Social Anxiety during the Covid-19 and Treatment with Cognitive Behavioral Therapy

Introduction

Anxiety disorders have become one of the most common mental health issues faced by adults today. Social anxiety disorder is the fourth most common psychiatric disorder, with only major depression, alcohol abuse, and specific phobia being more prevalent. More conservative lifetime prevalence estimates suggest that clinically significant social anxiety affects a compelling but more modest 4% of the population [1]. When social anxiety disorder was first included as a diagnostic category in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV) [2], it was thought to result in only minimal disruption in role functioning. Research has since revealed that social anxiety disorder can be quite incapacitating. The vast majority of individuals with social anxiety disorder report that their career, academic, and general social functioning has been seriously impaired by their fears [3].

Approximately 70-80 % of individuals with social anxiety disorder meet the criteria for an additional diagnosis and in most cases; social anxiety disorder predates the onset of the co-morbid condition. In community samples, the most common additional diagnoses include specific phobia, agoraphobia, major depression, and alcohol abuse and dependence. Compared to individuals with uncomplicated social anxiety disorder, persons with social anxiety disorder and co- morbid disorders have higher rates of suicide attempts, are more likely to report significant role impairment, and more often use medication to control their symptoms [4].

Cognitive-Behavioral Treatment and Social Anxiety

Researchers have investigated the efficacy of a broad range of treatments for social anxiety disorder, including social skills training, cognitive therapy, relaxation training exposure, interpersonal psychotherapy, dynamically oriented, supportive psychotherapy, and various pharmacotherapies [5]. Cognitive Behavior Therapy is one of the most effective ways of treating various disorders such as depression and anxiety. It has been indicated that CBT and its exposure- based modalities are effective to treat anxiety disorders such as SAD [1]. Cognitive Behavior Therapy includes techniques like verbal challenging for cognitive restructuring and behavior experiments. In addition, relaxation exercises are also used to treat symptoms like fatigue and tiredness [6].

Objective of the Study

The objective of the study was to find out the efficacy of cognitive therapy in cases of Social Anxiety Disorder during Covid-19. Cognitive behavioral therapy will significantly reduce the client’s complaints, such as excessive worry about going out in public, anxiety related to the fear of Covid-19, and concern for her family’s health, and the ability to return to studies and social life.

Case Presentation

Linda is 23 years, old Albanian female. She studies lawyer and she lives in Prishtina. She grew up in Pristina, she lives in a house with one brother and her parents. She appeared smartly dressed in an outfit, which was age-appropriate. She was attentive and oriented to person, place, and time and made every effort to be open with me. All the time during the session she was a cooperative attitude toward the therapist. Thus, it was easy to establish a good rapport with her. Her speech was coherent and relevant. Memory was intact as observed. Insight was estimated as good. Linda was highly motivated to change and willing to engage in therapy to improve her condition. Linda was referred by a psychiatrist who had gone with her mother to be checked for the first time.

After a consultation with a psychiatrist, he prescribed two types of tablets for you to use for one month and recommended a consultation with a psychologist. After the psychiatrist’s recommendation, she contacted me on the phone to make an appointment. The reason for the referral was that during the last 6-7 months, there was fear and anxiety to go out of the house. This fear has hindered them in their studies and social life in general. This situation started 6 months ago when she received the unexpected news about the death of her aunt’s son from Covid-19 on a bus, who was healthy and young. This sudden death on the bus caused the client fear and anxiety to travel by bus, leaving the house, going to college, and being with friends. Linda has never seen a psychologist or a psychiatrist before.

Assessment

For the specific case, we decided to offer individual cognitive behavior therapy based on Clark and Well’s model for Social Anxiety Disorder. We started with the observation and assessment of mental status, and Mini International Neuropsychiatric Interview. The Mini-International Neuropsychiatric Interview [7] is a brief structured interview designed to assess the major psychiatric disorders in the DSM-5 and ICD-10. Diagnostic criteria for anxiety disorders, bipolar disorders, depressive disorders, obsessive-compulsive and related disorders, trauma- and stressor-related disorders, feeding and eating disorders, and substance-related and addictive disorders. Then we use two assessment measures (STAI and SPAI).

The state-trait anxiety inventory (STAI) the appropriate instrument for measuring anxiety in adults, differentiates between state anxiety, which represents the temporary condition, and treats anxiety, which is the general condition. The STAI is a validated 20-item self-report assessment device that includes separate measures of state and trait anxiety. The STAI includes forty questions, with a range of four possible responses. In each of the two subscales scores range from 20 to 80, with high scores indicating a high anxiety level. Higher scores correspond to greater anxiety. The Social

Phobia and Anxiety Inventory (SPAI) is a 45-item self-report measure that assesses cognitive, physical symptoms, and avoidance/escape behavior in various situations. It includes two subscales: Social Phobia and Agoraphobia. A difference score above 60 indicates a potential phobia, and a cut-off score of 80 maximizes this identification rate [8].

Procedures

Conceptualizing the case. Following a model suggested by Clark DM, et al. [9], Linda’s experience of unhelpful social anxiety is conceptualized as follows. Examples of fearful situations included college exams, leaving home, talking to a group of students, fear of getting on the bus, fear of covid-19 being around other students and her worries including what others would think him as disabled or unfit for society. Her concerns seemed to be confirmed by physiological reactivity (eg, feeling warm) and feelings of “dread” by her performance. To avoid negative outcomes, Linda engaged in avoidance behavior, wearing “thick clothes that she perceived would not show sweat, or running out of class, or crowded places. The conceptual model is described in more detail below and the model is shown in Figure 1.

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Intervention

The total, the client was seen for 15 sessions.Sessions1-3 of treatment usually consist of case formulation, creating a therapeutic relationship, socialization, goal settings, cognitive preparations for restructuring, and psych education, involving manipulations of safety behaviors and of attention. Treatment sessions 4-6 we started with the structuring of the session, then the homework, after we focus on advanced cognitive restructuring, also on a continuation of behavioral experiments, in the beginner systematic exposure imaginative, after this involving exposure to test negative appraisal and predictions. During the session, 7-9 continue with cognitive and behavior reattribution methods and introduce band with man overs aimed at further interrogating the environment, also video feedback methods to correct the distorted self-image [10, 11].

We applied relaxation techniques, e.g. deep breathing and progressive muscle relaxation. In sessions 10-12 we continued with a review of homework after continuing to use cognitive restructuring to explore Linda’s core beliefs, and challenge them, also during the sessions we teach a coping strategy (i.e., Attitudes and actions that can help) [12]. In the last 2 final sessions, the treatment concludes with a discussion of relapse prevention and the therapist helping the clients set specific goals for the year the following treatment (Table 1).

During the presentation of the model, I give a brief description of what happened when the patient was confronted with a recent social situation. It is useful here to note the occurrence of automatic negative thoughts just prior to the situation that led to the reflexive activation of anxiety and anxiety symptoms. It should be noted that the patient has developed a series of coping or safety behaviors that have become counterproductive and lead to the maintenance of the problem. In the last two therapy sessions, we have focused on relapse prevention issues. This usually consists of prompting patients to describe a detailed summary of information learned during treatment. This therapy plan has also included a detailed list of strategies that have been helpful in overcoming social anxiety [13].

Results

During 15 therapy sessions, Linda has managed to reduce social anxiety and control her behavior. In general, sleep has improved; motivation each time was raised. It successfully passed the anxiety hierarchy facing fears and reducing anxiety in general. She demonstrates the ability to successfully pass exams. She has learned to identify her automatic thoughts and her opinion has improved in black and white by finding alternative answers [13]. She has started to appear more often in public places. It feels good, particularly about acquiring the knowledge, skills, and professional support in this process, and also it is ready to all these skills to use in different situations stressful everyday life (Figure 2).

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Figure 2_:_ Anxiety level during treatment sessions.

Follow-up

Results from symptom measures completed after session 15 supported the qualitative observation of significant improvement since baseline, as well as a continued improvement since the time point of the previous assessment, which had been before the onset of local measures of the COVID-19 pandemic. An additional follow- up appointment was scheduled for 6 months after the final session, to coincide with the client’s anticipated return to social life and college.

Discussion

Based on the studies done on mental health during the Covid-19 period, psychological treatment has been necessary and has been implemented in many hospitals and university clinics. One of the most favorable and effective psychotherapeutic approaches that have been applied is CBT. Also, based on studies, CBT has long been effective in the treatment of psychological disorders of clients during the pandemic situation, especially in the treatment of social anxiety disorder. During the intervention, it was found that by providing enough accurate information about the management of COVID-19, the client’s negative emotions were significantly improved. In addition, we found that by offering free psychotherapy to the client during the pandemic period, her anxiety level significantly improved during CBT treatment.

Conclusion

Future research should focus on and investigate the long-term effects of CBT for anxiety disorders specifically for social anxiety during Covid-19. It is also preferable to make a comparison between cognitive-behavioral psychotherapy and other psychotherapeutic treatments for social anxiety disorder.

Declaration of Conflict Interests

The author declared no potential conflict of interest with respect to the research, authorship, and or publication of this article.