**3.5. Therapy goal and treatment plan**

own, whereas social system models deal with an individual that fears to fail up to the expectations of others; and (4) cognitive behavioral models refer to interactions with close persons as well as with complete strangers, whereas social system models have a greater focus on relationships with important others. This becomes obvious when analyzing the understanding of *safety and self-protective behavior*, respectively. Both the cognitive-behavioral and social systems models emphasize these strategies in the light of avoiding scrutiny while exacerbating distorted mental processes in the long term. They however propose different explanations as to why this is the case: most cognitive behavioral models refer to the prevention of habituating to anxiety and correcting their maladaptive perception of how others, even strangers, evaluate them; most social system models refer to the disruption of relationships and the ability to

The therapy consisted of mainly weekly hours of therapy, in sum 25 h. Dyadic sessions took

**Anamnesis.** The 23-year-old medical student reported excessive anxiety, above all when being confronted with fellow students or authorities in performance situations (e.g., blood draw, state exam). He feared to behave unskillfully or to say something stupid and that others evaluate him negatively. Consequently, he tried to avoid such situations or got through them while suffering from extreme anxiety. At his first view in the outpatient clinic, he reported to stay at home all the day and presented intense worries about his future because of feeling much insecurity how to go on with his studies. He had stopped to follow joyful activities and his pleasure, felt much "blues," could not sleep, felt exhausted, had difficulties to concentrate,

The patient never was in psychotherapy or pharmacotherapy before. Psychosomatic disorders in his family were unknown. The patient reported minor alcohol use in positive social situations (e.g., a beer with a friend on Saturday evening). He denied the use of any additional

**Life history.** The patient described himself to be the third oldest child of a six-person family (father: engineer; mother, house wife; sisters: +8 years and +6 years; brother: −5 years). The very busy, successful, and well-known father was not often seen at home since the patient's 17th birthday. The development of a secure and trustful father-son contact thus firstly started 9 years ago. The mother was described as a very caring and calm person. The patient felt good contact to his siblings. Age differences however made it hard to establish secure and close ties.

**Diagnosis (ICD-10).** Social phobia (F40.1), moderate depressive episode (F32.1)

enter meaningful social relationships .

54 Cognitive Behavioral Therapy and Clinical Applications

**3.1. Setting and treatment conditions**

**3.2. Patient data**

60 min, and group sessions lasted 120 min.

**3. Treatment of a social anxiety disorder: a case study**

and make any decision. This state already lasted 8 months.

legal or illegal drugs, at present and in the past.

The therapy goals and treatment plan are listed in **Table 2**.


*Preventing depressive decompensation*: it also was of major importance to develop and stabilize the patient's social and professional resources (e.g., sport, cooking, family, friends, medical knowledge, and skills). Sleeping, eating, and movement protocols, and their evaluation in the dyadic sessions, help the implementation of an appropriate circadian rhythm. It emerged that it was very tough for the patient to allow himself and perceive positive feelings in social situation without anticipated high-performance standards (e.g., in leisure time). Group session started in this first one-third of therapy, and the positive feedback from the other group participants helped the patient to stabilize his self-worth and to spare time without the pressure to perform. This was the reason why he had the heart to spontaneously bring home-baked cookies to the third group session and notably allowed to be evaluated by the group members and therapist. He noticed how he promptly felt insecure and anxious while anticipating criticism. The reflection of his original motivation, i.e., "I made cookies because I like baking" versus "I made cookies because I will be loved by others," empowered him to accept the group members' feedback and above all to grasp their otherwise less perceived positive reactions. The analysis of the patient's goal to restore a healthy and individualized circadian rhythm moved the patient to the reflection of his needs and dreams (i.e., "I would like") in differentiation to those assumed from his parents and society (i.e., "I should be"). The similarly caring and demanding therapist behavior assisted the patient to find and perform an individual dayto-day routine with sufficient bedtime in between and to overcome several trials and errors en route. He created a morning ritual with several ingredients such as organic herbal tea

criticism; and making use of it

validating, assuring)

decatastrophizing). 5. **Reduction of safety/avoidance behavior** Individualized exposure to social anxiety including guidance for self-constitution

rhythm)

6. Development of a **positive self-concept** Interventions to increase self-worth and self-confidence

Above all, complementarity behavior of the therapist (i.e., valuing,

http://dx.doi.org/10.5772/intechopen.74302

57

Cognitive Behavioral Therapy for Social Anxiety Disorder: Intrapersonal and Interpersonal…

Development and stabilization of social and professional resources (e.g., sport, cooking, family, friends, medical knowledge, and skills), applying sleeping, eating, and movement protocols (i.e., circadian

Cognitive behavioral therapy, including individualized analyses of behavior in social evaluation situation (e.g., blood draws, exams)

Training of social skills: e.g., perception and expression of individual intra- and interpersonal needs, interests, and ideas; showing constructive criticism ("to argue"); accepting both praise and

Training to identify cognitive schemata that increase anxiety while anticipating negative social evaluation and decrease selfworth and training to control such situation (e.g., reality checks,

**Therapy goal Treatment plan**

1. Development of a **stable therapeutic** 

2. Preventing depressive decompensation, **stabilization of mood, and promotion of** 

3. Formulation of an **individual model of the disorder** and explanation of the social

4. Identification and **cognitive restructuring** 

7. Promotion of **skills to cope with intraand interpersonal conflicts**

**Table 2.** Therapy goal and treatment plan.

**relationship**

**activities**

anxiety

**of irrational beliefs**

**Table 1.** Microanalysis.

#### **3.6. Course of treatment**

The therapy started with dyadic sessions (patient, therapist) in which the development of a *stable therapeutic relationship* was of major importance and facilitated by the therapist's complementarity behavior. The therapist paid much attention to value the patient as a person and to validate his behavior in the good as well as his bad times to assure the therapeutic alliance. She also empowered the patient to test the therapeutic bond by facilitating autonomous decision-making, e.g., in the creation of homework assignments. The patient thus perceived increased self-worth, commitment for treatment success, and responsibility for his life already at the beginning of therapy though still being in a state of carefulness.


**Table 2.** Therapy goal and treatment plan.

**3.6. Course of treatment**

**Table 1.** Microanalysis.

The therapy started with dyadic sessions (patient, therapist) in which the development of a *stable therapeutic relationship* was of major importance and facilitated by the therapist's complementarity behavior. The therapist paid much attention to value the patient as a person and to validate his behavior in the good as well as his bad times to assure the therapeutic alliance. She also empowered the patient to test the therapeutic bond by facilitating autonomous decision-making, e.g., in the creation of homework assignments. The patient thus perceived increased self-worth, commitment for treatment success, and responsibility for his life already

Organic (O) Increased arousal in general, due to negatively priming experiences of distress in the

Cognitively "Watch it: Don't look incompetent! Don't make a mistake! Don't sweat!"

immobility), glimpsing, and avoidance of eye contact

C− Self-criticism, feelings of shame, and guilt ("I have to perform better!")

C;/− Ambivalence in the negotiation of a self-determined moderate conduct of life

C+ Staying in contact with those who are well known since years

perform better; helplessness

C+ Being cared for by significant others (e.g., mother)

C;/− Tension, failure, negative evaluation

network

Physiologically Accelerated heart beat; sweating, above all hands and axillary

Attitude (A) "Excellent performance is essential to be noticed and to survive well in contact with others!"

Emotionally Anxiety, due to anticipated failure or negative evaluation; shame, due to the inability to

Behaviorally Low voice to mutism, restlessness (e.g., wriggling, rightly drawing clothes) to freezing (e.g.,

C;/+ Getting into contact with strangers and becoming friends with others at the university place

C;/+ Pass exams, feelings of self-efficacy and competency, development of an integrative social

C− Accelerated vigilance of social environmental stimuli, decreased capacity to discriminate

between performance situations and daily life situations without pressure to perform, experience of insufficiency, and consolidation of shame and guilt feelings (vicious circle)

situations

Situationextern Contact with an authority

56 Cognitive Behavioral Therapy and Clinical Applications

Situationintern Anxiety, tension

Reaction

Consequences Short term

Long term

patient's life history when being confronted with social interaction and/or performance

at the beginning of therapy though still being in a state of carefulness.

*Preventing depressive decompensation*: it also was of major importance to develop and stabilize the patient's social and professional resources (e.g., sport, cooking, family, friends, medical knowledge, and skills). Sleeping, eating, and movement protocols, and their evaluation in the dyadic sessions, help the implementation of an appropriate circadian rhythm. It emerged that it was very tough for the patient to allow himself and perceive positive feelings in social situation without anticipated high-performance standards (e.g., in leisure time). Group session started in this first one-third of therapy, and the positive feedback from the other group participants helped the patient to stabilize his self-worth and to spare time without the pressure to perform. This was the reason why he had the heart to spontaneously bring home-baked cookies to the third group session and notably allowed to be evaluated by the group members and therapist. He noticed how he promptly felt insecure and anxious while anticipating criticism. The reflection of his original motivation, i.e., "I made cookies because I like baking" versus "I made cookies because I will be loved by others," empowered him to accept the group members' feedback and above all to grasp their otherwise less perceived positive reactions.

The analysis of the patient's goal to restore a healthy and individualized circadian rhythm moved the patient to the reflection of his needs and dreams (i.e., "I would like") in differentiation to those assumed from his parents and society (i.e., "I should be"). The similarly caring and demanding therapist behavior assisted the patient to find and perform an individual dayto-day routine with sufficient bedtime in between and to overcome several trials and errors en route. He created a morning ritual with several ingredients such as organic herbal tea and home-baked sweet rolls for breakfast in the sunroom, including the reading of *The Times* magazine. Most impressively for him however was his self-permission of this ritual taking 1 h before starting with "the rest of my day." He then started at 8.45–9.15 am with his day and was very surprised as well as much relieved that those asked in the reality checks organized the starting of their day equally in a small city where most people live only 15 min from their work place. The sweet rolls' flavor additionally attracted his roommates so that finally they joint his morning time. In times of experimenting with new recipes, the patient finally discovered that both positive and negative feedbacks meant to him and that sometimes criticism accounted better for social closeness (e.g., "When I disliked the rolls' taste, my roommates' critique made me even stronger—because I feel connected in our joint feeling of bad taste"). This experience strengthened the patient very much. He now felt how to wow himself as well as to wow others "when I do what I like to do and do not think that much about what I think I should do."

After the emotional stabilization and relapse prevention, the patient and therapist derived an *individual model of the SAD* including the patient's explanatory model of the social anxiety in interaction and performance situations with anticipated negative evaluation (see macro- and microanalysis). This model included biographical material, the functionality of the set of problems and information about the development and maintenance of the social anxiety, and was enriched according to Clark and Wells' cognitive behavioral models (**Figure 1**). The patient and therapist choose a recent and concrete social situation in which the patient showed anxiety and got through the event instead of avoiding it. First, the therapist asked for the negative cognitions and wrote them into the model template on a flip chart. Secondly, she asked for anxiety symptoms, i.e., how the patient felt when thinking the negative thoughts. Thirdly, the patient was asked for his security behavior. Finally, self-perception was introduced as the central model component by the therapist, directing the patient's attention toward inward on the one hand and the anticipated impression by others in this social situation on the other hand.

The central position of the self-focused attention became clear when the patient presented and discussed this individualized model with the other patients in the group session ("I rather concentrate on *my* mistakes and forget to face *others*!"). The patient recognized that this was the central feature in the maintenance of his social anxiety ("If I do not dare to look the others into their eyes, I will never know whom I am sitting vis-à-vis!"). This was followed by the drafting of an individualized anxiety graph, again in the dyadic setting. The situation was a blood draw in the context of conducting a medical exam, with the patient's fellow students and assistant medical director at present. The patient recognized that the perceived anxiety did not grow sky high like fooled by anticipatory anxiety. This caused much relieve, and social anxiety reduced anew. Additionally, the demonstration of negative effects of self-focused attention and safety behavior in role plays with strangers generated another two findings for the patient: Firstly, his safety behavior did not help him to reduce his social anxiety but rather contributed to its increase, while unexpectedly he felt more relaxation in social contacts with the stranger in times without its performance. Secondly, and again unexpectedly, the stranger reported that the patient's safety behavior made him unsecure and performed social distance rather approach. Similarly, the patient described that he had misinterpreted the stranger's increasing low voice in terms of social rejection. He made the corrective experience that self-confident

behavior from one person, like him, stimulates self-confident behavior from the other person, like the stranger in the role play, and that such an assuring social interaction incorporates the reduction of misperception with respect to negative social evaluation. This reciprocally reinforced feelings of safety and social bond when interacting with others. Watching the patient's video from this role play and its discussion as well as the patient's experience with the others in the group session, again, contributed to the fostering of the new recognitions and feelings

Cognitive Behavioral Therapy for Social Anxiety Disorder: Intrapersonal and Interpersonal…

http://dx.doi.org/10.5772/intechopen.74302

59

These successful therapeutic steps were accompanied by the patient's increasing distancing and humorous attitude toward his safety and avoidance behavior. He noticed that safety and avoidance behavior, among others, was responsible for his decreased self-determined life

and, thus, the patient's self-worth.

**Figure 1.** Individualized disorder model of SAD.

Cognitive Behavioral Therapy for Social Anxiety Disorder: Intrapersonal and Interpersonal… http://dx.doi.org/10.5772/intechopen.74302 59

**Figure 1.** Individualized disorder model of SAD.

and home-baked sweet rolls for breakfast in the sunroom, including the reading of *The Times* magazine. Most impressively for him however was his self-permission of this ritual taking 1 h before starting with "the rest of my day." He then started at 8.45–9.15 am with his day and was very surprised as well as much relieved that those asked in the reality checks organized the starting of their day equally in a small city where most people live only 15 min from their work place. The sweet rolls' flavor additionally attracted his roommates so that finally they joint his morning time. In times of experimenting with new recipes, the patient finally discovered that both positive and negative feedbacks meant to him and that sometimes criticism accounted better for social closeness (e.g., "When I disliked the rolls' taste, my roommates' critique made me even stronger—because I feel connected in our joint feeling of bad taste"). This experience strengthened the patient very much. He now felt how to wow himself as well as to wow others "when I do what I like to do and do not think that much about what I think

After the emotional stabilization and relapse prevention, the patient and therapist derived an *individual model of the SAD* including the patient's explanatory model of the social anxiety in interaction and performance situations with anticipated negative evaluation (see macro- and microanalysis). This model included biographical material, the functionality of the set of problems and information about the development and maintenance of the social anxiety, and was enriched according to Clark and Wells' cognitive behavioral models (**Figure 1**). The patient and therapist choose a recent and concrete social situation in which the patient showed anxiety and got through the event instead of avoiding it. First, the therapist asked for the negative cognitions and wrote them into the model template on a flip chart. Secondly, she asked for anxiety symptoms, i.e., how the patient felt when thinking the negative thoughts. Thirdly, the patient was asked for his security behavior. Finally, self-perception was introduced as the central model component by the therapist, directing the patient's attention toward inward on the one hand and the anticipated impression by others in this social situation on the other

The central position of the self-focused attention became clear when the patient presented and discussed this individualized model with the other patients in the group session ("I rather concentrate on *my* mistakes and forget to face *others*!"). The patient recognized that this was the central feature in the maintenance of his social anxiety ("If I do not dare to look the others into their eyes, I will never know whom I am sitting vis-à-vis!"). This was followed by the drafting of an individualized anxiety graph, again in the dyadic setting. The situation was a blood draw in the context of conducting a medical exam, with the patient's fellow students and assistant medical director at present. The patient recognized that the perceived anxiety did not grow sky high like fooled by anticipatory anxiety. This caused much relieve, and social anxiety reduced anew. Additionally, the demonstration of negative effects of self-focused attention and safety behavior in role plays with strangers generated another two findings for the patient: Firstly, his safety behavior did not help him to reduce his social anxiety but rather contributed to its increase, while unexpectedly he felt more relaxation in social contacts with the stranger in times without its performance. Secondly, and again unexpectedly, the stranger reported that the patient's safety behavior made him unsecure and performed social distance rather approach. Similarly, the patient described that he had misinterpreted the stranger's increasing low voice in terms of social rejection. He made the corrective experience that self-confident

I should do."

58 Cognitive Behavioral Therapy and Clinical Applications

hand.

behavior from one person, like him, stimulates self-confident behavior from the other person, like the stranger in the role play, and that such an assuring social interaction incorporates the reduction of misperception with respect to negative social evaluation. This reciprocally reinforced feelings of safety and social bond when interacting with others. Watching the patient's video from this role play and its discussion as well as the patient's experience with the others in the group session, again, contributed to the fostering of the new recognitions and feelings and, thus, the patient's self-worth.

These successful therapeutic steps were accompanied by the patient's increasing distancing and humorous attitude toward his safety and avoidance behavior. He noticed that safety and avoidance behavior, among others, was responsible for his decreased self-determined life 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 anxieties, and so do others!".

**3.7. Therapy outcome and test diagnostics: at the end of therapy (independent blind** 

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

ings. The American Journal of Psychiatry. 2000;**157**(10):1606-1613

ders. 5th ed. Washington, DC: APA; 2013

Psychological Medicine. 2008;**38**(1):15-28

Psychiatry. 2005;**162**(6):1179-1187

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

[1] Stein MB, Kean YM. Disability and quality of life in social phobia: Epidemiologic find-

[2] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disor-

[3] Bögels SM, Alden L, Beidel DC, Clark LA, Pine DS, Stein MB, et al. Social anxiety disorder: Questions and answers for the DSM-V. Depression and Anxiety. 2010;**27**(2):168-189

[4] Ruscio AM, Brown TA, Chiu WT, Sareen J, Stein MB, Kessler RC. Social fears and social phobia in the USA: Results from the National Comorbidity Survey Replication.

[5] Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: A systematic analysis for the global burden of disease study 2010. The Lancet. 2012;**380**(9859):2163-2196

[6] Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, et al. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: A 12-year prospective study. The American Journal of

*SCID diagnostics* demonstrated a remission of the SAD and depressive episode. The patient showed a well understanding for the complexity of his symptomatology and confrontation with otherwise too much anxiety causing social interaction and performance situations. Safety and avoidance behavior was no longer seen. *Standard diagnostics*: The *Symptom Checklist (SCL-K-9)* showed the psychological symptom pressure on average (T = 57, D = −14, *p* < 0.05). The *Brief Symptom Checklist (BSCL)* also showed all values on average. *Disorder-specific diagnostics*: The *Liebowitz Social Anxiety Scale (LSAS-SR)* total score was at 42 (cutoff, 30; LSASprä = 105), the *Social Interaction Anxiety Scale (SIAS)* at 17 (cutoff, 35; SIASprä = 46), the *Social Phobia Scale (SPS)* at 11 (cutoff, 24; SPSprä = 29), and the *Beck Depression Inventory (BDI)* at 2 (no depression; BDIprä = 17).

Cognitive Behavioral Therapy for Social Anxiety Disorder: Intrapersonal and Interpersonal…

http://dx.doi.org/10.5772/intechopen.74302

61

**diagnostician)**

**Author details**

**References**

Christina Hunger-Schoppe

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 an appropriate biopsychological arousal.

*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%."
