ABSTRACT | PDF
CASE REPORT
A casework report of social anxiety disorder with anankastic personality disorder: a cognitive behaviour therapy approach
Aarti Jagannathan, K Sekar1, YC Janardhan Reddy2
Assistant Professor, Swami Vivekananda Yoga Anusandhana Samasthana (SVYASA),
1Professor of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS),
2Professor of Psychiatry, NIMHANS, Bengaluru, Karnataka, India
Abstract
Co-morbidity of personality disorders is common with anxiety disorders; cognitive behaviour therapy (CBT) has shown some efficacy in treatment of such conditions. A 37-year-old male case of social anxiety disorder with anankastic personality disorder was referred to the psychiatric social worker by the unit consultant for psychosocial intervention inclusive of CBT. Twenty five sessions, each lasting around one hour, were conducted daily with the client on an inpatient basis to: (1) assess his problem, (2) grade the problem in a hierarchy, (3) expose him gradually to anxiety provoking situations, (4) teach cognitive behavioural techniques to ameliorate stress, (5) help him realise the safety behaviours used and to consciously cut down on them, (6) challenge and confront distortion, and (7) help him improve communication with his wife. At the time of discharge, the patient had improved nearly 30% and was more confident of facing social situations and interaction with people.
Jagannathan A, Sekar K, Janardhan Reddy YC. A casework report of social anxiety disorder with anankastic personality disorder: a cognitive behaviour therapy approach. Dysphrenia. 2013;4:158-64.
Keywords: Co-morbidity. Dynamics. Follow-up.
Correspondence: jaganaarti@gmail.com
Received on 1 March 2013. Accepted on 24 March 2013.
Theoretical and research basis for treatment
Meta analytical studies have shown that cognitive behaviour therapy (CBT) is effective in the treatment of social anxiety disorders (SAD).[1-6] Clark et al.[7] developed an idiographic model for the patient suffering from SAD, conducting safety behaviours experiments, providing video feedback after cognitive preparation, developing a hierarchy, conducting in vivo exposures and other behavioural experiments, imaginal exposure, social skills training, assertiveness training, and behavioural activation for depression.[8] Maladaptive interpersonal beliefs associated with social anxiety are seen to significantly reduce after CBT.[9] Post event processing (PEP - a post mortem review of a social interaction that focuses on negative elements) also is observed to decrease as a result of CBT treatment, and symptoms of social anxiety for individuals reporting greater levels of PEP improved at a slower rate than those with lower levels of PEP.[10] Further, greater left frontal electroencephalography (EEG) activity at pre-treatment is observed to predict greater reduction in social anxiety from pre to post CBT treatment and lower post treatment social anxiety after accounting for pre-treatment symptoms.[11]
Meta analytical studies on co-morbidity of personality disorders (PD) in anxiety disorders (AD) have shown that the rate of any comorbid PD was high across all ADs, ranging from .35 for posttraumatic stress disorder (PTSD) to .52 for obsessive-compulsive disorder (OCD).[12] Cluster C PD occurred more than twice as often as other clusters and within cluster C the avoidant PD occurred most frequently, followed by the obsessive-compulsive PD (OCPD) and the dependent PD.[12] Kumar et al.[13] suggest that a relationship exists between a subset of obsessive compulsive symptoms and the personality traits that constitute OCPD. Studies have specifically shown that patients suffering from SAD and co-morbid personality disorder show a smaller decrease in specific SAD symptomatology during CBT treatment compared to patients with SAD without personality disorders.[14] Specific PDs have demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders; e.g. schizotypal and avoidant PD with course of SAD.[15] Further, higher self-esteem variability in OCPD/anankastic PD who received cognitive therapy (CT) was observed to predict more improvement in PD and depression symptoms.[16]
In this social casework report, we present a case of a person diagnosed with SAD with co-morbid anankastic PD. The aim of the psychiatric social worker was to provide appropriate intervention for both the axis I disorder (SAD) and the axis II disorder (anankastic PD). Hence though the mainstay treatment was pharmacological, the interventions provided by the psychiatric social worker were CBT (to deal with the axis I disorder) and psychosocial intervention (to deal with the axis II disorder).
Case introduction
Mr X was a 37-year-old male of Hindu religion, who had completed his graduation and was working in a travel agency. He was married and living with his wife in a city. He was from a middle socioeconomic status and was well-versed in English and Hindi languages.
Presenting complaints
Chief complains of involuntary twitching movements of facial muscles in social situations, social withdrawal and low threshold for criticism for the past three years. The patient liked orderliness, wanted to be perfect, felt inferior and inadequate in many situations in front of people. The onset of the symptoms was insidious with episodic course and fluctuating progress precipitated by stopping medications.
Sources of information and reason for referral
The client himself was the main source of information as he had insight into his problem (for which he himself sought for help at the National Institute of Mental Health and Neurosciences [NIMHANS]). His information was considered reliable and valid. The patient was referred by the unit consultant for psychosocial intervention and CBT.
Brief clinical history
After stopping medications in 2000, Mr X had a relapse of symptoms such as involuntary twitching movements of facial muscles in social situations, social withdrawal and low threshold for criticism, and these symptoms progressively worsened. He had ideas of reference such as, “people mimic my movements – twitches”. This morbid belief was especially present during anxiety related situations. Mr X had become socially withdrawn significantly and had stopped attending social functions. He was unable to function in his profession, as his sole preoccupation was his facial twitches, resultant anxiety and guilt feelings related to them. Patient hence often got irritable and angry with his family members due to which his relationship with them was often strained. Thus apart from anti-anxiety medication (escitalopram 20mg), he was also given a low dosage of antipsychotic medication (risperidone 2mg) for his morbid belief and tics. It was also found that even before the starting of the illness in 1981, the patient liked orderliness, wanted to be perfect, felt inferior and inadequate in many situations in front of people. The mental status examination (MSE) corroborated the above findings. On the basis of the above case records and past history, a diagnosis of SAD with anankastic PD (with past history of severe depression and multiple substance abuses in remission) was made during his admission at NIMHANS in 2003.
Past history
Mr X’s problem started in 1981 and leading to it, he started using substances like alcohol, lorazepam and heroine. He also had depressive cognitions and a lethal suicide attempt. During this period, he was unable to attend to his work and had poor motivation to carry out his personal daily routine, e.g., bathing etc. He had disturbed sleep and his appetite was decreased. When he approached a psychiatrist in 1997, he was diagnosed as having severe depression with multiple substance abuses. He was hence put on antipsychotics and antidepressant medications from 1997. Patient responded well to medications and attained baseline premorbid state of functioning in 1999. During this year he also attended de-addiction services which helped him to achieve abstinence from all substances except nicotine. The Mr X then stopped taking psychiatric medications on the advice of his doctors by the end of 1999.
Family history
The family of origin of the client was a nuclear family which housed four members – the father, mother, his younger sister and himself. The parents had separated when the patient was six years of age. The patient then started staying with his mother and younger sister. There is family history of alcohol dependence in three maternal uncles and epilepsy in maternal cousin brother. The patient is currently (in 2003) married and stays with his wife in a nuclear family.
Family composition
Father: Fifty six years old, illiterate male, who runs his own business. He was an adopted son of his parents. He separated from his wife 31 years ago and remarried. After the death of his second wife, he restarted building contacts with the patient’s mother (first wife). Even during the time he was separated from the family, he financed all expenses of the patient’s household. The patient and his sister shared a formal relationship with their father, though the patient was the first to forgive his father and welcomed him back home.
Mother: Fifty three years old, housewife, who is illiterate. She brought up her children with the limited financial resources her husband provided her every month. She taught her children to be independent. Both her children are very attached to her and the patient recognises the hardships she has undergone to bring them up.
Sibling: She is 34 years of age, has completed her masters, and is currently working in the television media. She is affectionate and concerned about her brother. She advices him when needed. The patient is also very close to his sister and discusses his problems freely with her. She only took the initiative to introduce the patient to a psychiatrist to help him deal with his symptoms.
Spouse: Twenty six years old female, who has studied up to her graduation. She is working as a teacher. She had a four years courtship with the patient, before they decided to get married. She was aware of his drug use and his anxiety symptoms/problem. She has been supportive of his treatment. She shares a good communication with him; however at times there are differences in thinking and attitudes, which the patient attributes to their age difference.
Family dynamics
Family of origin: The family boundary between the father and children was closed whereas between the mother and children was open and clear. Parent child subsystem is present (mother-children have an alliance) but it never became a coalition against the father. In the initial seven years after marriage, the father was the nominal and functional leader of the house. However after the father separated from the family, the mother became the nominal and functional leader of the house. The mother played an instrumental role and the sister played a more expressive role of the mediator in case of disputes in the house. There was cordial interaction and the noise level in the family was low. There was healthy connectedness present in the house between the mother and the children. After the separation of both the parents, the financial support provided by the father was limited and the family had no adequate secondary or tertiary support system.
Family of procreation: There was a ten years age gap between the marital dyad. The boundary was clear and open, where the patient was the nominal and functional leader of the house. The leadership exercised by the patient was often not accepted, which lead to arguments between the couple. Although healthy connectedness was present occasionally between the couple, marital conflict was present most of the time. Conflict resolution seemed to be present in the family (due to which the wife still supported the patient) though not implemented adequately in crisis situations (during arguments). The family had adequate primary (self) and secondary (family) social support. However the presence of a strong tertiary support system was missing.
Personal history
As the patient presented himself to the hospital alone, there was no family member to corroborate the personal history. Hence once the patient was admitted, telephonic interview with the mother was conducted to elicit the personal history. The patient was a full term caesarian baby. There were no complications during delivery and he had normal developmental milestones. He did not have any behavioural problems during childhood, and shared a good relationship with his parents and sibling. He started going to school at the age of five years. He liked going to school and was a regular student. He was an average student in academics. He however shared a good relationship with all his teachers and had many school friends.
He had completed graduation and started working at the age of 34 years in a travel agency in Nepal. He was very organised and meticulous at his work. Due to this characteristic of his, he shared a good relationship with his superiors. He felt satisfied in his job; but always had the urge to excel in whatever he did. He also shared very warm relationship with his office colleagues.
Marital history: Patient married at the age of 36 years with the mutual consent of his spouse and himself (love marriage). There was a ten years age gap between the marital dyad. They share a good marital and sexual relationship.
Social analysis and diagnosis
Index client Mr X was a 37-year-old male of Hindu religion, who had completed his graduation, and was working in a travel agency. He was married and living with his wife in a city. He was from a middle socioeconomic status, presented with the chief complains of involuntary twitching movements of facial muscles in social situations, social withdrawal, and low threshold for criticism for the past three years. He liked orderliness, wanted to be perfect, felt inferior and inadequate in many situations in front of people. The onset of the symptoms was insidious with episodic course and fluctuating progress precipitated by stopping medications. MSE corroborated the above findings. On the basis of the above case records and past history, a diagnosis of SAD with anankastic PD (with past history of severe depression and multiple substance abuses in remission) was made.
The social analysis of the family of origin shows that the family boundary between the father and children are closed whereas those between the mother and children are open and clear. Parent child subsystem was present (mother-children have an alliance) but it never became a coalition against the father. In the initial seven years after marriage, the father was the nominal and functional leader of the house. However after the father separated from the family, the mother took over the leadership, and played an instrumental role. The sister played a more expressive role of the mediator in case of disputes in the house. Healthy connectedness was present between the mother and the children. Problem-solving and coping strategies of the family members were adequate. After the separation of both the parents, the financial support provided by the father was limited and the family had no adequate secondary or tertiary support system.
In the family of procreation, there was a ten years age gap between the marital couple. The boundary was clear and open, where the patient was the nominal and functional leader of the house. The leadership exercised by the patient was often not accepted, which lead to arguments between the couple. Although healthy connectedness was present between the couple but there was frequent (most of the time) conflicts was also present. Conflict resolution seems to be present in the family due to which the wife still supported the client though not implemented adequately in crisis situations (during arguments). The family had adequate primary (self) and secondary (family) social support. However the presence of a strong tertiary support system was missing.
During the present illness, the client had become socially withdrawn significantly and had stopped attending social functions. He was unable to function in his profession, as his sole preoccupation was his facial twitches, resultant anxiety and guilt feelings related to them. Hence, he often got irritable and angry with his family members due to which his relationship with them was often strained. In lieu of the above social analysis, the following social diagnosis was made (the tenth revision of the International Statistical Classification of Diseases and Related Health Problems [ICD-10], Z category):[17]
• Z50.3: Drug rehabilitation
• Z63.4: Disruption of family by separation
• Z72.2: Drug use
• Z81.1: Family history of alcohol abuse
• Z82.0: Family history of epilepsy and other diseases of nervous system.
Interventions
I. Goal of interventions for the patient (at individual level): To enable the client to practice the cognitive behavioural techniques to ameliorate his stress and face social situations effectively, to improve interaction, to help client to improve communication with his wife.
II. Interventions offered: Psychoeducation, CBT, Jacobson progressive muscular relaxation (JPMR).
III. Course of treatment and assessment of progress: Twenty five sessions, each lasting around one hour, were conducted on daily with the client as an inpatient basis to: (1) assess his problem, (2) grade the problem in a hierarchy, (3) expose him gradually to anxiety provoking situations, (4) teach cognitive behavioural techniques to ameliorate stress, (5) help him realise the safety behaviours used and to consciously cut down on them, (6) challenge and confront distortion, and (7) help him improve communication with his wife.
Initially an assessment of client’s problem was done in a systematic manner. It was found that the client felt increased anxiety: in social situations, in front of a number of people, while speaking to females more than males, with increased length of the conversation, and if he was approached by an unknown person suddenly.
Client was first given a medical model explanation on his illness of SAD. He was advised to look at his illness from an objective manner and not from the subjective aspect, so that he does not hold himself responsible for his failures. He was also advised that any social situation (event) which he gave increased importance did increase his anxiety, which in turn made it difficult for him to face the situation (event). The client was taught that in order to break the vicious cycle of EVENT – INCREASED IMPORTANCE – INCREASED ANXIETY – EVENT; he had to try not giving greater importance to the social event, to reduce his anxiety for the event (Figure 2).
The client was provided psychoeducation about his illness, and then he was educated about the cognitive behavioural model, its assumption and guidelines. Planned exposure was then discussed. Initially the client was advised to meet at least three people in a day: two males for a period of minimum eight minutes and one female for a minimum period of five minutes. The patient was also advised to initiate a conversation and maintain the conversation for the stipulated time period regardless of his anxiety. He was advised to confront and contest his negative cognition by asking the following questions:
Ø What is the evidence for and against this thought/belief?
Ø What is the evidence for alternative interpretations of the event/situation?
Ø What are the real implications if the relief were true?
The patient was taught to decatastrophise the severity of the outcome of the event. He was explained that no calamity would take place if he faced people or if they commented on his look. Further he was advised to maintain a record of his interaction in the format shown in table1.
Every day the diary/record of the client would be discussed and his cognitive distortions would be analysed. The main cognitive distortions of the client were:
Selective abstraction: The client chose to focus only on the non-verbal facial expressions of the people when he was interacting with them. He did not concentrate on the content or type of conversation.
Magnification: Based on the minor non-verbal facial movements of the other person, the client often magnified it and assumed that the people were mocking at him, criticising him, or noticing his facial twitches.
Personalisation: The client believed that any action or non-verbal cue of the opposite party was directed towards him and criticised him.
With discussion, it was found that the client had the above cognitive distortions while interacting with people because he believed that: he needed to be perfect and he needed to be superior in conversation than others. The client felt inferior to others, who were more knowledgeable than him. Also he felt scared of competing with them, as he never wanted to lose and wanted to be a ‘perfect man’.
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Table 1. Format for recording patient’s interaction |
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Situation |
% and type of emotions/anxiety |
Automatic thoughts |
Rational response to thoughts |
Outcome |
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The caseworker discussed with the client on how the concept of being perfect was utopian and that how he could not compare his ability/capacity to others as each individual was unique. The cognitive distortions of the client and his negative cognitions of being perfect and inferior to others were challenged in every session, till the client was more confident in contesting his cognitive distortions by himself. Further the client was helped to analyse, contest his distortions and evaluate the outcome of each of his interactions with others. The length of interaction with people was gradually increased. The client was made aware of the safety mechanisms he was using while interacting with people, to reduce his anxiety: wearing sunglasses, avoiding eye-contact, diverting the topic, leaving the place of conversation.
Client was advised to avoid using safety behaviour in his interaction. He was advised not to anticipate the anxiety during his interaction with other people. Client was advised to continue interaction, in spite of experience of anxiety and wait till the anxiety remitted on its own. Repeated exposure and analysis of the interaction through CBT techniques helped the client to maintain the conversation. There were days when he experienced no anxiety. The benefits of his effort were then reinforced. Client was also taught JPMR techniques, to help him to deal with his anxiety.
The client was made to realise that he was having high role expectations from his wife. During the discussion, the client realised that he was afraid of giving responsibility or freedom in decision making to his wife, because he believed that no one other than him could make a perfect decision. This cognitive distortion was identified, and the client was explained that communication is a two way process.
To improve communication between the couple, it was essential that both the partners had an equal participation in the decision making of the household. The client admitted that the disruption of his family of origin, due to the separation of his parents, could be the reason because of that he did not have trust in his wife which leaded to occasional unfavourable family environment. Client was thus taught appropriate communication and coping skills to improve his interaction with his wife.
Outcome of interventions
According to the client, he had improved nearly 30% at the time of discharge. He was more confident of facing social situations and interaction with people. He is aware of the various cognitive behavioural techniques he needs to use in order to ameliorate his stress.
Complicating factors
There were not any complicating factors found in this case during the assessment and intervention.
Access and barriers to care
As the client stayed far away from the NIMHANS (institute) and he was not financially well to do, he was unable to travel frequently for follow-up. His mode of communication and follow-up was thus done online via email – which restricted the type of care (especially CBT follow-up) which could have been conducted if the client had physically come for follow-up at NIMHANS. Further, due to above mentioned logistic reasons, the psychiatric social worker never had an opportunity to have a session with the wife and get her perspective on how the client was improving at home, post discharge.
Follow-up
The psychiatric social worker followed up with the client, once in three months via email and discussed the case with the unit psychiatrist (Dr YCJR) for the first two years post discharge. During this period, the client maintained improvement and is stated to have reached premorbid levels of functioning. He did not avoid interaction with people and did not use safety behaviours in his interaction.
At the end of the two years (post discharge of the client), the psychiatric social worker had to transfer the case to the concerned unit psychiatrist for follow-up, as she was relocating. The psychiatric social worker has since then not had any contact with the client. However to seek permission to publish this case record, the psychiatric social worker reconnected with the client. The client then reported that he had been well for the first two and the half years post discharge from NIMHANS, but later had started having relapse of his symptoms and was unable to practice the CBT techniques taught to him. Currently for the past three years, he is unemployed due to his condition and is staying away from his wife.
The plan of action was to follow-up with the client via email and convince him to come down for a check-up to NIMHANS (eight years since the client has visited the treating team at NIMHANS). The follow-up emails were also supportive in nature, to clarify certain minor specific problems. The client had promised to come for a follow-up, once he has garnered enough funds for his treatment. Once the client is able to come to NIMHANS for treatment, brief therapy would be planned along with medication review by the treating team.
Treatment implications of the case
CBT is a viable therapy that can be administered by psychiatric social workers on patients suffering from anxiety disorders with encouraging results. As CBT is a highly specialised therapy, psychiatric social workers need to be adequately trained in conducting the therapy (by a specialist), before attempting to administer it on the patients.
For the therapy to be effective and have continued effect, regular follow-up with the treating team and case worker (in this case for CBT) is essential. The psychiatric social workers need to insist on regular follow-ups and a brief therapy session should be conducted at each follow-up with the patient. At every follow-up, the cognitive behavioural techniques need to be reiterated and reinforced to the patient till the clinical team is able to reduce his dosage of medications.
In case of other co-morbid conditions in the patient, an eclectic approach – where techniques from suitable therapies other than CBT needs to be administered. CBT cannot be used as a lone treatment to solve all problems of the client. As in this case, the problem of marital conflict was dealt with by teaching communication and coping skills along with mirroring cognitive distortions about being a ‘perfect husband’ using CBT.
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