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Case formulation on agoraphobia and social phobia

Tsitsas and Antonia A. AP and GT designed the protocol, administer the CBT therapy sessions, analyzed and interpreted the data, and wrote the paper. Abstract George, a 23-year-old Greek student, was referred by a psychiatrist for treatment to a University Counseling Centre in Athens. He was diagnosed with social anxiety disorder and specific phobia situational type.

He was complaining of panic attacks and severe symptoms of anxiety. These symptoms were triggered when in certain social situations and also when travelling by plane, driving a car and visiting tall buildings or high places.

His symptoms lead him to avoid finding himself in such situations, to the point that it had affected his daily life. George was diagnosed with social anxiety disorder and with specific phobia, situational type in this case acrophobia and was given 20 individual sessions of cognitivebehavior therapy.

A Cognitive-Behavior Therapy Applied to a Social Anxiety Disorder and a Specific Phobia, Case Study

Following therapy, and follow-up occurring one month post treatment, George no longer met the criteria for social phobia and symptoms leading to acrophobia were reduced. He demonstrated improvements in many areas including driving a car in and out of Athens and visiting tall buildings.

  • George was diagnosed with social anxiety disorder and with specific phobia, situational type in this case acrophobia and was given 20 individual sessions of cognitivebehavior therapy;
  • George met the criteria for a Social anxiety disorder;
  • George was asked to monitor his thoughts, feelings, and behaviors and record any changes.

Social phobia can be described as an anxiety disorder characterized by strong, persisting fear and avoidance of social situations. As a result these situations are characteristically avoided or endured with dread.

Contemplating entry to the phobic situation usually generates anticipatory anxiety. Phobic anxiety and depression often coexist. Whether two diagnoses, phobic anxiety and depressive episode, are needed, or only one, is determined by the time course of the two conditions and by therapeutic considerations at the time of consultation.

The main cognitive factor is the fear of negative evaluation. This subtype has a bimodal age-at-onset distribution with one peak in childhood and another peak in mid-20s.

The phobic situation usually is avoided or else is endured with intense anxiety or distress. Heights often evoke fear in the general population too, and this suggests that acrophobia might actually represent the hypersensitive manifestation of an everyday, rational fear. Anxiety disorders have been shown to be effectively treated using cognitive behavior therapy CBT and therefore to better understand and effectively treat phobias.

The CBT model used in the present case, was based on Clark and Wells 24 model that places emphasis on self-focused attention as social anxiety is associated with reduced processing of external social cues.

The model pays particular attention to the factors that prevent people, who suffer from social phobias, from changing their negative beliefs about the danger inherent in certain social situations.

The following case it is a good representation of this model. Case Report George, was a 23-year-old single, Caucasian male student in his last academic year and was referred to a University Counseling Centre in Athens. The Centre provides free of charge, treatment sessions to all University students requiring psychological support.

He was living alone in Athens, as his parents live in a different region of Greece. He was an only child. When asked about his childhood, he said that he had been happy and did not report any traumatic events. He described a close relationship with both his parents and when asked, he did not report any family history of psychiatric or psychological disorders or substance abuse problems.

He complained of severe symptoms of anxiety and phobias during the last six months. He began case formulation on agoraphobia and social phobia severe heart palpitations, flushing, fear of fainting and losing control, when travelling by plane, when crossing tall bridges while driving or when being in tall buildings or high places, however he did not experience symptoms of vertigo.

  1. The psychiatrist suggested to George, to better help him with his current symptoms to take selective serotonin reuptake inhibitors SSRIs. He was an only child.
  2. George met the criteria for a Social anxiety disorder. His symptoms lead him to avoid finding himself in such situations, to the point that it had affected his daily life.
  3. At the time of the intake, George was in his final exams which he wanted to finish successfully, and continue his studies abroad. He also had to complete a self-monitoring scale through-out the 20 weeks of treatment.
  4. Social Phobia and Agoraphobia. He was diagnosed with social anxiety disorder and specific phobia situational type.

Additionally, he reported significant chest pain and muscle tension in feared situations. His fear of experiencing these symptoms worsened and led him to avoid these situations which made his everyday life difficult. He also experienced similar symptoms when introduced to people or meeting people for the first time.

He repeatedly went to see various doctors many times in order to exclude any medical conditions. At the time of the intake, George was in his final exams which he wanted to finish successfully, and continue his studies abroad. Due to his condition, he decided not to apply for a postgraduate degree in the United Kingdom, which he always wanted, and started looking for alternative postgraduate courses in Greece.

Assessment and treatment George was referred by a private psychiatrist. George met the criteria for a Social anxiety disorder. He also met the criteria for specific phobia limited-symptom, which was secondary to his social phobia. The psychiatrist suggested to George, to better help him with his current symptoms to take selective serotonin reuptake inhibitors SSRIs.

George however refused to take any medication and the psychiatrist referred him to the Counseling Centre.

For the specific case we decided to give individual cognitive behavior therapy based on Clark and Wells model for Social Anxiety Disorder, 24 as referred into the NICE guidelines. He also had to complete a self-monitoring scale through-out the 20 weeks of treatment. Monitoring progress measures State-Trait Anxiety Inventory The state-trait anxiety inventory STAI27 the appropriate instrument for measuring anxiety in adults, differentiates between state anxiety, which represents the temporary condition and trait anxiety, which is the general condition.

The STAI includes forty questions, with a range of four possible responses. In each of the two subscales scores range from 20 to 80, high scores indicating a high anxiety level. Higher scores correspond to greater anxiety. It includes two subscales: Social Phobia and Agoraphobia. A difference score above 60 indicates a potential phobia, and a cut off score of 80 maximizes this identification rate. Cognitive-behavior techniques such as self-monitoring, cognitive restructuring, relaxation, breathing retraining, and assertiveness training were employed to reduce anxiety and fear.

Kazdin 30 states that self-monitoring can lead to dramatic changes, while Korotitsch and Nelson-Gray 29 add that although the therapeutic effects of self-monitoring may be small, they are rather immediate. George was asked to monitor his thoughts, feelings, and behaviors and record any changes.