Case Illustration

J. L., a 32-year-old, single, African American woman employed as a temporary office assistant, sought help for extreme anxiety in a variety of social situations. When describing her difficulties, J. L. reported that she had had "problems with people" ever since she was teased and taunted in junior high school. She reported that she had had few friends and felt continuously uneasy, alone, and terrified in school. In addition, she feared parties; public speaking; participating in meetings and classes; speaking with unfamiliar people and authority figures; being assertive; maintaining a conversation; entering public places, such as restaurants, coffee shops, and stores; and dating. She reported that she never had a serious romantic relationship. J. L. stated that she feared all of these situations because she was worried that people were evaluating her negatively. She noted, "I just have a huge fear of people. I always think that I will not be liked." She further stated, "Initiating anything with people is difficult. I get immediately nervous." J. L. reported that her fear in social situations had resulted in a pattern of avoidance that had significantly interfered with her life. When describing the level of interference her social discomfort has caused, J. L. said: "I feel that I have missed my whole life. I just want to be able to communicate with others." J. L. revealed that she wished she could feel more relaxed in these situations and not be concerned about whether others were evaluating her.

In addition, J. L. reported long-standing difficulties with depressed mood. More often than not, she felt down and had difficulty engaging in activities. Along with her depressed mood, she reported that she had sleeping problems, low self-esteem, poor concentration, and a sense of hopelessness about the future. J. L.'s symptoms had been present since she was approximately 15 years old. Her depression appeared to have been a direct consequence of her social anxiety.

Her ultimate referral to CST was preceded by an acute worsening of both her social concern and her depression. J. L. had returned to school, taking evening classes. With her return to a classroom setting, her memories of her early teasing were enlivened, and she reported fearful ruminations on a daily basis. J. L. described being so nervous that she walked a greater distance to her class so that she could avoid crowds of people, including unexpectedly coming upon her classmates out of class. Her distress about her social concerns reached a peak around a class presentation where a mock interview had to be completed in front of the class. During her part of the interview, she felt her anxiety reach panic proportions, and she was sure that the whole class was riveted to her halting speech and trembling hands. After the class was over, she heard a student comment that the interview went poorly. She described this incident as the last straw. She drove home choking back tears and resolving that she would not be humiliated again. She described her thoughts as racing as she vowed not to go back to school or allow such feelings of humiliation to be elicited again. On the way home, she stopped at a drugstore and bought over-the-counter sleeping pills. Once home she searched the medicine cabinet for any pills she could take, and came away with a bottle of ibuprofen. She took handfuls of both the ibuprofen and the sleeping pills, thinking all the time of the need to escape from school, from humiliation, from her life. She covered herself with a blanket, began feeling sleepy, and waited to die. At this time her roommate came home from work, discovered her in this state, and called for an ambulance. With brief inpatient treatment, her acute suicidal intent resolved. Her chronic depressed mood— meeting criteria for major depression—her fears of humiliation, and her ongoing social anxiety disorder did not resolve. She was subsequently referred to outpatient treatment.

At the time of the interview, J. L. endorsed symptoms of depression and passive suicidal ideation. She stated that although she often "wishes for relief" from her current state of social anxiety, she did not feel that she was a danger to herself at the present time. On the basis of the information obtained during the diagnostic interview, a principal diagnosis of social phobia (generalized subtype) with avoidant personality disorder was assigned. In addition, she received the diagnoses of major depressive disorder, recurrent, moderate.

As a result of her suicide attempt at age 19, J. L. was hospitalized. She subsequently received individual psychotherapy and psychiatric treatment for a period of 5 years following this incident. At the time of the assessment, J. L. was taking Dexedrine, 5 mg/day; Klonopin, 1 mg/day; and Wellbutrin, 200 mg/day.

Shortly after this assessment, J. L. was invited to participate in a free treatment trial at an anxiety specialty clinic. As part of this study, she received 12 weekly sessions of CBT in a group format. J. L. responded very positively to the intervention. Her level of social anxiety, as measured with the Difference score of the SPAI, dropped from 158.2 to 133.6 at posttreatment (15.6% reduction from pretest), and further decreased to 110.4 6 months after the end of treatment (32.1% reduction from pretest). Although the treatment did not address specifically her symptoms of depression, her Beck Depression Inventory (BDI) score dropped from 26 before treatment to 9 at the end of treatment, which is a 65.4% reduction from the level at pretest (no information on her BDI score was available for the 6-month follow-up assessment).

Do Not Panic

Do Not Panic

This guide Don't Panic has tips and additional information on what you should do when you are experiencing an anxiety or panic attack. With so much going on in the world today with taking care of your family, working full time, dealing with office politics and other things, you could experience a serious meltdown. All of these things could at one point cause you to stress out and snap.

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