendant dangers of alcoholism which have been revealed through his self assessment reports might also be addressed in this manner. Mr. A has also taken the first most important step; he has submitted himself for treatment, thereby suggesting that he has taken the internal decision to step out of the world of social isolation that he had been inhabiting for so long. The development of his social phobia also appears to have been heavily conditioned by the lives of his own parents and his natural shyness. Treating Mr. A might also require some administration of drugs such as diazepam in the first instance, in order to provide Mr. A with an initial positive reaction to treatment. When Mr. A sees himself benefitting from treatment of his depression, he is more likely to believe that treatment would be successful and this would be extremely helpful when the cognitive approach is applied. His internal negative thought patterns would need to be articulated and identified through therapy and alternative scenarios would need to be put forward to replace the negative, self defeating mental schema which already exist in Mr. A’s mind. By suggesting to Mr. A that the reasons for his social anxiety may lie in the environmental conditions of his growing years and the nature of his job, and therefore to encourage him to think about alternative schema which could serve to explain his behaviour in a more positive light. Defeating the self critical root of Mr A’s frame of reference would be critical in ensuring a long term, sustainable positive outcome. It could also serve to address Mr. A’s developing alcoholism, because he would no longer need to use it as a means to overcome the social anxiety, he would be able to learn to do this by developing alternative mental schema which are more positive. References: * Beck, J.S., 1995. “Cognitive therapy: basics and beyond”, Guildford Press. * Bower, P. (2003). Efficacy in evidence-based practice. Clinical Psychology & Psychotherapy, 10, 328 – 336. * Butler, Gillian, 2002. “Exposure as a treatment for social phobia: Some instructive difficulties”, Behaviour Research and Therapy, 23(6): 651-657 * Guest, J.F., Russ, J and Lenox-Smith, A, 2005. “Cost effectiveness of Venlafaxine XL compared with diazepam in the treatment of generalised anxiety disorder in the United Kingdom”, The European Journal of Health Economics, 6(2): 136-145 * Heimburg, Richard G, 1995. “Social phobia: diagnosis, assessment and treatment”, Guildford Press. * Leary, M. R. (1983). A brief version of the Fear of Negative Evaluation Scale. Personality and Social Psychology Bulletin, 9, 371-376. * Leibowitz, M.R., Gorman, J.M., Fryer, A.J., and Klein, D.F., 1985. “Social phobia: Review of a neglected anxiety disorder”, Archive of General Psychiatry, 42: 729-36 * Mattick, R.P., 1988. “Treatment of severe social phobia: effects of guided exposure with and without cognitive restructuring”, Journal of Consulting and Clinical Psychology, 56(2):251-60 * Scheiner, F, 2003. “Social anxiety disorder”, British Medical Journal, 327(7414): 515-6 * Scheiner, F.R., Hockleman, L.R., Garfinkel, R, Ca,p[eas, R, Fallon, B.A., Gitow, A, et al, 1994. “Functional impairment in social phobia”, Journal of Clinical Psychiatry, 55:32-31 * Silveira, E, Taft, C, Sundh, V, Waern, S, Palsson, S and Steen B, 2005. “Performance of the SF-36 Health Survey in screening for depressive and anxiety disorders in an elderly female Swedish population”, Quality of Life research, 14(5): 1263-1274 * “Social Anxiety Disorder”, Retrieved May 20, 2010 from: http://www.webmd.com/anxiety-panic/guide/mental-health-social-anxiety-disorder Read More