Management of Social Phobia with Psycho-education - Research Paper Example

 Management of Social Phobia with Psycho-education and Cognitive Behavioral Therapy Referral Information Client X is a 15 year old Year 10 student. Student X was referred for counseling by her English teacher due to concerns regarding her anxious behavior. Total sessions with client: 24 individual sessions and three with her family Client Presentation The client presented as a 15 year old girl in her school uniform. She sat at the edge of the chair, rubbing her hands together, and avoiding eye contact. She gave one-word answers during the sessions. As the sessions progressed, she slowly started moving back in the chair appearing more comfortable in answering and adding details to the questions. Her speech was also intelligent and relatively clear. She was oriented in time, place, and date. She became more cooperative towards the end of the initial interview. She appeared nervous and embarrassed in talking about her anxiety and in giving details about her physical symptoms. The client did not present with any evidence of thought disorders, delusions, or hallucinations. Problem Situation The client expressed during the initial interview that she had an intense fear of giving oral presentations in front of strangers and even just the thought of giving such presentations caused her much anxiety and fear. She expressed that she has always had this fear and she has always struggled in giving oral presentations, in participating in group discussions, and in having general conversations with other people. Her English teacher first noted her difficulties for the last two years and encouraged her over the years to get over her fears; however, these fears remained. She pointed out that just thinking about speaking out in class mad her heart beat faster, made her feel shaky, made her blush, and caused her to experience shortness of breath and muscle tension. She fears being criticized and being judged by other people and so she avoids attracting other people’s attention. This phobia of hers has impacted significantly on her school performance, on her relationship with her family members, and on her decisions for her future. Her phobia prompted her not to study the Turkish subject, which also upset her parents. Her academic performance has relatively been good, except for her English subject because she lost points for her oral presentation and for her low classroom participation. Since she could not be picked up by her parents from her after-school activities, her avoidant behavior and social phobia has been reinforced. She only has two close friends in school, mostly friends he grew up with and who were also Turkish. She does not have any other close friends and during recess or lunch hours, she either stays with other girls in her class without conversing with them or she goes to the library to pass the time. Relevant client history Development and Family History The client’s mother expressed that the client is a good girl who hardly caused any problems. She is a good student and is well supported by her family. She has always been shy and the family did not think that to be a problem; they thought it was just part of their culture manifesting. She helped her parents whenever she could and she even helped her mother take care of her younger siblings. She rarely attended family gatherings due to the significant amount of homework she had to work on. Culturally, her parents thought that her behavior was acceptable. Interpersonal relationships Client has only two best friends and hardly interacts with her classmates in class. She interacts well with her parents and siblings but does not participate in other activities with other family members. Psychiatric history In the past, the client has exhibited shyness and anxiety in speaking in front of the public, but these qualities have not reached therapeutic levels for a clinical diagnosis of social phobia. Otherwise, no other psychological illnesses were seen manifested in the past with this client. Discussion of Evidence-based theories Social phobias are considered the persistent fear of social or performance scenarios, which is in general, associated with the presence of other people (Fritscher, 2009). In these instances, the individual with the social phobia would try to avoid situations which may be humiliating or embarrassing. These instances can be related to performing in public, making oral presentations, eating in public, and even using public rest rooms (Fritscher, 2009). Based on the degree of phobia, social phobia can either be general or specific. There are several theories which help explain the presence of social phobias. The psychoanalytic theories express that phobias are considered a means of defending against anxiety which is produced by repressed impulses (Kearney, 2005). Such anxiety is associated to an object or to a situation which then culminates as phobia. And in order to adequately cope with the repressed sense of conflict, the person avoids the situation causing him anxiety. Behavioral theories also explain that phobias are usually learned (Kearney, 2005). Cognitive theories assume that anxiety is associated with the dominant thought that negative stimuli and negative events are likely to occur in the future (Kearney, 2005). Various interventions may arise with phobias and the cognitive-behavioral remedies can assist in the management of these social phobias. In this treatment modality, exposure to the feared situation/object and coping with the frightening thoughts associated with such anxiety are considered (Bond and Dryden, 2005). In confronting the feared object, a graded exposure can be applied. A write-up of the hierarchy of feared situations or objects is therefore crucial to the treatment process. After establishing a personal hierarchy, the client must confront the least frightening object and attempt at managing and regulating such anxiety (Bond and Dryden, 2005). It is crucial to stay in this situation until the anxiety passes, even if the situation may take a while, the client has to wait until the anxiety would disappear. Afterwards, the next item in the list can be managed next. In the process of confrontation, relaxation techniques can be applied. In dealing with frightening thoughts, the client would write down frightening thoughts which relate to the phobia and then establish some good arguments against these phobias (Bond and Dryden, 2005). It is important to instruct the client at all times, that nothing would happen to him as he is experiencing these phobias; and while recalling these unpleasant thoughts, nothing unpleasant occurred. Formal Diagnosis A specific and detailed client history, including a mental status examination was carried out in order to establish the patient’s social phobia. Axis I 300.23 Social Phobia (Social anxiety disorder), Generalized Axis II V71.09 No diagnosis Axis III None Axis IV Problems related to the social environment Axis V GAF=65 (current) GAF: 85 (at discharge) Psychometric Assessment The DASS-42 was administered in the initial interview and anxiety was in the severe range with a score of 20; his social anxiety scale was at 75 which is very much above average, his depression is within the normal range of 8, and she scored moderate for stress at 22 (Clark and Beck, 2011). The Multidimensional Anxiety Scale for Children (MASC), which is a child self-report, in the social anxiety total, the score registered at 75 which is very much above average; and in the anxiety disorder index, the client’s total score was at 69 which is also very much above average (van Gastel and Ferdinand, 2008). Rationale for diagnosis Axis I 300.23 Social Phobia (Social anxiety disorder), Generalized The client established a distorted pattern of social adaptation which led to impairment in her social and academic activities. In effect, she has met all the criteria for Social Phobia or social anxiety disorder. The DSM-IV-TR establishes that clients must meet the criteria for social anxiety disorder or social phobia. Social Phobia The client was able to meet the criteria for social phobia. First, the patient has a marked and persistent fear of social situations because of fears of acting in an embarrassing manner (criteria 1). Secondly, there is an anxiety response which causes an anxiety reaction (criteria 2). Third, there is avoidance or distress where the sufferer goes out of his way to avoid the situation and can only be endured with a significant amount of distress (criteria 3). Fourth, the phobia is life-limiting significantly impacting on the patient’s personal and academic life (criteria 4). Fifth, the phobia has also lasted atleast six months as the patient has been suffering such social phobia for a long period of time (criteria 5). Sixth, the phobia is also not caused by any other disorder (criteria 6). Finally, the phobia is not related to any other physical disorder (criteria 7) (American Psychiatric Association, 2000). Axis V – Global Assessment of Functioning (GAF) Commencement GAF: 65: Some mild symptoms Some difficulties in social occupational and school functioning Generally functioning pretty well Has some meaningful interpersonal relationships. On discharge GAF: 85 (absent or minimal symptoms) Mild anxiety before speaking in class Good functioning in most areas Involved and interested in a wide range of activities Socially effective Generally satisfied with life No more than everyday problems or concerns Differential Diagnosis The client’s symptoms as described indicate that she has social phobia and does not have panic disorder. There is predictability to the patient’s social phobia, and this distinguishes it from panic attacks which are often unpredictable (Miranda, 2006). The feelings of the patient are also well defined. In panic disorders, the patient feels faint or that he might go crazy or might die from a heart attack; this is not seen in this case of social phobia. There are also differences in the evolution of the panic attacks, with the feelings going on for a long time; on the other hand, in social phobia, the person usually recovers quickly once he is out of the situation (Miranda, 2006). Treatment Objectives The Treatment Goals: 1. Psycho-education on the nature of the client’s anxiety and phobic avoidance for the client and her family. 2. To reduce her persistent fear of class participation, oral presentation, and social gathering by utilizing graded exposure therapy. 3. To reduce her anxiety related to social interactions and situations by using behavioral reinforcement and cognitive restructuring through modification of helpful beliefs. i.e. being judged. 4. To reduce somatic symptoms by using relaxation training and breathing control. 5. To develop resilience in facing social situations and participating in various activities through Social Skills Training. Treatment Plan 1. Psycho-education on the nature of the client’s anxiety and phobic avoidance for the client and her family. Teaching the patient about social phobia, its symptoms and its possible treatment Teaching the patient’s family about ways to change such phobia avoidance Prevention of relapse through adaptation techniques. 2. To reduce her persistent fear of class participation, oral presentation, and social gathering by utilizing graded exposure therapy. Asking the patient to list her fears in relation to her social phobia Asking her to confront each listed fear Slowly letting her join in social gatherings 3. To reduce her anxiety related to social interactions and situations by using behavioral reinforcement and cognitive restructuring through modification of helpful beliefs. i.e. being judged. Acclimatizing her to the social environment by encouraging her to think through her fears, and redirecting the usual thoughts which often lead to panic attacks. Restructuring her thought processes in terms of the application of more productive beliefs 4. To reduce somatic symptoms by using relaxation training and breathing control. The patient can practice breathing slowly and in a controlled manner to facilitate relaxation 5. To develop resilience in facing social situations and participating in various activities through Social Skills Training. Teaching new means of interacting with other people. Application of Appropriate Interventions 1. Psycho-education on the nature of the client’s anxiety and phobic avoidance for the client and her family. Psycho-education can be carried out with the client and her family, instructing and teaching them what the patient’s illness is, the causes of such illness, and the possible interventions which can be applied. Patient education is one of the more important tools which can be applied by the health providers in managing the patient’s condition (Day and Northcentral University, 2009). By educating clients and their families, a clearer understanding of the patient’s condition can be established and the patient’s anxiety can be eased. 2. To reduce her persistent fear of class participation, oral presentation, and social gathering by utilizing graded exposure therapy. First, the client can list her fears in relation to her social phobia, the list must be ranked from the greatest to the lowest fear. Secondly, the patient will be asked to confront each fear by exposing her to such fear. Lastly, each fear listed can be confronted until the last and most significant fear can be finally confronted. Graded exposure therapy is an effective means of managing a person’s social phobia. It is gradual and is usually not too overwhelming for the patient to face (Bond and Dryden, 2005). In effect, various patients facing this disease are likely to recover from their phobia, learning to cope with each symptom and related fear. 3. To reduce her anxiety related to social interactions and situations by using behavioral reinforcement and cognitive restructuring through modification of helpful beliefs. i.e. being judged. This intervention can be implemented by redirecting the patient’s thought processes, leading them away from patterns which lead to fears and anxieties (Flora, 2004). There are various literatures which support this therapy, mostly those which relate to gradual and relearning processes. These studies emphasize the importance of changing the client’s thought processes, modifying these in order to establish more logical conclusions and thoughts (Foa, et.al., 2005). 4. To reduce somatic symptoms by using relaxation training and breathing control. Teaching the patient relaxation techniques, including controlled breathing exercises can lead to the efficient management of social phobias and anxiety attacks. In many cases, studies support the use of relaxation techniques which help a patient in managing anxiety and nervousness (Cuncic, 2005). These breathing techniques can effectively fend off an impending social phobia or anxiety attack. 5. To develop resilience in facing social situations and participating in various activities through Social Skills Training. The patient can also be entered in seminars or trainings on social skills. These trainings can retrain and teach students on how to converse and interact with other individuals (Dalrymple, 2007). These trainings are valuable tools in managing patient’s social phobia because it teaches patients how to manage social scenarios calmly. Summary of Outcomes and Evaluation of Treatment The interventions applied above were able to help the client fulfill each treatment objective. The psycho-education was able to teach the clients and her family about her disorder and it taught them that there are possible interventions to this disorder. The CBT interventions empowered the patient to take control of her fears and to manage each aspect of her fear. At the end of the treatment, the client manifested a better frame of mind, in terms of her views on social interactions. Through a supportive family environment, the patient was able to confront her fears and deal with the social phobia. More CBT is needed however to keep her results consistent and to help her further manage her symptoms. Limitations and Future Modifications The CBT sessions with the client revealed the importance of getting to know one’s client and establishing rapport with them. The CBT approach cannot work effectively if the client and the therapist have not established a trusting relationship with each other. For a patient with a social phobia, who may be wary of strangers, it is important to ease into the communication process. This would help develop trust and confidence in the therapist, thereby ensuring improved patient outcomes. Ever since the client was treated, the psychologist has been introduced to data regarding the use of guided imagery in assisting the patient achieve a relaxed state. This may be a useful addition to prevent medical issues which relate to social phobia. Reference American Psychological Association (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. New York: APA Pub Bond, F. & Dryden, W. (2005). Handbook of brief cognitive behaviour therapy. London: John Wiley & Sons. Cerejo, J. and Northcentral University. (2009). Impact of caregiver psychoeducation as an adjunct treatment for children with psychiatric disorders. London: ProQuest. Clark, D. & Beck, A. (2011). Cognitive Therapy of Anxiety Disorders: Science and Practice. London: Guilford Press. Cuncic, A. (2009). Diagnosing Social Anxiety Disorder. About.com. Retrieved 03 November 2011 from http://socialanxietydisorder.about.com/od/diagnosisofsad/a/diagnosis.htm Dalrymple, K. & Herbert, J. (2007). Acceptance and Commitment Therapy for Generalized Social Anxiety Disorder: A Pilot Study. Behav Modif, 31; 543 Flora, S. (2004). The power of reinforcement. New York: SUNY Press. Foa, E., Hembree, E., Cahill, S., Rauch, S., Riggs, D., & Feenee, N. (2005). Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: Outcome at academic and community clinic. Journal of Consulting and Clinical Psychology, 73(5), 953-964. Fritscher, L. (2009). Diagnosing a Social Phobia: Diagnostic Criteria for a Social Phobia. About.com. Retrieved 03 November 2011 from http://phobias.about.com/od/symptomsanddiagnosis/a/socphobiadiag.htm Kearney, C. (2005). Social anxiety and social phobia in youth: characteristics, assessment, and psychological treatment. London: Springer. Miranda, R. (2006). Social Anxiety Disorder (Social Phobia): Differential Diagnosis. Social anxiety, anxiety, and shyness. Retrieved 03 November 2011 from http://www.social-anxiety-shyness-info.com/art/sad/a-10-SAD-diffdiag.htm Van Gastel, W. & Ferdinand, R. (2008). Screening capacity of the Multidimensional Anxiety Scale for Children (MASC) for DSM-IV anxiety disorders. Depress Anxiety, 25(12):1046-52. Read More