This document discusses Aaron, a 31-year-old man diagnosed with social anxiety disorder. It provides details about Aaron's symptoms and how they meet the DSM-5 criteria for social anxiety disorder. The document then discusses potential assessment tools and treatments that could help Aaron, including the Social Anxiety Questionnaire, Beck Anxiety Inventory, cognitive-behavioral therapy, and relaxation techniques.

1. Jonathan Tallmer (JT)
Psyc242/Gallagher
Millions of people deal with anxiety every day, whether it’s at home with kids, in the
workspace, or by one’s self. It is widely regarded that anxiety can be beneficial to people- in
motivating them to tend to obligations and complete daily tasks. However, this “base-level”
anxiety only helps to a certain extent. Often times, people with excess anxiety are hindered.
These people tend to decline in performance due to increased worry and panic, and can’t even go
about normal daily functioning without constant racing thoughts. Others only have anxiety in
certain situations. Individuals such as Aaron can be diagnosed with social anxiety disorder, or
social phobia- an anxiety disorder characterized by overwhelming anxiety and excessive self-
consciousness in everyday social functioning (Mayo Clinic, 2014). With the help of assessment
tools such as the Social Anxiety Questionnaire and Beck Anxiety Inventory, clinicians can get a
better understanding as to how these people really feel. Following up, therapists can work to
implement specialized treatment plans such as cognitive-behavioral therapy and relaxation
techniques that tend to the needs of people like Aaron, and help them overcome their specific
fears.
As a 31-year old father with two kids, Aaron meets the full criteria for social anxiety
disorder (aka social phobia) according to the Diagnostic and Statistical Manual of Mental

2. Disorders (DSM-5). The first symptom present is Aaron’s marked fear or anxiety about social
situations regarding other people. Aaron, when working, experiences panicky episodes. He
becomes especially scared when he has to make a weekly presentation during a team meeting.
This fear is also present when he has to talk one-on-one with other coworkers to discuss work-
related issues. Outside of his field of work, he also experiences these episodes when he’s forced
to attend school functions (such as recitals and parent-teacher conferences) for his two kids.
Aaron is very self-conscious about being negatively evaluated, which is the next DSM-5
symptom shown. Leading up to presentations and work meetings, Aaron indicated that he
worries that his coworkers will judge and think poorly of his performance. This is not all bad, for
in a way, this helps drive Aaron to prepare more and more for these meetings to prevent potential
embarrassment. However, it is only helpful to an extent. For Aaron, the worry has gotten out of
hand and has hindered his performance. Social situations almost always provoke fear in Aaron,
causing his attacks to occur 5-6 times a week. The anxiety is not only mental, but physical as
well (increase in heart rate, perspiration, and shakiness). In addition to the frequency of the
anxiety attacks, he’s also been experiencing such periods since he was a teenager. Since the
anxiety has been persistent for more than months, he meets the DSM-5 criteria. Aaron also
freezes and fails to speak in social situations: he describes that he feels like he’s at a loss of
words and has trouble finding the right thing to say. Aaron also tends to avoid or endure social

3. situations with intense fear: he denied the requests from his co-workers to get drinks, and also
seems to limit the activities he engages in with his family (he will dismiss himself from school
functions to avoid conversation). In addition, the activities Aaron does engage in seem to cause
extreme discomfort to him. The experienced fear/anxiety of social situations definitely are out of
proportion to the actual threat. People are only trying to reach out and help Aaron, yet he still
tries to avoid them at all costs. The situations that provoke anxiety in Aaron are normal day-to-
day things, such as meeting with co-workers and communicating with family and friends. Most
people would consider these things routine and not think twice about them. The fear and anxiety
not only takes a toll on Aaron’s mental health, but also causes him distress in other areas of
functioning, such as with his family (he thinks this anxiety is affecting his ability to be a good
father and husband) and with his work (much sleep is lost due to ‘next-day worries’, which could
potentially effect his performance at work). Lastly, Aaron isn’t taking any drugs and has no
medical illnesses related to his current problems. It seems that Aaron’s social anxiety is
performance-only, since communicating at work and in public are the biggest problem areas.
Communicating with his family does not seem to provoke any anxiety.
For Aaron, there are plenty of potential routes a clinical interviewer could take in
discovering feelings, causes, and potential treatments for social anxiety disorder. The areas of
Aaron’s childhood/upbringing, home/family life, and work life can help to answer some of the

4. unanswered questions regarding his functioning: The area of childhood and upbringing is
important because it could provide us with a background and understanding of where and how
the disorder started. Some questions that could be included in a clinical interview include:
1. Were one or both of your parents anxious? If so, what kind of symptoms did they
often display while you were growing up?
2. As a youth, where did anxiety hinder you the most, and how was dealing with anxiety
from public situations different than in-home situations?
3. When did you start feeling the anxiety set in? What was its course like in your
childhood (how did it progress)?
4. Can you recall any particular event in your childhood that would’ve triggered anxious
reactions?
5. How did anxiety play a part in how you interacted with your close friends (and
potential friends you tried to make) in school?
The area of Aaron’s life at home with family is the second area of questioning covered. Patients
with social anxiety disorder tend to spend a lot of time with their family, so it’s important to
know what strategies are employed by the patient to get along with family. These strategies are
looked at to see if they can translate to other areas outside of the home.
1. What strategies are used inside of your home by your family to help you cope with
your anxiety?
2. In what ways do YOU deal with your stress and anxiety in a safe manner? If you have
‘comforting activities’ that ease your anxious thoughts, what are they?

5. 3. Are you worried that your anxiety will be passed on to your children?
4. How do you go about expressing your feelings to your family about your anxiety?
5. How does your anxiety affect your relationship with your wife and kids?
Information about the work sector is the third and final area of questioning covered. Information
about this area is important because the patient presumably wants to be successful, and
addressing the workplace behaviors to improve them may lead to improved satisfaction and co-
worker relations:
1. Why do you find it easier to interact with your family than people at work?
2. Do you feel that anxiety is affecting your work performance?
3. Have you had jobs where you have not felt the present anxiety or ‘on-edge’ feeling
you feel today?
4. During your time at work, when are you the most and least anxious?
5. Have you discussed your anxiety and depression with your supervisor?
The first assessment tool that I would administer to Aaron is the Social Anxiety
Questionnaire for adults (SAQ). Six years of research were carried out in 16 Latin American
countries, where thousands of patients recorded social situations. Experts eventually narrowed
down the number to thirty situations, which is what the test is now composed of. The test has
undergone extensive revision to stay internally consistent over the years (Caballo, 2015). The
SAQ measures self-reports of a broad range of social situations and is based on a five-dimension

6. model, which allows the person administering the test to target specific fears/phobias in the
patient. The five dimensions are (1) speaking in public/talking with people in authority, (2)
interactions with the opposite sex, (3) assertive expression of annoyance, disgust and displeasure,
(4) criticism and embarrassment, (5) and interactions with strangers. One score is gained from
each dimension, and an overall mean score is calculated after the entire test is administered. This
multidimensional approach is one of the reasons why I would administer the test. I also chose
this measure because it has been proven to be statistically sound across a broad range of cultures
(CITE). By administering this test to Aaron, we could get an idea of if he fears all social
situations or just particular scenarios. We see that Aaron meets the three criteria of (1) speaking
in public, (5) interactions with strangers, and (4) criticism and embarrassment. In short, the
questionnaire can help medical professionals target the criteria that individuals such as Aaron
need to work on. It would be of great help to see how Aaron expresses himself at work and at
home. He may potentially meet the criterion of (3) assertive expression of annoyance, disgust
and displeasure.
The second assessment tool that I decided on is the Beck Anxiety Inventory (BAI). This
self-report also measures anxiety, but on a more general scale. The inventory is composed of
twenty-one questions regarding anxiety symptoms. Patients who are given this inventory are
asked to respond to each of the questions using a four-point scale (not at all, mildly, moderately,

7. and severely) and the time frame of the week leading up to administration. This assessment is
meant to measure general anxiety and can establish a baseline anxiety level. Some psychologists
have considered this inventory as a severity indicator (Muntingh et al., 2011). I chose this
measure because of its easy administration and repeatability, proven validity across various age
ranges and cultures, and its ability to discriminate between anxiety and depression. There is a
slight comorbidity that Aaron is showing symptoms of major depressive disorder (MDD) some
evidence of this is his decreased interest in activities, feelings of worthlessness, and change in
sleep pattern. The BAI’s ability to discriminate may be of great use to help Aaron deal with his
symptoms more efficiently. The BAI also helps to reveal potential co-morbid disorders
(Muntingh et al., 2011). For Aaron, it may be of help to see if there are other disorders present
(such as panic disorder). A study by de Beurs et al. (1997) gauged the effectiveness of the Beck
Anxiety Inventory in 82 patients with panic disorder. Patients were told to keep daily diaries of
their fear of panic, panic attacks, and average anxiety. The BAI was given to patients before and
after the treatment, and was proven to have good test-retest reliability and internal consistency.
The effect sizes for improvement were significant in comparison to other anxiety measures such
as the Beck Depression Inventory. This study is particularly relevant for Aaron because
symptoms of panic disorder are definitely present. According to the case study, Aaron has a hard
time falling asleep because he’s worried about the next day, which correlates with persistent

8. worry of one month or longer. It could be that Aaron doesn’t encounter unexpected panic
attacks, but situation-cued panic attacks (from social situations). The DSM-5 criteria for panic
disorder states that the patient must have four or more attacks in a four-week period. Aaron is
greatly surpassing this amount, for he has five to six attacks a week. Physical symptoms of panic
disorder that Aaron displays include increased perspiration, accelerated heart rate, and shaking
(MedScape, 2015).
As we read in the description, one of Aaron’s main problem areas is social isolation and
the feeling of failure. During his time at work and in social situations, Aaron often thinks that he
is being negatively evaluated. He has been invited out by co-workers, to attend his children’s
school performance, etc. but will try to avoid them at all costs. Avoidance tactics include
dismissing himself from social situations he feels uncomfortable in, or just straight-out declining
offers to engage in social situations. I believe that a good treatment for Aaron is ongoing
cognitive-behavioral therapy (CBT), the most common type of counseling for anxiety (Mayo
Clinic, 2014). CBT is a form of therapy that explores relationships among a person’s thoughts,
feelings, and behaviors. In my opinion, CBT is the most applicable in real life situations, since
patients are exposed to situations and learn to confront them. Its core principle includes
identifying negative/false beliefs and restructuring them gradually (National Alliance on Mental
Illness, 2015). It has also been proven to be an extremely effective treatment. In a randomized

9. controlled trial by Cottraux et al. (2000), sixty-seven socially phobic patients were put in either a
CBT treatment group or a supportive therapy (ST) treatment group. After six weeks, the CBT
group performed better than the ST group on the main social phobia measure. In addition, when
ST patients were switched to CBT, performance was significantly better. Due to his situation, I
believe that Aaron would benefit from engaging in CBT two times a week for twelve weeks.
This setup will give the therapist sufficient time to get to know Aaron and his viewpoints, and to
work towards achieving minimal and controllable anxiety levels. The cognitive part will involve
the gradual learning of healthier thinking on Aaron’s part, which will help to neutralize negative
thoughts and misperceptions. Such misperceptions and distortions include being negatively
evaluated by co-workers and constant feelings of failure. In addition, exposure to anxiety-
provoking situations will be included so Aaron can learn better coping strategies (Hauser, 2013).
The behavioral part will involve group therapy with other people who have been diagnosed with
social anxiety disorder. Group therapy will allow Aaron to be exposed to other people who are in
similar situations as him and will teach him better social skills. Listening to and engaging in
voluntary conversation will help ease his anxiety levels and help him open up a bit more in real-
life situations. Eventually, Aaron would ideally be able to overcome the excess anxiety and
communicate openly and comfortably with his bosses, co-workers, and even strangers. Initial
resentment, fear, and anxiety may be present during the first few weeks of therapy. After a while,

10. I believe that Aaron can start getting more comfortable when he sees that he’s not alone in the
battle with social anxiety disorder. Exposure to anxiety-provoking situations, combined with
restructuring of negative thoughts and beliefs, can lead to a successful outcome. Aaron’s fear
hierarchy may include conversations with relatives, interactions and requests from strangers, and
in-work presentations. Situation exposure could be gradual, starting inside of the office and
moving to other locations such as restaurants, shopping malls, and parks. Eventually, the
therapist could work to put Aaron in a workplace presentation setting to show him that he is
capable of overcoming his hindering anxiety.
Aaron also seems to worry about future events that are impending. During the nights
before these events occur, his worries and anxiety overcome him and it takes him several hours
to even fall asleep. I believe that some good treatments to help Aaron sleep better are the
relaxation techniques of diaphragmatic breathing and guided imagery. Guided imagery involves
visualizing/imagining ideal situations that bring your mind to ease. Diaphragmatic breathing
involves breathing to allow the maximum amount of oxygen to enter the bloodstream (Wong).
The therapist could teach Aaron how to use both efficiently and implement practice at the
beginning and end of each session. For him, I would recommend practicing diaphragmatic
breathing three times a day for five to ten minutes. Guided imagery could be practiced by Aaron
twice a day—when going to sleep and waking up. Aaron may question the purpose of relaxation

11. techniques due to their simplicity. He is obviously very ‘on-edge’ about many things and may
not see immediate improvement, which could lead to arguments and resentment much like the
arguments he has with his wife. Eventually, through a sleeping log that he will keep, Aaron will
see that engaging in these techniques will help him sleep better. In this log, Aaron will record the
time and type of practice he does and how many hours of sleep he gets a night. The progression
that he sees will help reinforce the practices taught by the therapist.
We see that people such as Aaron have an extremely difficult time dealing with social
situations and communication with others. Even people close to those with social anxiety
disorder, such as Aaron’s wife, see that those diagnosed tend to stray away from interpersonal
settings. This anxiety not only hinders one’s personal life, but life in the workplace as well. With
the help of treatments such as cognitive-behavioral therapy and relaxation techniques such as
diaphragmatic breathing and guided imagery, clinicians can move a great a deal forward in
helping socially phobic patients progress and become more comfortable in the interpersonal
world we live in.

12. References
Caballo, V. E., Arias, B., Salazar, I. C., Irurtia, M. J., & Hofmann, S. G. (2015). Psychometric
Properties of an Innovative Self-Report Measure: The Social Anxiety Questionnaire for
Adults.
Cognitive Behavioral Therapy. (2015). Retrieved from https://www.nami.org/Learn-
More/Treatment/Psychotherapy
Cottraux, J., Note, I., Albuisson, E., Yao, S. I. N., Note, B., Mollard, E., ... & Coudert, A. E. J.
(2000). Cognitive behavior therapy versus supportive therapy in social phobia: a
randomized controlled trial. Psychotherapy and Psychosomatics, (69), 137-46.
de Beurs, E., Wilson, K. A., Chambless, D. L., Goldstein, A. J., & Feske, U. (1997). Convergent
and divergent validity of the Beck Anxiety Inventory for patients with panic disorder and
agoraphobia. Depression and anxiety, 6(4), 140-146.
Diagnostic and statistical manual of mental disorders (5th ed.). (2013). Washington, D.C.:
American Psychiatric Association.

13. Hauser, J. (2013). Treatments for Social Phobia. Psych Central. Retrieved on April 11, 2015,
from http://psychcentral.com/lib/treatments-for-social-phobia/00066
Muntingh, A. D., van der Feltz-Cornelis, C. M., van Marwijk, H. W., Spinhoven, P., Penninx, B.
W., & van Balkom, A. J. (2011). Is the beck anxiety inventory a good tool to assess the
severity of anxiety? A primary care study in The Netherlands study of depression and
anxiety (NESDA). BMC family practice, 12(1), 66.
Panic Disorder Clinical Presentation. (2015, January 1). Retrieved from
http://emedicine.medscape.com/article/287913-clinical
Social Anxiety Disorder: Treatments and Drugs. (2014). Retrieved from
http://www.mayoclinic.org/diseases-conditions/social-anxiety-
disorder/basics/treatment/con-20032524
Wong, C. (n.d.). How to Breath with your Belly. Retrieved from
http://altmedicine.about.com/od/optimumhealthessentials/ss/Belly_Breathing.htm