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Psych 233: Abnormal

Psychology


Anxiety Disorders
Panic Disorders, Phobias and
Generalized Anxiety Disorder
Tyrone Reden Sy & Daniella Morga Tyrone Reden Sy & Daniella Morga Tyrone Reden Sy & Daniella Morga Tyrone Reden Sy & Daniella Morga
ATENEO DE MANILA UNIVERSTY

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GENERALIZED ANXIETY DISORDER (I CANT STOP MY HEAD) ................................................................. 3
BRIEF THEORETICAL BACKGROUND ............................................................................................ 3
SOCIAL ANXIETY DISORDER ................................................................................................................ 13
BRIEF THEORETICAL BACKGROUND .......................................................................................... 13
ILLUSTRATIVE CASE STUDY ....................................................................................................... 14
CASE DISCUSSION ..................................................................................................................... 14
TREATMENT .............................................................................................................................. 15
SPECIFIC PHOBIAS ............................................................................................................................. 16
CASE STUDY: VOMIT PHOBIA .................................................................................................... 17
CASE DISCUSSION ..................................................................................................................... 18
TREATMENT .............................................................................................................................. 18
PANIC DISORDER (WITH AGORAPHOBIA) .............................................................................................. 18
BRIEF THEORETICAL BACKGROUND .......................................................................................... 18
ILLUSTRATIVE CASE STUDY ....................................................................................................... 19
CASE DISCUSSION ..................................................................................................................... 20
TREATMENT .............................................................................................................................. 21
References .................................................................................................................................... 22




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GENERALIZED ANXIETY DISORDER (I CANT STOP MY HEAD)

I always thought I was just a worrier. Id feel keyed up and unable to relax. At times
it would come and go, and at times it would be constant. It could go on for days. Id
worry about what I was going to fix for a dinner party, or what would be a great
present for somebody. I just couldnt let something go. Jason, diagnosed with
GAD
BRIEF THEORETICAL BACKGROUND

While it is common for people to worry about objects or concerns of daily life from time to
time, people with Generalized Anxiety Disorder (GAD) do so uncontrollably to the point that their
worry impedes them in their daily functioning. Indeed, Kring et al. (2013) notes that the central
feature of GAD is worry, and those with GAD usually chronically worry about a lot of things, some of
them usually minor and mundane. GAD is a new diagnosis, being previously classified under the
label of anxiety neurosis before 1980 (Tyrer & Baldwin, 2006).
Previously, the DSM IV TR (APA, 2000) enumerated the following as symptomatic of GAD:
the essential feature of Generalized Anxiety Disorder is excessive anxiety and worry (apprehensive
expectation), occurring more days than not for a period of at least6 months, about a number of
events or activities (Criterion A). The individual finds itdifficult to control the worry (Criterion B). The
anxiety and worry are accompaniedby at least three additional symptoms from a list that includes
restlessness, being easilyfatigued, difficulty concentrating, irritability, muscle tension, and disturbed
sleep (only one additional symptom is required in children) (Criterion C). The focus of theanxiety
and worry is not confined to features of another Axis I disorder such as havinga Panic Attack (as in
Panic Disorder), being embarrassed in public (as in SocialPhobia), being contaminated (as in
Obsessive-Compulsive Disorder), being awayfrom home or close relatives (as in Separation Anxiety
Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in
Somatization Disorder),or having a serious illness (as in Hypochondriasis), and the anxiety and
worrydo not occur exclusively during Posttraumatic Stress Disorder (Criterion D) (p. 472).
However, the DSM 5 (APA, 2013) added some changes to the diagnostic criteria for GAD
namely, that the excessive anxiety and worry be present at least 50% of days in at least two life
domains, worry is sustained for at least three months (previously from 6 months) and that the worry

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and anxiety are associated with marked avoidance of situations in which negative outcomes could
occur, marked time and effort preparing for situations that might have a negative outcome (Kring et
al., 2013).
ILLUSTRATIVE CASE STUDY

Attached is the psychological evaluation report of Angelita, a 45 year old female, who
presented for psychological evaluation at the Section of Psychology, Philippine General Hospital.
Angelitas presenting symptoms and behavioral manifestations seem to be typical of a person with
Generalized Anxiety Disorder.
CASE REPORT: ANGELITA

SECTION OF PSYCHOLOGY
Department of Rehabilitation Medicine
Philippine General Hospital
Taft Avenue, Manila
5548400 loc 2421

PSYCHOLOGICAL EVALUATION REPORT

DATE OF EVALUATION: September 7, 2011

IDENTIFYING INFORMATION:

REASON FOR REFERRAL
Angelita was referred for psychometric evaluation to rule out the presence of
generalized anxiety disorder and hypochondriasis. The results of this evaluation can also be
used as reference to determine her fitness for employment and to determine future
psychotherapeutic interventions to enhance her well-being.

Name of Client: Angelita
Sex: Female
Date of Birth: July 26, 1966
Chronological Age: 45 years, 1 month, 11 days
Present home address: Imus, Cavite
Educational Attainment: College Graduate, BS Commerce (1991)
Referring physician: Mylene Rose Benigno, M.D.
Diagnosis/Working Impression: Osteoarthritis of the Right Knee;
R/O Generalized Anxiety Disorder;
R/O Hypochondriasis

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PERSONAL BACKGROUND
Family History
Angelita is the second to the youngest of the eleven children of Pablo and Mercedes
(both deceased). At present, she is married to Susano (51), a former OFW from Qatar and
presently unemployed since 2008. A housewife, Angelita seems to experience some distress
because of the financial difficulties their family is currently experiencing. Susano and Angelita
have three children: Shekainah (14), Stephen John (12) and Samuel James (10). Presently,
Angelitas in-laws are financially supporting their family.
Domestic Environment
Angelita shared that during her childhood, her parents did not employ corporal
punishments on her nor any of her siblings. Once or twice, Angelitas father would spank or
shout at her and her siblings and their mother would comfort them afterwards. At present, the
client explained that her relationship with her husband is somewhat harmonious.
Significant Health History
Recently, Angelita complains of osteoarthritis (pain and discomfort) of the right knee.
She has been confined after her tonsillectomy in 1998, and contracts allergic rheinitis
occasionally. Last June 2011, she has been to a psychiatrist after complaining that she was
lagingkinakabog, laging tense. She shared that during times of emotional unpreparedness and
stressful situations, she would experience palpitations, dyspnea, trembling and incessant crying.
There have also been times during class discussions and oral presentations that she would not
be able to think clearly (mental block) or to speak coherently and audibly (garalgal
angboses). She had been prescribed Alprazolam and Venlafaxine since. However, Angelita
shared that on certain occasions where she needs to be alert (e.g. household chores), she
would not take these medicines because they make her feel sleepy.
Aside from wearing reading glasses, Angelita shared that she has no major difficulties in
her eyesight and hearing although she would stammer when under distressful situations. Her
appetite is relatively elevated (she has to restrain herself from eating) and she currently
experiences some sleep disturbance because of intrusive thoughts relating to their financial
difficulties.
Social, Emotional and Behavioral History
Angelita has no notable mannerisms. She shared that whenever she is denied of what
she wants or does not get what she wants, she would often get disappointed but after some
time of thinking and analyzing, she would let go of these frustrations. Angelita describes herself
as a person who is maligalig (tense or agitated), workaholic, impulsive, socially reserved and
melancholic.
The client shared that after her mother and father died when she was in Grade 6 and
2
nd
year High School, respectively, she felt neglected and uncared for by her siblings. This is
why she sought for a boyfriend on the hope that this could satisfy her need for love from her
family. However, when her boyfriend left her for another woman, Angelita sank in a state of
depression to the point that she had thoughts of suicide and death.

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Angelita shared that while she appears to be very talkative, friendly and sociable on the
outside, at the end of each day she would get lonely and cry. According to her, she fears
rejection and somehow gets hurt easily by criticisms or rebuttal to the extent that she would
resort to evading interaction with others so that she may not offend (or get hurt). She also
seems to express some apprehension in her inability to restrain herself from sharing her
personal life to other people she just met. She also seems to be frustrated at herself for not
being able to overcome her weaknesses and insecurities which include her inability to speak in
English fluently because of her regional dialect (kapampangan).
The client also shared that her decision to marry her present partner seems somewhat
impulsive. She claims that nakapag-asawasiyang di niyamahal and this resulted to her present
regrets of not being able to work (and wasting her education) because of child-rearing
responsibilities. She also shared that in the past few months, she had been disappointed by a
lot of people who owed her money, and felt that they took advantage of her back when they
still had the financial-capacity because her husband was still in Qatar.
Angelita seems to express some fears about the safety of her children, and the kind of
death that she would have if ever she will pass away.
Educational and Work History
After working in a factory for two years, Angelita went back to school and finished a
degree in Commerce from the Baguio College Foundation in 1991. After which, she took a job
as an accounting clerk at Del Monte but resigned 6 months later because she wanted to work
abroad. However, she was not accepted after knowing that she was pregnant with her second
child.
In August of last year (2010), Angelita enrolled in an English-proficiency course at the
Imus Institute and Computer-skills training at the Cavite Computer Center because she wanted
to work as a Call Center agent. However, the client shared that she wanted to work but is
unable to pass job interviews because she would often tremble uncontrollably. At present,
Angelita wants to overcome her uncontrolled anxieties and physiological responses so that she
could work.
BEHAVIORAL OBSERVATIONS
Physical Appearance and Clothing
Angelita has an average height, weight and physique for her age and has fair
complexion. Her facial features are proportionate to his body whereas her hair and over-all
appearance was tidy, proper and well-groomed. There were no peculiarities in her walking
ability or posture.

Speech Behavior
Angelita spoke in an audible volume and at a relatively fast speaking rate. There were
also no noticeable distortions in her pronunciation. The patient primarily spoke in Filipino and
can fully understand and speak English. During the evaluation, Angelita responded to every
question that the clinician asked of her attentively and sensibly.


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Quality of Communication
Angelitas vocabulary and grammar skills were suggestive of normal intellectual
functioning. She showed affects that were appropriate to verbal content and displayed emotions
such as happiness, agitation, sadness and anxiety. Thought content revealed no evidence of
delusions, paranoia or suicidal/homicidal ideation. Flight of ideas, clang associations and
perceptual disorders were absent.Angelitas level of insights about herself, loved ones and other
people seem to be intact.

Movement/Activity
Throughout the evaluation, Angelita remained seated and maintained eye contact and
attention towards the clinician. She emotionally appeared agitated and tense especially when
she is not able to answer questions asked of her. Over-all, Angelitas attitude during the
evaluation was open and cooperative. No imminent dangers were evident.

CURRENT EMOTIONAL STATE

Depression Level
Angelita seems to show no overt signs and behavioral manifestations of depression at
the time of psychological evaluation. She also does not seem to show any signs of lethargy or
fatigue. She also seems to be able to concentrate in detailing vital information needed by the
clinician.

Anxiety Level
Angelita seemed relatively agitated and apprehensive in her actions and behaviors
during the evaluation. She seems to be able to keep her agitation under control when she is
asked.

Premorbid personality
Angelita shared that it was only recently that the people around her noticed her relative
agitation and nervousness. She contends though that even before she was really a very nervous
person.

Coping Style
Angelita seems to cope with her difficulties and anxieties positively and actively.

Perception of Disability
Angelita perceives her difficulties and present anxieties negatively because she sees
them as hindrances for her to be able to work and function normallyin social settings.

Self-esteem and Level of Motivation
Angelita has low to average levels of self-esteem despite her present difficulties. At
present, she verbalizes her intent and dedication to renew her mind and to overcome her
anxieties.




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Patients Plans
Angelita plans to find an occupation which could sustain their familys financial needs.
She also aims to know and resolve the underlying tensions for her nervousness.

Social Support System
Her family relationships seem harmonious although the client has only a few networks
outside the home. Her strong belief in God is also one of her coping mechanisms to accept the
things she cannot change.


Patients Expectations
Given her social support system, her abilities and her determination and perseverance,
with some external assistance, Angelitas planned activities seem to be realistic and attainable.

TESTS ADMINISTERED
1. Slosson Intelligence Test Revised (SIT-R)
2. Test of Non-Verbal Intelligence 2
nd
Edition (TONI-2)
3. Minnesota Multiphasic Personality Inventory 2 (MMPI-2)
4. Draw-a-Person Test (DAP)
TEST RESULTS AND INTERPRETATION
Slosson Intelligence Test Revised (SIT-R)




In the SIT-R, Angelitas true standard score is 98 and her IQ exceeds 45% of the general
population. This being the case, it can be said that Angelita has relatively normal verbal intelligence
or intelligence learned from exposure to ones environment, culture and life experiences. This
suggests she has adequate capacities to learn and recall information, to reason quantitatively and to
apply these abilities in solving problems and dealing effectively with the environment.

Test of Non-Verbal Intelligence 2
nd
Edition (TONI-2)




The results of Angelitas TONI-2 are concurrent with the findings of her SIT-R. For her age,
Angelita possesses normal intelligence especially in concepts involving abstract reasoning. Her
performance in TONI-2 would imply that she has adequate abilities to solve problems and form
decisions, to engage in analysis of information presented to her and to think critically. She may also
possess some significant potential in processing and remembering abstract and complex
information.
Taking into consideration the clients performance in the TONI-2 and SIT-R, it can be said
that the clients orientation, memory and attention are intact during the psychological examination.

Raw Score TONI-2 Quotient Percentile Rating
26 94 34% Average
Raw Score True Standard Score Percentile Classification
130 98 45% Average

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Minnesota Multiphasic Personality Inventory II (MMPI-II)
Measures of inconsistent responding indicate that Angelitas MMPI profile is valid although
characterized by some minor inconsistencies. Despite her elevated scores on the Lie scale, other
measures of infrequent responding indicate that the client accurately described her mental health
status in taking the test.
Angelitas scores indicate that she is presently experiencing a great amount of psychological
turmoil (fear, anxiety, tension, depression). At the time of evaluation, her relatively elevated scores
in various clinical scales indicate that she is highly anxious, apprehensive, unhappy and cynical.
Somatic complaints may occur as a result of these elevated scores. Intruding thoughtscould also be
present and thus she may have some difficulty in concentrating. She may also have low energy
levels and unique beliefs. Angelita may also have a tendency to over-control her emotions and
maysomewhat feel inferior and uneasy in social situations. She may be excessively sensitive and
responsive to the opinions of others and feel misunderstood and unloved. The client is highly
introverted, having some tendencies to avoid social situations and interpersonal relationships
whenever possible. In dealing with her psychological problems, Angelita tends to internalize and
tends to be conventional and cautious.
Draw-a-Person Test (DAP)
Angelitas drawings are suggestive of feelings of weakness, inadequacy, futility and
depression. They are also indicative of the clients need for emotional support when under stress
and her tendency to head for flight from a frustrating environment. They also imply the clients
refusal to listen to the criticism of others and her detached interactions with them. The features of
her drawing indicate that the client has a tendency to avoid unpleasant situations, and some free
flow of basic drives and impulses with inadequate controls.
Over-all, the strokes of her drawing implies determination and fearfulness although the
location of her drawn figure is indicative of the need to maintain careful control in freely expressing
feelings or emotions.
DIAGNOSTIC IMPRESSIONS
Based on Angelitas self-reports and shared experiences, her psychological test results and
the clinicians personal observations, Angelita qualifies for a clinical diagnosis of Generalized
Anxiety Disorder. For the past six months, she has experienced excessive and uncontrollable
anxiety and worry about a number of events. Furthermore, her worry and apprehension was
accompanied by at least three physiological symptoms that included agitation, disturbed sleep and
difficulty concentrating. Also, her anxiety does not occur within the context of other disorders such
as a Panic Disorder nor Social Phobia because the client experiences anxiety and apprehension even
without fear of an upcoming panic attack or social situations in which others will evaluate her. In
her apprehension, Angelita also experiences distress and difficulty in controlling her worries to the
extent that it has impaired her from communicating effectively and working productively. Finally, the
disturbance that the client is presently experiencing is not due to the direct physiological effects of a
substance.
On the other hand, Angelita does not qualify for a clinical diagnosis of Hypochondriasis.
Although the clients score in the hypochondriasis scale of the MMPI is moderately elevated, her
somatic complaints are a result of her highly elevated scores in other clinical scales such as
depression and anxiety. These somatic complaints could be viewed as a kind of coping mechanism

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in dealing with her psychological tensions resulting from their financial difficulties including her
unemployment.
Given the results of her intelligence test, it can be said that Angelita is capable of engaging
in productive work. However, it is recommended that her working environment be free from as
much pressure and tension as possible (e.g. clerical or secretarial work). Also, she would need to
undergo psychotherapy so that she may be taught relaxation and stress management techniques in
order for her to be able to effectively manage her agitation and anxiety.
RECOMMENDATIONS
Angelitais recommended to:

Continue medications prescribed by her psychiatrist.
Be taught stress management and relaxation techniques.
Undergo desensitization, imaginal flooding and behavior rehearsal psychotherapy in
order for her to be able to manage her anxiety and agitation in unfamiliar social
situations.
Undergo gestalt therapy as a way of integrating previous emotional issues she has
faced.

For her work environment:
It is recommended that Angelita find an occupation whose working environment
has minimal pressure and work tension (e.g. clerical or secretarial work).
Research more on generalized anxiety disorder, depression and/or suicide to
further enhance their knowledge of interacting and helping their co-worker.
Make Angelita feel that she is accepted, loved and understood for who she is,
her conditions, limitations and abilities.

For her family and friends:
Be on the lookout for possible behavioral and cognitive symptoms of depression
and suicidal tendencies in Angelita.
Research more on generalized anxiety disorder, depression and/or suicide to
further enhance their knowledge of interacting and helping their loved one.
Make Angelita feel that she is accepted, loved and understood for who she is,
her conditions, limitations and abilities.

Thank you for referring Angelitato us. It has been a pleasure working with her. If there are
any concerns regarding the evaluation, please do not hesitate to call us at 5548400 Loc. 2421.


Prepared by:

_______________________
Tyrone Reden L. Sy
Clinical Psychology Intern




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THERAPY PLAN
GOAL # 1: To reduce the clients anxiety and apprehension to manageable levels that
will enable her to express herself better.
Number and Duration
of Sessions
Specific Behavioral
Objectives
Methods/Strategies Evaluation/Assessment
Method to be used
2 - hour sessions
(Relaxation techniques
and mental imagery)
1) Make the client
relax and tension-free
for a period of 30
minutes to 1-hour.
Teach client relaxation
techniques and
breathing exercises
Behavioral observation;
self-reports of client;
take-home exercises;
journal; assignment:
list anxiety hierarchies
2 - hour sessions
(Systematic
desensitization and
imaginal flooding)
1) The client
progresses up to the
second highest
anxiety-provoking
scene or stimuli in her
list of anxiety
hierarchies in imaginal
flooding.
Systematic
desensitization and
imaginal flooding
Behavioral observation;
self-reports of client;
journal writing; take-
home practice;
assignment: list of
social situations which
had been highly
anxiety-provoking
2 - hour sessions
(Behavior Rehearsal)
1) The client is able to
remain calm, and able
to appropriately
respond to at least
75% of the social
situations which she
has listed as anxiety-
provoking.
Behavior rehearsal and
simulation; social skills
training
Behavioral observation;
self-reports of client;
journal writing; take-
home practice;


GOAL # 2: To enable the client to face unfinished businesses in her past and integrate
her experiences into one coherent whole.
Number and Duration
of Sessions
Specific Behavioral
Objectives
Methods/Strategies Evaluation/Assessment
Method to be used
One 2 - hour
session (Gestalt
Therapy)
1) Make the client
realize the baggage
she still carries inside
of her (and the effects
of these in her present
life) as well as those
aspects of herself that
she is unaware of or
denying.
Internal dialogue
exercise and empty-
chair technique
Behavioral observation;
self-reports of client;
take-home advices

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DISCUSSION

As Kring et al (2013) has stated, the central feature of GAD is worry. This is particularly
applicable in the case of Angelita who constantly worries about a lot of things. For one, she reported
being particularly worried about the present financial concerns of their family and this has
generalized to other aspects of their domestic life. Angelita has expressed some agitation about the
health of her children, as well as their academic welfare. She seems to be worried that if she doesnt
have an active part in her childrens studies, then they will automatically fail. She also seems to be
apprehensive about the kind of death that she will have if ever she will pass away. Angelita has
been experiencing these worries and anxieties for the past three months and these have been
associated with other physiological symptoms such as restlessness, difficulty concentrating and sleep
disturbance.

Most importantly, Angelita has been avoiding situations in which negative outcomes could
occur. For example, while she wanted to talk to her acupuncture therapist to assert for better
treatment, she hesitated doing so out of fear that she will be unable to get her message across
clearly because her mind will just go blank (mental block) and will not be able to speak coherently
(garalgal ang boses). The same goes with her psychiatrist.

Biologically-speaking, how and why Angelita has acquired GAD could have been a
malfunction of her GABA system (Kring et al, 2013). There could also be some abnormalities in her
serotonergic and noradrenergic neurotransmission (Tyrer & Baldwin, 2006). However, a better
explanation would be that of Borkovec & Newman (1998, as cited in Kring et al, 2013) who said that
people with GAD worry in order to distract/relieve themselves from overwhelming emotions brought
about by early experiences of trauma. This is very much applicable to Angelita. At a young age,
Angelita suffered many traumatic experiences from the death of her parents, from being left by her
boyfriend for another woman, and from being cheated on by people who owed her some money.
From Borkovecs perspective, then, it would seem that all these free-floating anxiety as Freud
originally described GAD, is a result of unresolved and unfathomable emotionally-charged
experiences. Hence, Angelita worries in order to avoid facing these emotions.

TREATMENT
As Angelitas therapist, the original goals of my therapeutic plan were two-fold: (1) to equip
her with the necessary relaxation techniques and skills to manage her anxiety, worry and

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physiological agitation; and (2) help her face her unresolved emotional baggages through catharsis
and cognitive reframing. These kinds of treatment have been proven to be more effective than
nondirective treatment or no treatment at all (Kring et al, 2013). However, because of the clients
financial limitations and time constraints, therapy sessions were limited to addressing goal 1.
For eight weeks, the client underwent therapy for 1 to hours per session. Each session
began with brief processing of the clients experience for the past week through minimal CBT/RET to
establish rapport. Relaxation techniques such as deep breathing exercises, progressive muscle
relaxation and guided mental imagery were done and taught to the client. Succeeding sessions also
involved a review and reinforcement of previously learned techniques. Likewise, since the client
reported some difficulty asserting her needs to persons in authority or even to other people,
behavior rehearsal was also done within the therapy sessions. I also tried to invite family members
however, they refused to come with the client.
SOCIAL ANXIETY DISORDER
When I would walk into a room full of people,Id turn red and it would feel like everybodys eyes
were on me. I was embarrassed to stand off in a corner by myself,but I couldnt think of
anything to say to anybody. It was humiliating.I felt so clumsy, I couldnt wait to get out.

BRIEF THEORETICAL BACKGROUND
Social anxiety disorder (SAD) is one of the most common among all mental health disorders
(Shorey & Stuart, 2012). According to Kring, Johnson, Davison and Neale (2012), social anxiety
disorder is a persistent, unrealistically intense fear of social situations that might involve being
scrutinized by, or even just exposed to, unfamiliar people.
This disorder is also and previously called social phobia in the DSM-IV-TR. The shift from the
previous label to social anxiety is due to its more pervasive resulting problems which interferes more
with a persons normal activities (Kring et al., 2012). According to the Diagnostic and Statistical
Manual of Mental Health Disorders (DSM-IV-TR, American Psychiatric Association, 2000) individuals
suffering from this syndrome are afraid of negative evaluation by others and typically worry that
they are perceived as inadequate, weak or dumb. They also experience intense anxiety during social
or performance situations, where the level of fear is unreasonable or excessive. As such the

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individual either suffers through the situation with intense anxiety or avoids situations entirely; this
results in impairment on the persons life.
The proposed DSM-5 Criteria for Social Anxiety Disorder specifically lists the following:
marked and disproportionate fear and consistently triggered by exposure to potential social scrutiny,
exposure to the trigger leads to intense anxiety about being evaluated negatively, trigger situations
are avoided or else endured with intense anxiety and symptoms persist for at least 6 months (Kring
et al., 2012). While the DSM-IV-TR specified that the person recognizes the fear is unrealistic, under
DSM-5, this is not mentioned (Kring et al., 2012). Also, not included in the criteria in DSM-5 is the
inclusion of the duration criterion for those under age 18, which was in DSM IV-TR (Kring et al.,
2012).
ILLUSTRATIVE CASE STUDY
This case study is lifted from the journal article of Shorey and Stuart (2012).
Henry is a 26 year old male of Caucasian decent that was referred to a psychological unit
of a university due to anxiety symptoms. The patient reported living alone while working as a
cashier in a retail company on a part-time basis, as he studies full-time at the local university.
Henry presented with symptoms of social anxiety disorder. He reports being fearful that
others would judge him negatively in social situations. He becomes anxious when a teacher asks him
questions and when thinking of having to speak in public. He also mentioned that he is more
anxious when he is around women. He added that he is anxious about his writing and that other
people would see his hand writing and considers it bad and illegible. He said that this fear was
increasingly affecting his life negatively. Within the two years after Henry was discharged in the
army that he reported having intense increase in his social anxiety. While Henry did not directly
mention that he avoids social situations, he did mention that he interacted rarely with his peers, and
chooses not to speak in class.
CASE DISCUSSION
Henry reports a history of punitive and restrictive parenting. He remembers his father as
severely judgmental of him while demanding perfection and strict adherence to his standards. He
also remembers being disallowed to express emotions or complaints. As Festa and Ginsburg (2011)
suggested, this type of parenting termed parental overcontrol is related to higher levels of social
anxiety in children and adolescents, and ultimately in adults. Parental overcontrol limits the chances
of a child to try and explore the world, situations and learn and develop new skills (Festa &

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Ginsburg, 2011). This limitation decreases the childs ability to develop social competencies that
results to anxious and avoidant children, and then adults (Festa & Ginsburg, 2011). In instances
that Henry would fall short from his fathers expectations, which happens to all children, his fathers
prevention of voicing emotions as well as his negative reactions and expressions may have appeared
to Henry as signs of rejection. This feeling of rejection would also have led Henry to believe that
other people, especially his peers, reject him (Festa & Ginsburg, 2011).
It may not have been helpful for Henry also, that as a child, he and his family moved and
transferred homes multiple times, and even moved countries. Being uprooted many times may have
lessened Henrys chances of forming friendships as a child. Festa and Ginsburg (2011) mentioned
that children who can find people they can talk and connect to and share experiences with worry
less about what outsiders think of them and would feel socially accepted, thus, lowering their levels
of social anxiety.
Henry has a level of awareness that the negative treatment and words he heard and
absorbed from his father and their home environment may have influenced the way he views and
talks to himself, his view of the world, and especially how other people may perceive him. He
imbibed the habit of evaluating himself and being overly critical of how he behaves with other
people. His social anxiety disorder appears to have been the result of the combination of his
upbringing and home environment, gender and cultural pressures that imposes strict rules on
expression and behavior, and negative beliefs.
Feeling incompetent in his social skills, and fearingcritical evaluation from others in social
situations became a vicious cycle for him, which led him to experience intense feelings of anxiety
that pushed him to avoid social encounters. On the other end, Henry feels the desire and need to
connect with other people as he wishes to meet more people, make new friends, and have a
romantic relationship. This burning desire to move towards one direction, while being pulled back by
fear further increases Henrys anxiety and causes him emotional pain.
TREATMENT
Social anxiety disorder is a condition that does not have a cure. However, through therapy, a
person may be able to manage the condition and live a functioning, productive and meaningful life.
Having a solid motivational base - his desire to meet new people, make friends and eventually have
a romantic relationship - treatment outlook for Henry is hopeful.

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The treatment would be an adaptation of Mindfulness-based Cognitive Behavioral Therapy
(CBT) and will be a progression starting from alliance formation, psycho-education about his
condition, self-report and awareness of his own symptoms and experience, learning tools and tips
for self-monitoring activities and strategies, learning relaxation techniques through mindfulness-
meditation, and cognitive reframing and progressive exposures. Mindfulness-based CBT may help
Henry reduce somatic symptoms of his social anxiety, as may also help with the cognitive reframing
of his negative beliefs, by being present in the moment, avoiding cascading destructive critical
thoughts and blocking over focus on external cues (Sharma, Mao, & Sudhir, 2012). The duration of
the treatment would be around 23 (to 25) sessions over a period of four to six weeks.
Treatment goals are in line with Henrys goal, which is to develop relationships and connect
with people. Progression from one step to another will depend on Henrys confidence level and
readiness to proceed, with the guidance and support of the therapist, especially during the
progressive exposure part of the treatment.
SPECIFIC PHOBIAS
Ginko is a 32-year-old woman who presented with a history of fear of cockroaches that had
begun during adolescence. This fear impacted markedly on her life. She continuously
anticipated the possibility that cockroaches would come in to her home; and she often
avoided places where there were likely to be cockroaches. When cockroaches were present,
her anxiety was noticeably increased and included panic attacks. Over the years, she felt
increasingly demoralized by her circumstances.

Brief Theoretical Background
The DSM IV-TR specifies the following as symptomatic of Specific Phobias (formerly Simple
Phobia): the essential feature of Specific Phobia is marked and persistent fear of clearly discernible,
circumscribed objects or situations (Criterion A). Exposure to the phobicstimulus almost invariably
provokes an immediate anxiety response (Criterion B).This response may take the form of a
situationally bound or situationally predisposedPanic Attack (see p. 430). Although adolescents and
adults with this disorder recognizethat their fear is excessive or unreasonable (Criterion C), this may
not be the casewith children. Most often, the phobic stimulus is avoided, although it is sometimes
endured with dread (Criterion D). The diagnosis is appropriate only if the avoidance, fear, or anxious
anticipation of encountering the phobic stimulus interferes significantlywith the person's daily

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routine, occupational functioning, or social life, or if the person is markedly distressed about having
the phobia (Criterion E). In individualsunder age 18 years, symptoms must have persisted for at
least 6 months beforeSpecific Phobia is diagnosed (Criterion F). The anxiety, Panic Attacks, or
phobic avoidance are not better accounted for by another mental disorder (e.g.,
ObsessiveCompulsiveDisorder, Posttraumatic Stress Disorder, Separation Anxiety Disorder,Social
Phobia, Panic Disorder With Agoraphobia, or Agoraphobia Without History ofPanic Disorder)
(Criterion G). (p. 443). The DSM IV-TR then goes on to enumerate the following as subtypes of
specific phobia: (1) animal type; (2) natural environment type; (3) blood-injection-injury type; (4)
situational type; and (5) other type.

According to Kring et al (2013), it is likely that two key changes in DSM 5 regarding
specific phobias would include (1) a specification of the duration criteria for adults and (2) that the
person would need not perceive fear as unrealistic.
CASE STUDY: VOMIT PHOBIA
Veale and Lambrou (2006) studied the specific phobia of vomiting (also known as
emetophobia). They found that vomit phobics did not discriminate between fear of vomiting whether
they were alone or in public situations. They also feared that they or others will vomit however, the
frequency of vomiting was not significantly greater in individuals with vomit phobia compared to the
control group of the study. Vomit phobics also reported feeling nauseous almost every day or every
other day and that the sensation lasts longer than in the panic disorder group. Those with vomit
phobia were also found to higher scores in the Beck Anxiety Inventory than those with panic
disorder. For vomit phobics, the seven perceived cause of nausea included: (i) anxiety; (ii) irritable
bowel syndrome;(iii) migraine; (iv) gastric/duodenal ulcer; (v) chemotherapy; (vi) middle ear
disease/balance disorder; (vii) brain tumour. Vomit phobics were more likely to report looking for an
escape route, tryingto keep tight control of their behavior, taking medication, reading, sucking
antacids/mints, and moving very slowly. The study concluded that there seems to be an overlap in
the cognitive processes and behaviors with panic disorder as well as obsessive compulsive disorder
(fear of contamination) and social anxiety.




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CASE DISCUSSION
The behaviorist perspective notes that phobias are conditioned responses that develops after
a threatening experience and is sustained by avoidant behavior (Kring et al, 2012). It can be said
that the same mechanism applies to the perpetuation of vomit phobia. Avoidant behaviors (and
even the act of vomiting itself) provide relief that reinforces vomit phobia through negative
reinforcement.
TREATMENT
As with other specific phobias, Veale and Lambrou (2006) recommended the use of imaginal
exposure to vomiting and role plays of the self-vomiting so as to help the client reduce the
awfulness of vomiting and thereby drop their avoidance, excessive vigilance towards vomiting and
safety seeking behaviors. As vomit phobia has similar characteristics with panic disorder, the authors
also recommend that therapists explore with their client the meaning or imagery associated with
losing control and to practice losing control.
PANIC DISORDER (WITH AGORAPHOBIA)
For me,a panic attack is almost a violent experience. I feel disconnected from reality. I feel like
I'm losing control in a very extreme way. My heart pounds really hard, I feel like I cant get my
breath, and theres an overwhelming feeling that things are crashing in on me.
BRIEF THEORETICAL BACKGROUND
Panic disorder is a condition characterized by recurring severe panic attacks (Marazziti,
Carlini, & DellOsso, 2012). According to Kring et al. (2012), a panic attack is a sudden attack of
intense apprehension, terror, and feelings of impending doom, accompanied by at least four other
symptomsthat typically last for about 10 to 15 minutes. However, attacks may be as short as one
to five minutes and as long as 30 minutes, coming and going for a period of hours with varying
intensity and varying symptoms (Marazziti, Carlini, & DellOsso, 2012). These attacks happen during
occasions that may not seem related with each other (Kring et al., 2012). These attacks may be
triggered by specific and clear causes (cued) or may be set off randomly (uncued) (Kring et al.,
2012). Marazziti, Carlini, and DellOsso (2012) specified the common symptoms of a panic attack as
including rapid heartbeat, perspiration, dizziness, dyspnea, trembling, uncontrollable fear and
hyperventilation. Further, other symptoms listed were sweating, shortness of breath, sensation of
choking, chest pain, nausea, numbness or tingling, chills or hot flashes, and some sense of altered
reality. Other symptoms include a feeling of being outside ones body (depersonalization) and a

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feeling of the worlds not being real (derealization) (Kring et al., 2012). Additionally, a person
experiencing a panic attack may have thoughts of impending doom and has a strong desire of
escaping from the situation. A persons experience is made worse by ongoing worries about
developing other attacks and eventually dying, which increases the likelihood of feeling more fear.

The criteria for Panic Disorder as identified by DSM-5 are recurrent, uncued panic attacks, at
least 1 month of concern about the possibility of more attacks, worry about the consequences of an
attack, or maladaptive behavioral changes because of the attacks.
Previously, Agoraphobia was included as a diagnosis under Panic Disorder however, the DSM
5 has pushed for its diagnosis as a separate disorder because numerous studies have shown that
panic disorder and agoraphobia may occur independent of each other (Kring et al, 2012). The DSM
5 proposes the following criteria for Agoraphobia as a separate diagnosis: Disproportionate and
markedfear or anxiety about at least2 situations where it would bedifficult to escape or receivehelp
in the event of incapacitationor panic-like symptoms,such as being outside of thehome alone;
traveling on publictransportation; being in openspaces such as parking lots andmarketplaces; being
in shops,theaters, or cinemas; or standingin line or being in a crowd. These situations
consistentlyprovoke fear or anxiety. These situations are avoided,require the presence of a
companion,or are endured withintense fear or anxiety. Symptoms last at least 6 months (Kring et
al, 2012, p. 180).
ILLUSTRATIVE CASE STUDY
This case study is lifted from the book Case Studies in Abnormal Psychology by Oltmanns,
Martin, Neale and Davison (2012)..
Dennis Holt was a 31 year old salesman (no ethnicity or descent indicated). He is divorced
but has a fiance named Elaine. He has experienced several panic attacks during the past 10 years
but did not seek psychological treatment immediately. He appeared confident with his tall posture,
neatly trimmed hair, and friendly smile.
Dennis was referred to a psychological clinic after an incident while he was doing his
Christmas shopping with his fiance in a mall. Even though Dennis was usually uneasy in large
crowds, he was preoccupied with the Christmas rush and the motivation to buy gifts to mind.
Suddenly, Dennis felt very sick, his hands began to tremble and his vision became blurred. He felt
weak and started gasping for air as he felt heavy pressure on his chest, as if he was being

20

smothered. He felt terrified, but was unsure why. He swiftly ran out of the store and entered their
car, opened the window, lay down and closed his eyes. His dizziness and shortness of breath
continued for around 10 more minutes.
Denniss condition appears to be a combination of panic disorder, agoraphobia and
generalized anxiety disorder.
CASE DISCUSSION
Dennis does not remember having panic attacks in his childhood. He was a shy child, but he
had friends and was a member of his high school drama club. His father, though, was a difficult
person, often demanding perfection and unrealistic expectations of him. Even as an adult, his father
never missed an opportunity to show disapproval and disappointment. This type of parenting may
have had a effect on Dennis self-constructs and his sense of control (Festa & Ginsburg, 2011). He
may have developed a negative view of himself as a person, as well as his future. He may have also
felt that no matter what he does, nothing is good enough.

Dennis remembers choking during tests in college where his hands would sweat and his
breathing would become rapid and shallow, his mouth becoming dry. It was also during his college
years when he developed gastrointestinal problems, interchanging between constipation, cramping
and diarrhea. These experiences and symptoms may have been rooted in his father; from the
psycho-physiological stress of his fear of not measuring up to his fathers expectations that were
transferred to him.
Dennis became an anxious and tense person, frequently having headaches, muscle tension
and insomnia. He became self-conscious, and preoccupied with what others think of him and
generally fearful and overly cautious.
The panic attack in the mall was not the first for Dennis as an adult. Hes had these attacks
since he was 24 years old. The first attack happened during a dinner theatre where Dennis was self-
conscious about eating in public and did not really like the company. He suffered from
gastrointestinal problems and was worried he might have an attack during that dinner and will have
to use the restroom and explain the problem to his company. Perhaps a slight discomfort in his
stomach during dinner caused Dennis to respond and think catastrophically. In a couple of minutes,
he started to feel like he was choking and having a heart attack. Six months later, another attack
happened while driver during rush hour. The panic attacks made Dennis cautious of the things he

21

does and places he goes to. It impacted his social life considerably and eventually caused his first
marriage to end.
Dennis situation may have been a result of cognitive and behavioral responses that
interacted with and made worse by his sensitivity to stress. His first panic attack happened during a
stressful activity for Dennis, and the experience in turn, traumatized him. He became fearful of
many different situations that he thinks will cause an attack and avoided them, again perhaps due to
how he thinks of himself, about whats going to happen to him and what other people will think of
him, rooted in his relationship with his father. Dennis negative beliefs about what is going on with
him worsens his condition, as consequently thinks and fears that he will die as soon as he feels
some new or different bodily sensation or senses cues from his environment (Kring et al., 2012).
TREATMENT
Panic attacks may have its roots in the persons past and its effect on the persons
unconscious(Kring et al., 2012). As such, a combination of psychodynamic and cognitive behavioral
therapy would be used.
In line with Dennis objective to manage his panic attacks, the treatment goals would be to
identify the triggers, emotions and meanings surrounding the panic attacks (Kring et al., 2012) with
the hopes that Dennis will face, fight and defeat his demons. After such phase of the treatment,
the next goal would be focused on the present and to aim achieve his objective.
The therapy would progress from alliance formation, psycho-education about his condition,
psychotherapy, self-report and awareness of his own symptoms and experience, learning tools and
tips for self-monitoring activities and strategies, learning relaxation techniques, and cognitive
reframing and progressive exposures. Part of the cognitive treatment would be identifying triggers
and starting points of attacks, and learning how to challenge the catastrophized thoughts that follow
(Kring et al., 2012). With the progressive exposures, Dennis would be exposed, in progressive
quantities, to triggers and starting points and sensations that lead to the attack (Kring et al., 2012).
These exercises would demonstrate to Dennis the realistic outcome, instead of what he negatively
visualized. These would also empower Dennis as it would make him realize that he has the power to
control his emotions and reactions as well as his thoughts. The duration of the treatment would be
around 23 (to 25) sessions over a period of four to six weeks.
Dennis has had successes in his life particularly with his job as a salesman. The strength and
will to achieve his current success can also be his strength to finally overcome and manage his

22

condition. With the support and encouragement of his fiance Elaine, his friends and co-workers,
Dennis can reach his goal, manage his condition and live a functioning and fulfilling life.
References

Festa, C. C.& Ginsburg, G. S. (2011). Parental and peer predictors of social anxiety in youth. Child
Psychiatry & Human Development,42(3), 291-306. doi:10.1007/s10578-011-0215-8
Kring, A. M., Johnson, S. L., Davison, G., & Neale, J. (2012). Abnormal Psychology (12th ed.).
Hoboken, NJ: John Wiley & Sons, Inc.
Marazziti, D., Carlini, M., & DellOsso, L. (2012). Treatment strategies of obsessive-compulsive
disorder and panic disorder/agoraphobia. Current topics in medicinal chemistry, 12(4), 23853.
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