Anxiety Disorders

Sy and Morga
Presentation Flow
I. GAD Angelita
II. SAD Henry
III. Snippet: Social Anxiety Disorder
IV. Journals
Angelita
A case of Generalized
Anxiety Disorder
Identifying Information
Name of Client: Angelita
Sex: Female
Age (as of Sep 7, 2011): 45 years, 1 month, 11 days
Present home address: Cavite
Educational Attainment: College graduate, BS
Commerce
Working Impressions:
Osteoarthritis of the Right Knee;
R/O Generalized Anxiety Disorder;
R/O Hypochondriasis
Personal background
Married to Susano, former OFW from Qatar and
unemployed since 2008.
Currently experiencing distress because of the
present financial difficulty of their family (in-laws
are supporting them)
Three children: Shekainah (14), Stephen John (12)
and Samuel James (10).
Relationship with husband somewhat
harmonious
Significant health history
June 2011: has been to a psychiatrist after
complaining that she was laging kinakabog, laging
tense.
In 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 ang boses).
Significant health history
Prescribed Alprazolam (Xanax; benzodiazepine) and
Venlafaxine (anti-depressant; SNRI) doesnt
usually take them
Appetite is relatively elevated (she has to restrain
herself from eating)
She currently experiences some sleep disturbance
because of intrusive thoughts relating to their
financial difficulties (worry).
Worries about the school performance of her
children.


Significant health history
Describes herself as maligalig (tense or agitated),
workaholic, impulsive, socially reserved and
melancholic.
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.
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.
Significant health history
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
The client also shared that her decision to marry her
present partner seems somewhat impulsive. She claims
that nakapag-asawa siya ng di niya mahal and this
resulted to her present regrets of not being able to
work (and wasting her education) because of child-
rearing responsibilities.
Significant health history
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.
Behavioral Observations
Speech behavior:
Angelita spoke in an audible volume and at a relatively
fast speaking rate
Appropriate affect, no perceptual and thought
distortions
Client emotionally appeared agitated and tense
especially when she is not able to answer questions
asked of her.
Appeared agitated and apprehensive in her actions.
Angelita shared that it was only recently that the
people around her noticed her relative agitation
and nervousness (premorbid personality).
Test Results
Average intelligence (Slosson Intelligence Test
Revised and Test of Non-Verbal Intelligence 2)
MMPI 2:
Valid profile with minor inconsistencies
Presently experiencing a great amount of psychological
turmoil (fear, anxiety, tension, depression).
Various clinical scales indicate that she is highly anxious,
apprehensive, unhappy and cynical
Intrusive thoughts present
Tends to internalize and be conventional and cautious
Test results (Draw-a-Person
test)
Suggestive of feelings of weakness, inadequacy, futility
and depression.
Indicative of the clients need for emotional support
when under stress and her tendency to head for flight
from a frustrating environment
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.

Qualifies for a diagnosis of
GAD
Excessive anxiety and worry at least 50% of days
about at least two life domains (finances, school,
work, family)
Sustained for at least three months (June to Sep
2011 and even before)
Anxiety and worry associated with difficulty
concentrating or mind going blank, restlessness,
sleep disturbance
Avoids situations in which negative outcomes could
occur (confrontations)
Therapy Plan (8 to 10 sessions)
Initially, therapy had two goals:
1. To reduce the clients anxiety and apprehension to
manageable levels that will enable her to express
herself better.
2. To enable the client to face unfinished businesses
in her past and integrate her experiences into one
coherent whole.
Limitation:
Financial concerns of client
Time constraints for therapist
Priority: Management of anxiety symptoms (Goal 1)
Goal of Therapy: Teach client skills
to cope with agitation and anxiety
Once a week for 1 to 1 hours, for 8 weeks
Relaxation techniques (deep breathing exercises
and progressive muscle relaxation, guided mental
imagery)
Behavior rehearsal (how to talk/assert ones needs
to a person in authority or to other people)
Some cognitive behavior therapy/RET (countering
some of the clients automatic thoughts such as if I
do not assist my children in school they will fail)
Tried to invite family members (refused to go)
Henry
A case on Social Anxiety Disorder
Personal Background
Henry
Caucasian descent; 26 yrs old
Took a test so he can leave high school earlier than
usual (GED)
Enrolled in a community college but could not afford to
continue school
Was in the military for 6 years, was deployed to Asia
and Middle East
Now a part-time cashier in a retail company
And a full-time student (University); completed 2
semesters; major in Engineering
Personal Background
Born in Europe, moved to America at the age of 2
or 3
Moved again to Asia and finally to a southern state
Has 2 older brothers
Never been married
Lives alone
Has few close friends
Doesnt interact much with peers
Significant History
Had many academic problems as a child
Would get into fights; interrupts others; loiters in
classroom
Described himself as a shy and timid child/introvert
Family environment:
Father was critical and remorseless in upholding
his standards of behavior
Father was judgmental and did not allow voicing
of complaints or expression of emotions

Significant History
Started experiencing loss of sleep, low appetite and
feelings of sadness while in the military
Had difficulty adjusting after returning from his
final assignment in the military (could not sleep)
But these symptoms did not last long
Feelings of anxiety has been increasing in the past 2
years
Significant History
Denies smoking tobacco
Denies taking illegal substances
Rarely consumed alcohol
Reason for Referral
Does not like to speak in classes
Becomes anxious when a teacher asks him in class
Gets anxious when her has to speak in public
Anxious around women
Anxious when he knew people would see and read
his handwriting (problems with hand written
tests/exams)

Assessments
Diagnostic Interview
Anxiety Disorders Interview
Schedule for DSM-IV (ADIS-IV)
It was determined he
met criteria for SAD

Treatment used in actual
case
Cognitive Behavioral Approach
from Therapist guide for managing social anxiety: A
cognitive-behavioral therapy approach by Hope and
colleagues (2006;2010)
Approximately 16 weekly 1-hour sessions that are to
occur within a 16 to 20 week period.
Comprised of five segments (psychoeduation,
cognitive restructuring, exposure, advanced cognitive
restructuring, and termination)
Use of a Workbook for SAD with outline and home
works

Treatment used in actual
case
Psychoeduation 4 sessions
Self-report on physiological, cognitive, and
behavioral components of his social anxiety
Self-monitoring
Cognitive restructuring 2 sessions
Learning automatic thoughts, thinking errors and
rational responses
Exposure 6 sessions
Engaging in situations he identified on his fear and
avoidance hierarchy
Treatment used in actual
case
Advanced cognitive restructuring 2 sessions
Move the client from situation-specific automatic
thoughts to being able to recognize more general themes
in automatic thoughts and core beliefs
Use the techniques they have learned to challenge and
modify their automatic thoughts and core beliefs.
Termination
Discussed assessment of progress and relapse prevention
Processed the emotions he felt about the course of
treatment and termination.
Agreement to come back if necessary


Outlook: Hopeful
Henry seemed motivated throughout his treatment; he
was diligent in his home works, including exposure
exercises outside therapy
His goal was to connect with other people and to form
a romantic relationship and this seemed like a sufficient
source for motivation
By continuously applying techniques he learned from
the therapy, Henry may be able to manage the
condition and live a functioning, productive and
meaningful life.
Snippet:
Afraid of People:
A Social Anxiety Documentary
Journals
Mindfulness-Based Cognitive Behavior
Therapy in Patients with Anxiety
Disorders
Mindfulness-based CBT
Meditative technique from ancient India (Vipassana
meditation)
It is a state in which one is required to remain
psychologically present and with whatever happens in
and around one, without reacting in any way.
The practice enables the person to respond
consciously and reflectively (vs auto react)
Mindfulness-based CBT
Used to address stress related medical conditions,
emotional disorders and anxiety and depression
Effective in reducing both physiological / somatic
symptoms, as well as cognitive symptoms of
anxiety in patients with anxiety disorders

Mindfulness-based CBT
MBCT Program: 23 sessions, over four to six weeks
Education about anxiety
Self-monitoring of symptoms,
Relaxation training - mindfulness meditation,
Cognitive restructuring for dysfunctional beliefs
Worry postponement and distraction
Verbal challenging and reattribution
Although relaxation is not the primary aim of
mindfulness meditation, it does produce the benefits
of relaxation through its focus on breathing.
Mindfulness-based CBT
Mindfulness works on anxiety through detachment
between external contingencies and internal
experience enhanced by worry
Awareness of the present-moment experience and
reflective focus replaces usual patterns of
responses
Relaxation techniques
CBT monitoring techniques complements this
Mindfulness-based CBT
Mindful focus on the present provided an
alternative response that may have facilitated
adaptive responding
Training in mindfulness meditation is cost-effective
in terms of time and is applicable to a wide range of
patients
Parental and Peer Predictors of Social
Anxiety in Youth
Predictors of Social Anxiety
in Youth
Are there parental and peer factors?
Parental Predictors:
Parental Anxiety, Parental Overcontrol, Parental
Rejection
Peer Predictors
Social acceptance, social support and friendship quality
Importance of parental and peer variables in
predicting social anxiety in children
Predictors of Social Anxiety
in Youth
Parental anxiety predicts child social anxiety based
on independent evaluator
Validation from a friend reduces child social anxiety
based on independent evaluator
Parental over protection (or over control) predicts
child social anxiety based on child reported
symptoms
Social acceptance based on child reported
symptoms
Predictors of Social Anxiety
in Youth
Children whose parents had higher levels of anxiety
were rated as having higher levels of social anxiety.
genetic and environmental factors likely contribute.
Parental rejection may negatively affect childrens
self-perceptions
May lead them to believe that their peers will also reject
them
Predictors of Social Anxiety
in Youth
Children who perceived themselves as more
socially accepted (e.g., have classmates who like
them and spend time with them) reported lower
levels of social anxiety
Children who have friends and classmates who talk
with them about problems, understand their
problems, enjoy spending time with them, and care
about their feelings worry less about criticism and
humiliation in social interactions.

Predictors of Social Anxiety
in Youth
Children who have friends that make them feel
good about their ideas, tell them they are good at
things, and make them feel important and special
are less likely to experience social anxiety
symptoms.
Predictors of Social Anxiety
in Youth
Peer factors may be more robust predictors than
parental factors
Peer experiences are direct influences
Parental factors are indirect
Positive peer experiences (or perception of it) may
buffer the impact of parental factors
Association between social phobia, social
anxiety cognitions and paranoid
symptoms
Aims and methods
Cross-sectional and longitudinal associations
between social phobia and paranoid symptoms
were examined.
2,584 respondents
Significant findings
Social phobia and paranoid symptoms were
significantly associated with each other cross-
sectionally.
There is an association between social anxiety
cognitions (negative evaluations of the self) and
paranoid thinking
Paranoid symptoms are predicted by negative beliefs
about self
Significant findings
Paranoid ideations are thought to build upon
common interpersonal anxieties and worries such
as fears of rejection
Social anxiety has been found to be correlated with
feeling hostile towards others, and with hostile
perceptions of others.

Thank you.