- Identifying information:
- SANDRA 19-year-old single Hispanic female
- Cisgender, no relationship
- Living with biological mother and father. Parents are of Mexican nationals and have a conflictual relationship
- Has two older sisters – first generation and have some college.
- Reason for Referral:
- Referred by mother and her pediatrician, Dr. Doe M.D.
- Mother- Very isolated and does not interact with others.
- Client- have social anxiety, not very active, use to be more active when young but after being bullied stopped.
- Description of the client (appearance) and manner of relating:
- Younger appearance than chronological age, dressed in age-appropriate clothes and carries a purse
- Short and slender and has long black curly hair
- Wears eyeglasses and has a light facial complexion
- Demeanor- shy, passive, nervous, and made minimal eye contact – eye contact has improved since initial visit
- Pressured speech and not spontaneous; uses two to three word (verbal ) responses with limited detailed information
- Difficulty with providing specific and detailed information; results in deferring to her mother for an explanation
- English speaking and appears to be bilingual Spanish speaking as her parent is dominant Spanish speaking and she showed some comprehension of Spanish language.
- Interpersonal –relies on therapist to initiate conversation; tendency to have motor movement when nervous or anxious (leg shakes).
- Socially and emotionally interacts in a childlike manner with clinician. Tearful and cries softly when describing history of bullying incident in the 3rd and 4th grade (teased for her nose—name calling).
- Presenting problems:
- Socialization problems since early childhood
- Early childhood- Anxiety and peer bullying
- Prior treatment for anxiety with counselor as child
- Learning problems- reading and writing
- Diagnosed with ADHD and Autism / Asperger’s
- Isolates in social situations.
- Sensitive to noise, specifically loudness in crowds
- Recent high school graduate, limited social interactions
- Social circle limited to family events and often relates to younger relatives
- GAD 7= 2 Negative PHQ9= 3 Negative
- Fears interacting with others and getting hurt like before
- Fearful being ridiculed about her nose by others
- Does not initiate conversation with others
- Gets moody when too much noise and gets headache and ends up leaving
- Can’t trust others
- Goes out with parent only and feel anxious in family gatherings
- Precipitating events/factors:
- Since graduating high school, more withdrawn and does not socialize with others. Has trouble with communicating with others in social or public situations. Does not go places unless accompanied by parent and does not initiate conversations with others. She gets frustrated and irritated with too much noise. She does not like to socialize with others other than those she knows. She explained that her last difficult social situation was at the school prom (few months ago) in which she was alone after her friend did not show up to the dance and she had high level of anxiety and became upset with others. She reports that her social anxiety is primarily when attending parties.
- Previous and current treatments:
- Childhood history of counseling and medication treatment. She received medication for anxiety and attention for a brief period as a child. Parent reports counseling seem to help SANDRA with expressing herself. She also had a problem not eating and she had severe weight loss (15lbs); and given medication by her doctor. Her mother reports a history of peer bullying in early childhood and SANDRA he did not want to go to school at that time. Counseling was discontinued as her counselor retired and has no had another counselor. In the past, she reports having a counselor during middle school. According to SANDRA, she says she was shy, and she was in counseling. She says that counseling helped. She reports that she was given medication for Social Anxiety a few months ago. She reports that the medicine affected her and her head hurt; so, she stopped taking the medication. Currently, SANDRA is not receiving any psychotherapy treatment or medication.
- Brief Pertinent Life History:
- Family of origin/ childhood: SANDRA was born in McAllen, Texas. She has lived in Weslaco with her family. She was born premature (7 months). She had strabismus of the eye (right) surgery at age 2 and she has limited vision. Developmental milestones were delayed for speech and has a history of learning problems and she was retained in the second grade. She also has specific motor deficits and had occupational therapy for poor hand coordination. Early childhood school experiences were significant for peer bullying from second to fourth grade resulting in change of school. Graduated high school and had some friends at school; however, no social contact with prior friends from school.
- Current life situation & relationships: Lives with biological parents and has four older siblings (living outside the home). Denied any romantic relationship at this time and she is “straight” (heterosexual). Does not currently work and dependent on parents. Does not drive at this time and desires to work someday. Parent is Spanish speaking and reported a history of significant conflicts with the school due to the peer bullying and having to advocate for SANDRA at school. Medical/ Biological history is significant for strabismus with limited eye vision of the right eye. Parent- child relationship- SANDRA is dependent on parent for activities of daily living and decision making. Social activities centered on family events and relationships.
- Client’s mental status and observations.
- Initially, SANDRA presented nervous and shy. She had difficulties with maintaining the discourse and responded in a timorous and passive manner. Comprehension was generally adequate and at times anxiety interfered as she was not able to understand some of the inquiries. She often was slow to respond and not able to provide detailed information about her personal history. She made intermittent eye contact and often looked down when conversing. She responded to encouragement and she seemed more open toward the latter part of the interview. She cried softly when discussing her childhood experience with peer bullying. She denied any suicidal or homicidal ideation.
- Patient’s goals and strengths.
- Strengths: Family support, Open to talk about problems, Desires to improve, Self-awareness to social issues
- Goals: SANDRA identified her goal as: being to trust people more and to be more social. She realizes that she want to get a job and needs to be able to communicate with others at work.
- Questions that remain unanswered:
- Further understanding of the successful relationships in the past – reportedly dated someone.
- Diagnostic formulation of client: Include (a) DSM-5 and (b) Clinical Case Formulation (from any chosen theoretical orientation–cognitive behavioral / biopsychosocial / or psychodynamic formulations)
- DSM-V Diagnosis
- Social Anxiety
- SANDRA demonstrates the following Social Anxiety symptoms
- Social Anxiety
Emotional and Behavioral symptoms:
- Intense fear of interacting or talking with strangers
- Fear of situations in which you may be judged
- Enduring a social situation with intense fear or anxiety
- Having anxiety in anticipation of a feared activity or event
- Expecting the worst possible consequences from a negative experience during a social situation
Physical signs and symptoms:
- Blushing/ hot flush
- Trembling
- Sweating
- Dizziness or lightheadedness
- Feeling that your mind has gone blank
- Muscle tension
- Avoiding common social situations
- Difficulties with interacting with unfamiliar people, attending parties or social gatherings, starting conversations, making eye contact etc.
- Autism Spectrum Disorder, without accompanying intellectual impairment, Level 1 SANDRA demonstrates the following ASD symptoms and behaviors: Social- Difficulties with eye contact, failure to develop developmentally appropriate peer relationships, Communication- History of delayed speech, Difficulties with initiation or sustaining conversation, Repetitive/ Stereotypic Behaviors: History of preference for routine, limited / restricted interest in activities, sensitivity to noise
- Clinical Case Formulation
- Cognitive Behavioral Formulation
- In childhood and adolescence, SANDRA was viciously teased and humiliated by her peers (ORIGINS). As a result, SANDRA learned the schemas “I’m inadequate and have an ugly nose,” and that “Others are critical, attacking, and not to be trusted” (MECHANISMS). These schemas were activated recently by a negative experience at her last school social (PRECIPITANT). As a result, SANDRA has become more socially withdrawn and has no contact with her friends from school and does not go out with others other than her parent. She has developed automatic thoughts (MECHANISMS), including, “I can’t trust others and fear they will not like me (reject) and experiences anxiety (SYMPTOMS, PROBLEMS), with which she copes by avoiding (MECHANISM) important social situations and withdrawing from interpersonal interactions with both family and unfamiliar people in any social or public situations (PROBLEMS). The avoidance causes SANDRA to withdraw when attending family events and does not talk to others (PROBLEM), and has led to increased sadness, feelings of inadequacy, self-criticism and loss of interest in others (SYMPTOMS, PROBLEMS). In these social situation SANDRA experiences anxiety symptoms including sweating palms, hot flush, shaking, feeling not being able to speak, headache, and confusion.
- Treatment plan for client:
- Empirically Supported Treatment: Cognitive Behavioral Therapy and Exposure
- Basic premise: thoughts, feelings and behaviors are inter-related, so altering one can help to alleviate problems in another
- Essence of therapy: Cognitive therapy techniques focus on modifying the catastrophic thinking patterns and beliefs that social failure and rejection are likely; exposure therapies are designed to gradually encourage the individual to enter feared social situations and try to remain in those situations.
- Focus of Treatment: Social anxiety and Social skills training.
Reviewing with the client the conceptualization of her problems – Explain how her concerns about not trusting others and fear of being rejected (bullied) have her engaging in avoidance behaviors. Provide the client feedback of how the social anxiety should be the primary treatment target and social skills training will be part of the therapy to develop new interpersonal communication skills.
Treatment play will be including the following:
- Client’s Goals and Strengths
- Client specific plan for change—how do I know I have achieved my goal—
- Specific behavioral objectives with intervention methods
- Measures to be used to assess treatment outcomes
- Intervention Methods include the following exposure, cognitive restructuring, psychoeducational counseling of CBT model, relaxation training, social skills training, and behavioral analysis.
- Timeline for putting plan into action through gentle and gradual exposure to social situations
- Cultural Issues/ Concerns
Possible Issues of concern:
- SANDRA’s role in the family and any cultural barriers which may stifle independence and autonomy.
- Dependency characteristics – Difficulties with assertiveness and inflexibility (ASD)
- Transference issues— with therapist (older) and possible “mother role” issue hindering autonomy.
