References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
Beidel, D., Turner, S., Young, B., Ammerman, R., Sallee, F., Crosby, L. (2007, March). Psychopathology of Adolescent Social Phobia. Journal of Psychopathology and Behavioural Assessment, 29, 1, 46-53
Hawton, K., Salkovskis, P., Kirk, J., & Clark, D. (1998). Cognitive behaviour therapy for psychiatric problems: a practical guide. Oxford: Oxford University Press.
Mancini, C., Van Ameringen, M., Bennett, M., Patterson, B., Watson, C. (2005). Emerging Treatments for Child and Adolescent Social Phobia: A Review. Journal of Child and adolescent Psychopharmacology, 15, 4, 589-607
Spence, S, H., Donovan, C., Brechman-Toussant, M. (2000).The Treatment of Childhood Social Phobia: The Effectiveness of a social Skills Training-based, Cognitive-behavioural Intervention, with and without Parental Involvement. Journal of Child Psychology and Psychiatry, 41, 713-726. Cambridge University Press
Velting, O, N., and Albano, A. (2001). Current Trends in the understanding and Treatment of Social Phobia in Youth. Journal of Child Psychology and Psychiatry, 42, 1, 127-140 Cambridge University Press
Case Write-up “Joe”
Case History
Identifying Information
Joe is a 17 year old New Zealand European young man who lives with his mother, Mandy and 19 year old sister Sue, in a rented property on a farm. Joe’s mother separated from his father when she was pregnant with Joe. He has not been involved in Joe's upbringing and until last year was living in Australia.Joe first met his father at age 16 and now sees him occasionally. He left school just after he turned 16 and now spends most of his days and nights in his room playing world of war craft and similar computer games.
Chief Complaint
Joe reported that things had changed for him about a year ago. At that time he began feeling increasingly anxious especially around friends and withdrew from them believing that they talked negatively about him and laughed behind his back especially about the way he looks and presents. He started to feel inadequate when with them and experienced difficulty initiating and maintaining conversation in social situations. “I don’t even know what to say in a conversation and find myself stammering even with friends I have known for years”. At the thought of having to speak to people he starts to panic, becomes nervous, sweaty and pale. He feels unable to see anyone socially and refuses to answer the phone as he thinks he will not be able to sustain a conversation with anyone and they will realise just how boring and inadequate he is. Joe also believes that there is something wrong with his physical health and he will be dead by age 21. He does not believe his doctor who has medically cleared him. He is unsure if how he feels has been caused by daily use of marijuana and is trying to stop using it, if only to determine if drug use is at the root of his problems.
History of presenting problem
Mandy referred Joe to CAMHS after Joe threatened to suicide by putting a plastic bag over his head to stop himself from breathing. This happened after an argument with his mother when she suggested that he needed to either find work or enrol in a course. According to Mandy in the last year Joe has become increasingly withdrawn, refuses to leave his room, especially when they have visitors, plays computer games most of the day and well into the night, he won’t answer the phone, won’t see friends and when taken to task easily becomes verbally and physically abusive towards Mandy. According to Mandy volatile arguing and name calling happens frequently between them, for example Joe will call his mother “fat bitch” and his mother will tell him, “no one wants you or likes you”.
Mandy reported that Joe was brought up around a lot of marijuana use and admitted to introducing him to smoking marijuana at age 14 and supplying him with it until recently. Mandy did not see anything wrong with this as she has been using Marijuana since she was a teenager and believes this never affected her functioning. Joe believes his problems started during a period of three months over a year ago when he used the drug ecstasy together with a large quantity of party pills. During one such occasion with his friends, he became paranoid and thought they were talking about him and intended to beat him up. He left their house and called his mother to pick him up. As he waited for her he thought another group of friends were following him with similar intentions. Joe has since asked his friends about this and they had no idea what he was referring to. Joe also has had body image issues for over a year. He is a good looking, lanky young man but he feels he has a lot of spots on his face (untrue) and he believes he has lost a lot of weight which to him means he has a medical problem thus far undiagnosed by the General Practitioner. He does not believe he will live beyond the age of 21, although he doesn't know how he will die and doesn't believe he will take his own life.
Past Psychiatric History
Joe was previously referred to CAMHS last year after assaulting his mother and ending up in police custody. He was seen for assessment and diagnoses of parent-child relational problems and Cannabis abuse were made. It was felt at that time that he would benefit from input from Altered High (Alcohol and Drugs services). Family therapy was also offered for the family. Joe refused to engage in either treatment and was therefore discharged. Joe’s maternal grandmother and maternal aunt have a diagnosis of depression and are accessing treatment.
Personal and Social History
Joe’s mother, Mandy reported that she has always mixed with “colourful personalities” in the show business world and these are the people that Joe grew up around. Joe did well socially and academically until the family moved out of central Auckland a few years ago; necessitated by mother thinking that Joe’s sister Sue was mixing with the wrong crowd. Joe believes that this was when he got in with the wrong friends and began truanting from school, then started using marijuana.
According to his mother Joe has always had phobias (afraid of the sea and dense bush as a child) and highly anxious about being sick and will escalate minor aches and pains to a point he believes he is dying. Mandy has also been very anxious at times in her life and had the same reaction.
Until last year Joe’s father was living outside the country. Since he has been back Joe sees him occasionally. Joe’s father is gay and has stated to Joe that he does not regard himself as a father to Joe but a friend, and will usually spend the time with Joe using drugs and alcohol with him. Mandy also admitted that she set out to be a friend to Joe given her own experience of a mother who was cold and aloof and did not really have time for her. Mandy has a sister but stated that they have never been close. Joe occasionally spends time with his maternal grandmother and some of the extended family on his father’s side but his mother remains his main support. He is not close to his sister.
Joe is very interested in astronomy and questions “why we are here”. He believes there is a yet undiscovered good reason why we are really here and wants to be the person who discovers this. Joe does not have a girlfriend.
Joe’s symptoms include
Emotional symptoms: fear, anxiety, anger, irritability, and hopelessness
Cognitive symptoms: Fear of negative evaluation, thoughts of death and dying, low self esteem, existential questioning, constant negative thoughts about himself.
Behavioural symptoms: avoidance of social situations, Social withdrawal from friends, angry outbursts, verbal and physical aggression targeted at mother, mostly staying in his room when home. Joe is spending a lot of time playing computer games (fantasy world). Joe never answers the phone, never goes out unless he is with his mother.
Physiological symptoms: Sweating, palpitations, goes pale, gastrointestinal discomfort, initial insomnia. Going to bed at 2am, and waking up at noon. Joe also reports vivid dreams that worry him.
Medical History
Joe was medically cleared before accessing CAMHS and did not present with any medical problems which may have been impacting his psychological functioning.
Mental Status Examination
Joe attended dressed in dark jeans and wore a sweater with a hoody covering his head and long hair shading his eyes. Intermittent eye contact achieved throughout the session. He had not wanted to come so was initially sullen and unresponsive. In one to one session quickly developed good level of rapport. He was very focused and participative. Speech was very articulate and spoke openly. Thought form appropriate recognising that his fears may be unfounded but acknowledging that fears are very real for him. Joe’s speech and language was normal and no perceptual disturbances were noted. Joe had some insight into his difficulties although was ambivalent about changing things at that time.
DSM-IV Diagnoses
Axis I: Social Phobia (Social Anxiety disorder) 300.23, Cannabis Abuse
Axis II: Nil
Axis III: Nil
Axis IV: Difficult relationship with mother, no friends.
Axis V: GAF: Current 41
Case Formulation
Precipitants
At present this is largely unclear. A possible hypothesis could be drawn from the information obtained in Joe’s social history, Joe has always been an anxious child and the continued use of marijuana as well as the brief period in which he used the drug ecstasy and party pills may have triggered his social anxiety. Joe is able to pinpoint the onset of his current difficulties to that time. The dilemma however is that according to the DSM-IV TR one of the criteria for meeting the diagnosis of Social phobia is “the fear or avoidance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder.” In the last three months Joe has greatly reduced his use of marijuana to the extent that he is using once a week if that given that his mother has stopped supplying him and is no longer using in the house herself. Joe has continued to fear the negative scrutiny and evaluation of him by his friends and peers, and exposure to situations in which he is with friends’ causes sweating, palpitations and stammering.
Cross Sectional view of current cognitions and behaviours
- A typical problem situation is when Joe gets a phone call from a friend and refuses to take it. His automatic thought is “I don’t know what to say , they will think I am a loser”, the meaning of his automatic thought is “ I am inadequate and defective”, he feels anxious and panics about taking the call and in the end withdraws to his room where he feels safe.
- Another problem situation is Joe being asked by his mother to find a course or work. Joe’s automatic thoughts are “they will want to talk to me and I won’t be able to do it. Everyone will think I am a loser.” The meaning of this automatic thought to Joe is “I am boring and not good enough” He feels self conscious, fearful and panicky and he therefore avoids going to the course.
- The third situation is when Joe is asked by his mother to go and do grocery shopping. Joe’s automatic thoughts are “People will think I am a freak, they will look at me and see how thin I am and how ugly I am. The meaning of this automatic thought to Joe is “I am unlovable” He feels self conscious, exposed and sad, and avoids going to the supermarket.
Joe’s mother threatens his ability to avoid social situations by constantly pushing him to spend time outside of his room, trying to make him see friends (despite her knowledge of his fears), find a course to do, go grocery shopping and other things, which serve to increase his anxiety. Joe gets very angry with his mother and verbally and occasionally physically abuses her. At times Joe questions what life is all about and cannot see the point of his existence, especially given his current life. He feels that generally, having friends, going to a course or finding a job is all very stereotypical and he does not want that for himself and states that he is happy having no friends and being a “bum” and wishes his mother would stop trying to change him.
Longitudinal view of cognitions and behaviours
Joe has grown up in a family in which both parents have not been available to parent him and meet his emotional needs. His mother describes having used marijuana since she was a teenager and while she maintains that she functioned well enough on it and was a responsible parent one has to question her emotional availability as well as the quality of that functioning while under the influence marijuana. Rules and boundaries have been largely lacking in Joe’s life given that his mother set out to be his friend which may mean that Joe could have found the lack of containment difficult, especially given the limited supports in his life.
Joe has developed the following key assumptions: If I do not see friends, then I will not risk being negatively evaluated. If I do not expose myself socially to people then they will not see my inadequacies.
His behavioural strategies include, remaining in his room day and night, not going out, not seeing friends and not answering the phone, aggression towards his mother when she attempts to change the status quo. He is non compliant with his mother’s directives and will threaten self harm or suicide in an attempt to stop her from hassling him. Joe admitted to using suicidal actions to get his mother stop trying to run his life as well as admit that she cares for him and does not want him to die.
Strengths and Assets
Joe has a supportive relationship with his mother who works hard to try and get him engaged in services. Joe also comes across as an intelligent young man who is aware of his current difficulties and would like to change things for the better. He has greatly reduced his marijuana use with his mother’s support and is committed to stopping in the near future. He has also started treatment with Cognitive Behaviour Therapy and is committed to attending.
Joe feels connected to his father and stated that although his drug taking behaviour is not good role modelling he has nevertheless had the most useful and practical conversations with him.
Working Hypothesis
On the basis of the information obtained from Joe and his mother, Joe met criteria for Social Anxiety Disorder, given that his symptoms have caused and continue to cause clinically significant impairment in social and occupational functioning. Joe believes himself to be inadequate, boring, un likeable and worthless and he sets out to prove this by not giving anyone a chance to prove that this view is incorrect and holding on to his expectations of being found wanting in all of his interactions with others. The relationship between Joe and his mother has largely contributed to this given the lack of adequate parenting, the lack of rules and boundaries within the home in which societal rules and norms could have been modelled in a safe environment from an early age. Joe is already anxious about being negatively perceived by his friends and others so it does not help when his mother confirms his negative thoughts about himself, “no one wants you and no one likes you,” even if the words are said in anger and not meant. Joe struggles with making and maintaining friendships, he also lacks self esteem especially around social interactions with people in general which impacts on his ability to effectively attend a course or find and keep a job.
To manage Joe takes the safest option, which is remaining in his room and playing computer games and forcing his mother into accepting his chosen lifestyle by becoming aggressive and threatening suicide each time she tries to change the status quo.
Treatment Plan
According to Hawton, Salkovskis, Kirk and Clark (1998), the therapist is particularly guided by the hypotheses developed around the cognitive and behavioural processes that are maintaining the client’s anxiety state. This is therefore the basis on which the treatment plan is crafted.
Problem List:
- Fear of negative evaluation by friends and others
- Low self esteem
- Suicidal ideation
- Psychiatric symptoms: sleep difficulties, sadness, irritability, anhedonia,
- Anxiety about existential issues
- Occupational issues
Treatment goals:
- Reduce social anxiety through graded exposure
- Increase self worth
- Manage parent-child relationship so it does not become destructive to both mother and Joe.
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Reduce negative thoughts while increasing positive thoughts.
Plan for treatment
The treatment plan was to initially reduce Joe’s risk of suicide. Given that Joe indicated that he had no plan to suicide but only intended to call his mother bluff about not caring for him, the risk was managed by working out a safety plan with him and his mother which included ensuring all instruments that might be used to suicide around the farm were put away, given that young people are impulsive. Family was provided with crisis numbers and a plan for Mandy to obtain respite by asking her own mother to have Joe for a few days if it all became too much, was put in place. Joe was to also be reviewed by the child and adolescent psychiatrist and a referral was to be made to the alcohol and drug service to support his efforts to stop using marijuana completely
CBT was prescribed as the best treatment for Joe with regards to developing coping strategies around his social anxiety. According to Reinecke, Dattilio, and Freeman (2006) a number of trials have demonstrated the efficacy of CBT for Social Anxiety as indicated by a number of authors such as Beidel, Turner and Morris (2000).
Taking into account the CBT model of anxiety which denotes anxiety as the overestimation of threat or danger against the underestimation of ability to cope, treatment would take the form of a realistic evaluation of what Joe perceives as threatening. For example the fear of negative evaluation by friends, and work towards increasing his skill levels around coping with this threat, for example using graded exposure.
This would serve to reduce his perception of threatening situations while increasing his ability to cope in such situations.
Collaboration and guided discovery would be utilised to assist Joe to reconstruct his automatic thoughts around interacting with friends and being in social situations. According to Dattilo and Padesky in Friedberg and McClure(2002, p. 35), “ emphasis is placed on the collaborative aspect of the approach, on the assumption that people learn to change their thinking more readily if the rationale for change comes from their own insights rather than from the therapist.”
The Skate board model of anxiety, adapted from the 5 Part Model of anxiety would be used to analyse Joe’s cognitions, behaviours, physical reactions and emotions when faced with social situations that cause huge anxiety, given that he used to skateboard and gave it up after sustaining a number of serious injuries, this is an analogy he would definitely understand and feel able to work with. The treatment would be carried out as prescribed in CBT treatment for anxiety. This would take the form of 13 sessions starting with developing rapport, and setting goals followed by introduction of the CBT model and cognitive restructuring, through to utilising graded exposure and social skills training.
Course of Treatment
Therapeutic Relationship
This is still a relationship in the making. Joe has thus far attended two therapy sessions which were as follows:
Session one - Collaboration on drawing up the problem list, psycho education on what CBT is all about and setting goals for treatment. We discussed the importance of doing homework as an important treatment criteria, necessitated by his current lack of motivation communicated in the initial assessment. . Given that Joe likes to analyse things hence his existential questioning, he thought CBT would work for him and was keen to get started. Joe asked to keep a diary for the week on any social interactions he has or passes up and what his thoughts are at that time.
Joe did not turn up to his second session. He had an argument with his mother on that day and decided that he no longer wanted therapy given that he had had enough of his mother telling him what to do and being bribed to attend. It was stated to Joe that given the nature of CBT a specific requirement was that he be willing to engage in therapy without coercion and attend regularly otherwise it would not work. Joe rang a week later asking for another appointment and asking that he continue with CBT.
Session two – This started with learning some useful relaxation techniques, especially given that he was very tense when he first came in. This was followed by an introduction to the CBT model and cognitive restructuring, which took the form of searching for the evidence that supported his core beliefs that he was unlikeable, boring, inadequate and not good enough. We then used the pie chart to determine how much of that is actually true; by the end of the session Joe admitted that his view of himself and others may not be very realistic. His homework was to go home and try to respond to his automatic thoughts through thought catching when he started to think negatively.
Interventions/Procedures
- Skate board five part model
- Cognitive restructuring and thought catching
- Role plays
Our first few sessions included utilising the five part model depicted as a skateboard to reflect on Joe’s cognitions, behaviours, feelings and physical reactions when faced with a situation of having to interact socially. Joe initially had difficulty remembering recent events in which he had become anxious in a social situation. We therefore utilised a role play which helped to trigger his memory of a recent event. We discussed identifying, measuring and responding to his automatic thoughts in a more helpful way as opposed to immediately jumping to negative conclusions.
Obstacles
Difficulty trying to shift Joe’s rigid thoughts about other’s opinions and perceptions of him.
Reliability as far as attending sessions regularly may be a problem.
Carrying out homework is a problem as he did not do the homework given him in the first session
Outcome
No outcome as yet as we have had two sessions of CBT. Joe remains reluctant to completely shed his negative automatic thoughts and states that he views them as a security blanket.
Formulation
Beck Conceptualisation
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
Beidel, D.C., Turner, S. M, & Morris, T. L. (2000) Behavioural treatment of childhood social phobia. Journal of consulting and Clinical Psychology, 68, 1072-1080
Friedberg, R. D. & MCClure, J.M.(2002). Clinical Practice of Cognitive Therapy with Children and Adolescents. New York: The Guildford Press.
Hawton, K., Salkovskis, P., Kirk, J., & Clark, D. (1998). Cognitive behaviour therapy for psychiatric problems: a practical guide. Oxford: Oxford University Press.
Reinecke, M., Dattilio, F., Freeman, A. (2006). Cognitive therapy with children and adolescents: a casebook for clinical practice. New York: Guilford Press.
