case study on anxiety disorder slideshare

Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

Powerful PowerPoint Presentation on Anxiety Disorders: A Comprehensive Guide

Sweaty palms grip the podium as hearts race and minds whirl—welcome to the world of anxiety disorders, where PowerPoint becomes a powerful tool for unraveling the complexities of the anxious mind. Anxiety disorders affect millions of people worldwide, impacting their daily lives, relationships, and overall well-being. As we delve into this topic, we’ll explore how PowerPoint presentations can be used effectively to educate, raise awareness, and ultimately help those struggling with anxiety disorders.

Understanding Anxiety Disorders: A Brief Overview

Anxiety disorders are a group of mental health conditions characterized by persistent, excessive worry and fear. These disorders can manifest in various forms, each with its unique set of symptoms and challenges. Understanding Anxiety Disorders: A Comprehensive Guide to Anxiety Disorders on Wikipedia provides an in-depth look at the various types and their definitions.

The impact of anxiety disorders on individuals and society is profound. Those affected may experience difficulties in their personal relationships, work performance, and overall quality of life. Anxiety can lead to physical symptoms such as increased heart rate, sweating, and trembling, as well as emotional distress and avoidance behaviors. On a societal level, anxiety disorders contribute to increased healthcare costs, reduced productivity, and a significant burden on mental health services.

PowerPoint presentations have emerged as a valuable tool in educating and raising awareness about anxiety disorders. These visual aids can help break down complex information into digestible chunks, making it easier for audiences to understand and retain important facts about anxiety disorders . By combining text, images, and multimedia elements, PowerPoint presentations can create a compelling narrative that engages viewers and promotes deeper understanding of this critical mental health issue.

Creating an Engaging PowerPoint Presentation

To effectively communicate information about anxiety disorders, it’s crucial to create a visually appealing and engaging PowerPoint presentation. Here are some key considerations:

1. Choosing the Right Design and Layout: – Select a clean, professional template that doesn’t distract from the content. – Use a consistent color scheme that reflects the tone of the presentation (e.g., calming blues or greens for a soothing effect). – Ensure text is easily readable by using appropriate font sizes and contrasting colors.

2. Utilizing Engaging Visuals and Graphics: – Incorporate relevant images, diagrams, and infographics to illustrate key points. – Use Anxiety Disorders Pictures: Understanding and Identifying Different Types to visually represent various anxiety disorders and their symptoms. – Create simple animations to reveal information gradually, helping to maintain audience attention.

3. Incorporating Relevant Statistics and Research Data: – Include up-to-date statistics on the prevalence of anxiety disorders. – Present research findings using clear, easy-to-understand charts and graphs. – Cite reputable sources for all data to enhance credibility.

Structuring Your Presentation for Maximum Impact

A well-structured presentation ensures that your audience can follow the flow of information and retain key points. Here’s a suggested structure for a comprehensive PowerPoint presentation on anxiety disorders :

1. Introduction and Definition: – Begin with a brief overview of what anxiety disorders are and their significance in mental health. – Provide a clear, concise definition of anxiety disorders.

2. Exploring Different Types of Anxiety Disorders: – Discuss common types such as Generalized Anxiety Disorder (GAD), Social Anxiety Disorder, Panic Disorder, and Specific Phobias. – Include lesser-known types like Agoraphobia and Separation Anxiety Disorder. – Use separate slides for each disorder to avoid overwhelming the audience.

3. Highlighting Symptoms and Diagnostic Criteria: – Present the common symptoms across anxiety disorders. – Explain the specific diagnostic criteria for each type of anxiety disorder. – Include information on how healthcare professionals diagnose these conditions.

4. Discussing the Effects of Anxiety Disorders on Daily Life: – Explore the impact on personal relationships, work performance, and overall quality of life. – Include The Effects of Anxiety Disorders on the Body to highlight physical manifestations of anxiety. – Discuss the potential long-term consequences of untreated anxiety disorders.

5. Addressing Treatment Options and Support Resources: – Present evidence-based treatments such as Cognitive Behavioral Therapy (CBT) and medication options. – Discuss the importance of a comprehensive treatment plan tailored to individual needs. – Provide information on support groups and online resources for those affected by anxiety disorders.

Delivering an Effective Presentation

Creating a great PowerPoint is only half the battle; delivering it effectively is equally important. Here are some tips to ensure your presentation on anxiety disorders resonates with your audience:

1. Mastering Public Speaking Skills: – Practice your presentation multiple times to build confidence and familiarity with the material. – Use a clear, steady voice and maintain good posture to project confidence. – Make eye contact with audience members to establish a connection.

2. Engaging the Audience through Storytelling and Personal Experiences: – Incorporate real-life examples or case studies to illustrate the impact of anxiety disorders. – Consider sharing personal experiences if appropriate, as this can help destigmatize anxiety disorders. – Use Quotes about Anxiety Disorders: Finding Inspiration and Understanding to add a human touch to your presentation.

3. Using Audio and Video Elements to Enhance Engagement: – Include short video clips demonstrating anxiety symptoms or treatment techniques. – Use audio recordings of individuals describing their experiences with anxiety disorders. – Incorporate Understanding Anxiety Disorders: A Comprehensive Video Guide to provide a multimedia perspective on the topic.

Providing Additional Resources and References

To ensure your presentation has lasting impact, it’s crucial to provide your audience with additional resources and references for further exploration:

1. Sharing Links to Online Resources for Further Information: – Include slides with QR codes or shortened URLs for easy access to online resources. – Recommend reputable websites, such as national mental health organizations or university research centers. – Highlight resources like the UCLA Anxiety Disorders Program: A Comprehensive Guide for those seeking specialized treatment options.

2. Citing Credible Sources and Studies: – Include a bibliography slide with all the sources used in your presentation. – Mention key studies or research papers that support the information presented. – Provide information on how to access full research papers or reports for those interested in deeper exploration.

Addressing Anxiety Disorders in Specific Contexts

To make your presentation more relatable and comprehensive, consider including information on how anxiety disorders manifest in different settings:

1. Anxiety Disorders in the Workplace: – Discuss the prevalence of anxiety disorders in professional settings. – Explore the challenges faced by employees with anxiety disorders. – Provide strategies for managing Anxiety Disorder at Work: Understanding and Managing Work-Related Anxiety. – Include information on workplace accommodations and legal rights for individuals with anxiety disorders.

2. Anxiety Disorders in Educational Settings: – Address the impact of anxiety on academic performance and social interactions. – Discuss the role of educators in identifying and supporting students with anxiety disorders. – Provide information on accommodations available for students with anxiety disorders in schools and universities.

3. Anxiety Disorders and Relationships: – Explore how anxiety disorders can affect personal relationships, including friendships, romantic partnerships, and family dynamics. – Discuss strategies for supporting loved ones with anxiety disorders. – Provide resources for couples therapy or family counseling specializing in anxiety disorders.

The Role of Specialized Treatment Centers

Highlight the importance of specialized treatment centers in managing anxiety disorders:

1. Introduce the concept of anxiety and stress disorder institutes: – Explain the benefits of seeking treatment at specialized centers. – Discuss the comprehensive approach offered by institutions like the Anxiety and Stress Disorders Institute: Understanding and Overcoming Anxiety and Stress .

2. Outline the services typically offered by these specialized centers: – Individual and group therapy sessions – Medication management – Intensive outpatient programs – Research opportunities and clinical trials

3. Discuss the advantages of multidisciplinary teams: – Explain how different specialists work together to provide comprehensive care. – Highlight the importance of tailored treatment plans for individual needs.

Finding the Right Healthcare Provider

Provide guidance on how to find appropriate healthcare providers for anxiety disorders:

1. Types of mental health professionals: – Psychiatrists – Psychologists – Licensed Clinical Social Workers (LCSWs) – Licensed Professional Counselors (LPCs)

2. Factors to consider when choosing a provider: – Specialization in anxiety disorders – Treatment approaches offered (e.g., CBT, exposure therapy) – Insurance coverage and accessibility

3. Resources for finding qualified providers: – Mental health association directories – Insurance provider networks – Referrals from primary care physicians

4. Importance of finding the right fit: – Encourage seeking Health Providers Who Treat Anxiety Disorders: A Guide to Finding the Right Doctor to ensure effective treatment.

The Future of Anxiety Disorder Treatment and Research

Conclude your presentation by discussing emerging trends and future directions in anxiety disorder treatment and research:

1. Technological advancements: – Virtual reality exposure therapy – Mobile apps for anxiety management and tracking – Teletherapy and online support groups

2. Promising research areas: – Neuroimaging studies to better understand the brain mechanisms of anxiety – Genetic research to identify potential risk factors – Development of new medications with fewer side effects

3. Integrative approaches: – Combining traditional therapies with complementary treatments like mindfulness and yoga – Exploring the role of nutrition and exercise in anxiety management

4. Increased focus on prevention: – Early intervention programs for at-risk individuals – Public education initiatives to reduce stigma and promote mental health awareness

By covering these additional aspects, your PowerPoint presentation will provide a comprehensive overview of anxiety disorders, their impact, and the various approaches to treatment and management. This in-depth exploration will help your audience gain a deeper understanding of anxiety disorders and empower them to seek help or support others who may be struggling.

In conclusion, PowerPoint presentations serve as a powerful medium for spreading awareness about anxiety disorders. By combining visual elements, data, and personal stories, these presentations can effectively educate audiences and inspire action. As we continue to improve our understanding of anxiety disorders, it’s crucial to keep the conversation going and provide support to those affected. Through education and awareness, we can work towards destigmatizing anxiety disorders and ensuring that individuals have access to the help and resources they need to lead fulfilling lives.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. National Institute of Mental Health. (2022). Anxiety Disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders

3. Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in Clinical Neuroscience, 19(2), 93-107.

4. Craske, M. G., & Stein, M. B. (2016). Anxiety. The Lancet, 388(10063), 3048-3059.

5. Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617-627.

6. Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. The Journal of Clinical Psychiatry, 69(4), 621-632.

7. World Health Organization. (2017). Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization.

8. Anxiety and Depression Association of America. (2022). Facts & Statistics. https://adaa.org/understanding-anxiety/facts-statistics

9. Stein, M. B., & Sareen, J. (2015). Clinical practice: Generalized anxiety disorder. New England Journal of Medicine, 373(21), 2059-2068.

10. Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Andersson, G. (2014). Psychological treatment of generalized anxiety disorder: a meta-analysis. Clinical Psychology Review, 34(2), 130-140.

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CASE STUDY Mike (social anxiety)

Case study details.

Mike is a 20 year-old who reports to you that he feels depressed and is experiencing a significant amount of stress about school, noting that he’ll “probably flunk out.” He spends much of his day in his dorm room playing video games and has a hard time identifying what, if anything, is enjoyable in a typical day. He rarely attends class and has avoided reaching out to his professors to try to salvage his grades this semester. Mike has always been a self-described shy person and has had a very small and cohesive group of friends from elementary through high school. Notably, his level of stress significantly amplified when he began college. You learn that when meeting new people, he has a hard time concentrating on the interaction because he is busy worrying about what they will think of him – he assumes they will find him “dumb,” “boring,” or a “loser.” When he loses his concentration, he stutters, is at a loss for words, and starts to sweat, which only serves to make him feel more uneasy. After the interaction, he replays the conversation over and over again, focusing on the “stupid” things he said. Similarly, he has a long-standing history of being uncomfortable with authority figures and has had a hard time raising his hand in class and approaching teachers. Since starting college, he has been isolating more, turning down invitations from his roommate to go eat or hang out, ignoring his cell phone when it rings, and habitually skipping class. His concerns about how others view him are what drive him to engage in these avoidance behaviors. After conducting your assessment, you give the patient feedback that you believe he has social anxiety disorder, which should be the primary treatment target. You explain that you see his fear of negative evaluation, and his thoughts and behaviors surrounding social situations, as driving his increasing sense of hopelessness, isolation, and worthlessness.

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• Social Anxiety

Diagnoses and Related Treatments

1. social anxiety disorder and public speaking anxiety.

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Generalized Anxiety Disorder (GAD)

Jul 13, 2014

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Generalized Anxiety Disorder (GAD). By: Astrid Zamora & Crystal Guzman. General Anxiety Disorder (GAD).  is an  anxiety disorder that is characterized by excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry . .

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Presentation Transcript

Generalized Anxiety Disorder (GAD) By: Astrid Zamora & Crystal Guzman

General Anxiety Disorder (GAD) •  is an anxiety disorder that is characterized by excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry.

Some physical health conditions are associated with anxiety. • In Example: • Gastroesophagealreflux disease (GERD) • Heart disease • Hypothyroidism or hyperthyroidism • Menopause

Symtoms Include: • Restlessness or feeling keyed up or on edge • Being easily fatigued • Difficulty concentrating or mind going blank • Irritability • Muscle tension • Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Facts: • People with GAD can't seem to shake their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. • People with GAD also seem unable to relax. They often have trouble falling or staying asleep. Their worries are accompanied by physical symptoms, especially trembling, twitching, muscle tension, headaches, irritability, sweating, or hot flashes. • They may feel lightheaded or out of breath. They may feel nauseated or have to go to the bathroom frequently. Or they might feel as though they have a lump in the throat.

Treatment: •  Typically the most effective treatment will be an approach which incorporates both psychological and psychopharmacologic approaches. • Medications, while usually helpful in treating the bodily symptoms of acute anxiety (e.g., panic attacks), are best used for this disorder as a short-term treatment only (a few months). • Clinicians should be especially watchful of the individual becoming psychologically or physiologically addicted to certain anti-anxiety medications, such as Xanax [Psychcental.com]

Case Study :“I can’t stop my head” • Nancy L. is 45 year old married lawyer with chronic generalized anxiety. • She worried constantly about her parents, who were healthy, and school even though she was a good student. • She was able to grow out of these fears except she still had a terrible fear of spiders.

Nancy L. Case Study: (continued) • Nancy experienced insomnia, irritability, tension, and fatigue. • Over the last 25 years suffered 6 major episodes of anxiety lasting 3-4 months to a year. • These are triggered by situational stressors • She was put on low dosages of benzodiazepines, which she took as needed for fear of addiction • Later was put on fluoxetine & she discontinued because it made her jittery.

Famous Figures with GAD Sigmund Freud Michael Jackson Cher Oprah Winfrey Johnny Depp

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

Contributions: AP and GT designed the protocol, administer the CBT therapy sessions, analyzed and interpreted the data, and wrote the paper.

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. 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.

Introduction

Social anxiety disorder (SAD), also known as social phobia, is one of the most common anxiety disorders. Social phobia can be described as an anxiety disorder characterized by strong, persisting fear and avoidance of social situations. 1 , 2 According to DSMIV, 3 the person experiences a significant fear of showing embarrassing reactions in a social situation, of being evaluated negatively by people they are not familiar with and a desire to avoid finding themselves in the situations they fear. 4 , 5 Furthermore people with generalized social phobia have great distress in a wide range of social situations. 6 The lack of clear definition of social phobia has been reported by clinicians and researchers because features of social phobia overlap with those of other anxiety disorders such as specific panic disorder, agoraphobia and shyness. 7

According to ICD-10, 8 phobic anxiety disorders is a group of disorders in which anxiety is evoked only, or predominantly, in certain well-defined situations that are not currently dangerous. As a result these situations are characteristically avoided or endured with dread. The patient’s concern may be focused on individual symptoms like palpitations or feeling faint and is often associated with secondary fears of dying, losing control, or going mad. 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.

Prevalence of social phobia varies from 0-20%, depending on differences in the classification criteria, culture 9 , 10 and gender. 11-13 The onset of the disorder is considered to take place between the middle and late teens. 14 The NICE guidelines for social anxiety disorder, describe it as one of the most common of the anxiety disorders. Estimates of lifetime prevalence vary but according to a US study, 12% of adults in the US will have social anxiety disorder at some point in their lives, compared with estimates of around 6% for generalized anxiety disorder (GAD), 5% for panic disorder, 7% for post-traumatic stress disorder (PTSD) and 2% for obsessive-compulsive disorder. There is a significant degree of comorbidity between social anxiety disorder and other mental health problems, most notably depression (19%), substance-use disorder (17%), GAD (5%), panic disorder (6%), and PTSD (3%). 15

Social phobia is also developed and maintained by complex physiological, cognitive, and behavioral mechanisms. Biological causes of social anxiety/phobia have been reported by some researchers while others look on behavioral inhibition 16 and the effects of personality traits such as neuroticism and introversion 17 as the mediators between genetic factors and social phobia.

Apart from the biological factor, the role of cognition in the acquisition and maintenance of social anxiety/phobia is very important. The main cognitive factor is the fear of negative evaluation. 18 Beck, Emery, and Greenberg 19 associated the possibility of negative evaluation by others with beliefs of general social inadequacy, concerns about the visibility of anxiety, and preoccupation with performance or arousal. 20

Specific phobia situational type, is described as a persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation such as public transportation, tunnels, bridges, elevators, flying, driving or enclosed places. This subtype has a bimodal age-at-onset distribution with one peak in childhood and another peak in mid-20s. 21

Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response which may take the form of a situational bound or situational predisposed panic attack. The phobic situation usually is avoided or else is endured with intense anxiety or distress. The avoidance interferes often with the person’s normal routine occupational functioning, social activities or relationships. 21 Fear of heights, or acrophobia, is one of the most frequent subtypes of specific phobia frequently associated to depression and other anxiety disorders. 22 It is one of the most prevalent phobias, affecting perhaps 1 in 20 adults. 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. 23

From a behavioral perspective, feared situations negatively maintain phobias. 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.

George was diagnosed with Social Anxiety Disorder and with Specific phobia, Situational Type i.e . acrophobia. 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 experiencing 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. 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. George stated that he didn’t experience any symptoms of depression, had no prior psychological or psychiatric treatment and/or medication, and had first experienced this problem in the course of the previous year.

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. The psychiatrist used the Mini International Neuropsychiatric Interview, 25 which is a structured interview based on DSM-IV diagnostic criteria. 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. 26 To better assist conceptualization and treatment and also monitor his progress, two therapists were assigned to George and two assessment measures (STAI and SPAI) were given, prior to the course of treatment, following therapy and at one month follow-up. 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 (STAI), 27 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.

Social Phobia and Anxiety Inventory

The Social Phobia and Anxiety Inventory (SPAI) 28 is a 45 item self-report measure that assesses cognition, physical symptoms, and avoidance/escape behavior in various situations. 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.

George’s pre-treatment scores were, SPAI:126, State Anxiety: 64 and Trait Anxiety: 63. The ultimate goal in each situation was to reduce the client’s level of anxiety.

Cognitive-behavior techniques such as self-monitoring, cognitive restructuring, relaxation, breathing retraining, and assertiveness training were employed to reduce anxiety and fear.

Cognitive behavior therapy techniques

Self-monitoring.

Self-monitoring refers to the systematic observation and recording of one’s own behaviors or experiences on several occasions over a period of time. 29 Self-monitoring can be used as a therapeutic intervention, because it helps the patient to evaluate his/her thoughts, emotions, and behaviors, recognize the feared situations and find appropriate solutions. 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.

George had to complete an Every Day Self-Monitoring Scale for 20 weeks measuring feelings of anxiety (0=no anxiety to 10= most anxiety) and phobia (0=no feelings of phobia to 10=most feelings of phobia), ( Figure 1 ).

Every day self-monitoring scale score.

Cognitive restructuring

Beck and Emery, 19 have identified three phases in cognitive restructuring: i) identification of dysfunctional thoughts ii) modification of dysfunctional thoughts and iii) assimilation of functional thoughts. During cognitive restructuring, the client starts recognizing his/her automatic or dysfunctional thoughts and emotions that derive from this thoughts. For example, one of George’s thoughts was that: it is dangerous to drive at night , which made him feel very anxious and frightened. However, an adaptive thought could be that: that sometimes is dangerous but also a lot of times are not, due the fact that at night there is less traffic in the streets . Therefore, throughout the sessions he was taught how to substitute several automatic negative thoughts with adaptive ones. He also kept a dysfunctional thought record for 6 sessions, which he discussed with his therapist every week.

Muscle relaxation

Relaxation techniques were used for the treatment of George’s symptoms and more specifically for the physiological manifestations of anxiety and panic. 31

George was trained in breathing and muscle relaxation exercises, based on Jacobson’s technique and he was given 8 relaxation training sessions, in order to establish a sense of control over his physical symptoms. The client learned to apply brief muscle relaxation exercises in his daily life and especially every time he had to face an uncomfortable situation.

Assertiveness training

Assertiveness training can be an effective part of treatment for many conditions, such as depression, social anxiety, and problems resulting from unexpressed anger. Assertiveness training can also be useful for those who wish to improve their interpersonal skills and sense of self-respect and it is based on the idea that assertiveness is not inborn, but is a learned behavior. Although some people may seem to be more naturally assertive than others are, anyone can learn to be more assertive. In the specific case the therapists helped George figure out which interpersonal situations are problematic to him and which behaviors need the most attention. In addition, helped to identify beliefs and attitudes the client might had developed, that lead him to become too passive. The therapist used role-playing exercises as part of this assessment.

Clinical sessions

George completed 20 individual, 50 min therapy sessions that took place within a period of 5 months. During the first session the rationale of the cognitive-behavioral treatment was analyzed and special emphasis was given to educate the patient on Social Anxiety disorder and Specific phobias. An introduction was made to the role that automatic thoughts play in our cognitions and helped him to recognize automatic negative thoughts and feelings. A self-monitoring diary of anxiety was given to him as homework. Emphasis was also given to establishing good rapport and collaboration in the therapeutic relationship. During the second session, George narrated stressful life events and reported specific cases in which the anxiety symptoms increased. He was also taught how to identify the three phases of cognitive restructuring and was given the dysfunctional thought record as homework. The third session was based on teaching him breathing exercises and muscle relaxation. Relaxation techniques were taught by a different therapist, with expertise in stress management and relaxation techniques. George was given 8 such sessions, each lasting 20 minutes while he also practiced the sessions daily at home and completed a Daily-form for progress monitoring.

Sessions 4 to 9 were devoted to ways of challenging dysfunctional thoughts by resorting to adaptive responses. At first we tried to recognize negative automatic thoughts during specific situations and record George’s mood in that situation. After recognizing George’s negative thoughts, emotions and behaviors, we worked on the evidence that supported these thoughts.

The next three sessions (10-12) were devoted to teach him assertiveness skills to learn to socialize with people more effectively. We explored what assertiveness meant for George, what prevented him from being assertive and what were the differences between assertive, submissive and aggressive behavior, which he found really helpful and role-playing exercises were initiated to exercise these skills.

Sessions 13-20 were devoted identifying anxiety provoking situations which were hierarchically classified according to the degree of anxiety they produced. An example is shown in Table 1 . Exposure to feared situations was performed by facing in vivo each level of the hierarchy and gradually practice each step, until he was confident enough to go on to the next.

Fear hierarchy for visiting tall buildings.

Accordingly, situations such as driving, crossing bridges etc were also explored.

During the last session, George referred to overcoming challenging experiences, such as meeting new people, visiting friends living in tall apartment buildings and crossing two high bridges, while driving to visit his parents in a different part of Greece. He effectively challenged his cognitions in all relevant situations and utilized muscle relaxation and breathing exercises to control feelings of anxiety. Last session was also devoted to discuss relapse prevention, ways to avoid it and how to overcome past failures and difficulties. Finally, we discussed how he could modify and apply the skills and techniques that he had learned, in his daily routine.

The post-treatment scores of STAI and SPAI obtained by George at termination indicated an improvement. The Social Phobia score dropped to 100, the Anxiety State score was 41 and the Trait score was 42.

During the follow-up session one month later, George talked about his improvement, he mentioned that his progress continued and that he was not experiencing any of the averse symptoms of the past, while driving, visiting tall buildings/bridges and meeting new people. He continued the relaxation and the cognitive restructuring exercises. The STAI & SPAI scales were administered again. The assessment revealed maintenance of gains in terms of reduced anxiety and fear symptoms with State anxiety score: 38, Trait anxiety score: 39 and SPAI score: 77 ( Figure 2 ).

STAI and SPAI Scores.

Treatment implications

In the present clinical case, George attended 20 individual sessions of CBT, in order to reduce his anxiety levels and phobias and learn how to monitor his progress in his daily life. His anxiety levels were reduced in social situations and also he managed to overcome his fear of heights in specific provoking situations. His progress was inevitable which was confirmed by the anxiety scores of the STAI and SPAI. The follow-up session that took place a month later, showed that his progress was sustained. The Every Day Self-Monitoring Scale during the 20 weeks period, showed a gradual reduction in self monitoring feelings of anxiety and phobias ( Figure 1 ).

However although we based our CBT model on Clark and Wells model for Social Anxiety, we had certain variations from the original model. For example, the Clark and Wells model suggests, that individual therapy for social anxiety disorder should consist of up to 14 sessions of 90 minutes’ duration over approximately 4 months. In our case study, the duration of each session lasted 50 minutes and we gave 20 sessions of individual therapy to our client over a period of 5 months, thus trying to tailor our client’s needs and requirements for treatment.

A good rapport was developed with George and that helped the entire treatment process. Working on a list of feared hierarchies in combination with relaxation training skills, George was able to manifest his high level anxiety visiting tall buildings, crossing tall bridges etc. Furthermore, the fact that George learned to identify his automatic thoughts, helped him to reduce his unpleasant feelings by alternating his thoughts. Role-playing exercises in order to acquire assertiveness training skills helped him in relation to meeting new people. It is also worth mentioning that George was motivated and completed his CBT homework every week, something that helped the therapeutic outcome.

Conclusions: recommendations to clinicians and students

Cognitive behavioral therapy is very effective in treating anxiety. It is a structured intervention that follows a general framework that is modified for each individual. For the successful treatment of social phobia, the cognitive behavior therapy must be thorough and comprehensive. Sometimes is needed to use combinations of techniques, like in this case we used traditional CBT techniques in combination with assertiveness skills training. Collaboration with other specialists is also advised for ultimate results, as in this case two therapists were involved, one main therapist and one specialist on stress management techniques. The cognitive-behavior therapist is important to adapt the session, on the basis of his/her client’s needs, for example in the case of George we used exposure based techniques and although the Counseling center offers a maximum of 6 therapeutic sessions, in the case of George we decided on 20 sessions, in order to fully accommodate his problem. It is also very important for the therapist to explain the rationale behind each CBT session and help the patient understand each session’s agenda up to the point he/she feels comfortable to set their own agenda during the session. However, despite the therapist’s best efforts, the patient often hesitates to carry out the everyday homework, thus sometimes delaying the therapeutic progress. Therefore, the good rapport established with the patient will almost certainly add greatly to his/her adherence during the treatment.

Therapist-client relationship, play a fundamental role in the therapy process. It is important for the client to trust the therapist and feel comfortable within the therapy context. Creating a safe and empathetic environment is important from the first therapy session. Furthermore as CBT is directive, a strong therapeutic alliance is necessary to allow the client to feel safe engaging in this type of therapy. It is also important to mention that therapists need to refer to the widely accepted guidelines and recommendations for treating Social anxiety disorders and specific phobias, from widely accepted national institutes, such as the National Institute for Health and Care Excellence that covers both pharmaceutical and psychotherapeutic approaches. However, it is necessary sometimes to tailor-made therapy around client’s needs, as each case must be seen individually . There are too many manuals on CBT and there is the danger for the therapist to work in such a program that can lose creativity, individual thought, imagination and contact with the client. The crucial role of any therapeutic intervention, is not only to help people to acquire the techniques, but to feel comfortable to apply them daily in situations they feel discomfort.

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Anxiety Disorders.

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