**Author details**

in which "I had gone crazy." The distancing from his social anxiety, which simultaneously decreased more and more, strongly supported him in the *identification and cognitive restructuring of irrational beliefs*. Finally, and again subsequent to a role play, he formulated "I have social anxieties, but they do not have me any longer!", "I have an influence on how much anxiety and relaxation are tolerable when interacting with others!", and also "I have social

The increased feeling of control over his life made it easier for the patient to get engaged into the following *rational of exposure*. The patient formulated approach goals (Grosse Holtforth, Grawe, Tamcan, [47]) in the preparation phase of the exposure procedure (short term, e.g., "to pass the state exam," "to pass the conductance of medical exams," and "to stay in contact with the professor"; long term, e.g., "to live a life of my own," "living appropriately independent from my parents while still staying in good contact with them," and "differentiating between what I like to do and what I think I should do but do not necessarily have to do"). Individualized body exercises served the increased vigor and corporeal tension so that the patient could easily step out of his anxiety-related rumination before the exposure and also in his daily routine. Subsequent to the identification and restructuring of the irrational beliefs, the patient developed alternative ways of thinking and behaving in contrast to his safety and avoidance behavior (e.g., "The professors often do not know who I am and where I come from," instead of "I always feel as if I have this post-it on my forehead' the rural goose!, which is well seen by everybody!"). He used a scaling from 0 ("no anxiety") to 100 ("terrifying panic") for self-observation during the self-conducted exposure in his daily environment and recognized that his anticipatory anxiety (e.g., "10: The assistant medical director and the fellow students will see my stupidity and incompetency and will reject me!") often exceeded the situation with his highest felt anxiety ("8–9: They will give me a D for my medical skills!"). He experienced the positive power of active behavior reducing anxiety (e.g., "attending the appointment with the professor and/or fellow students") and the negative power of avoidance increasing anxiety and anticipated negative evaluation (e.g., "staying in the car, facing all possible scenario of failure in a certain social interaction or performance situation"). This experience and its reflection with others in the group sessions helped him to reduce social anxiety (before exposure, 10; after three exposures, 3). He continuously confronted himself with numerous anxiety situations that he had avoided in previous times. Step by step he faced them with increased calmness and initiated social contacts even with strangers in both interaction and performance situations. Finally, he passed the state exam successfully and in

*In summary*, the patient initiated and practiced meaningful intra- and interpersonal changes in line with his self-formulated therapy goals over the course of 1 and a half year of therapy. On the intrapersonal level, he reported the following experience of most importance "that I have had the heart to face myself and others and to look into their eyes so that now I can evaluate them better and how they face me." On the interpersonal level, he attributed the highest importance to the following experience "that I now have the power to tell others when I feel anxious of being negatively evaluated and that I can ask them whether they feel the same." In summary, he concluded that his social anxiety had decreased from "over 100%" to "about 35%."

anxieties, and so do others!".

60 Cognitive Behavioral Therapy and Clinical Applications

an appropriate biopsychological arousal.

Christina Hunger-Schoppe

Address all correspondence to: christina.hunger@med.uni-heidelberg.de

Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany
