Social Anxiety Disorder: a clinical case conceptualized according to the LIBET model
From a nosographic point of view Andrea suffers from Social Anxiety; now that he is alone in a new city this ‘excessive shyness’, as he describes it, is becoming a problem for him and he has decided to undertake a course of therapy.
Andrea (invented name) is 20 years old, has always lived in the countryside, but has just moved to the city to enroll in university. Contrary to expectations, his class is composed ‘only’ of about twenty students. ‘And that’s the problem!’ He sighs. ‘I imagined that at university we would have been many, many, and that I could have studied quietly on my own, without many problems. Instead it’s all different! We are few, they all talk to each other … There are always those group works where you have to talk, ask, say your opinion … and I don’t know what to say, I’m silent, or I stammer …! It’s a nightmare, I’m constantly worried! ‘
Andrea describes himself as a very shy boy. He is not worried about his preparation, he is a studious boy, he wants to do well and if he tries hard he usually manages to get excellent results. The drama comes when he is forced to speak in front of others. In those moments Andrea feels very bad: he blushes, sweats, his hands tremble and his mouth feels dry. Some time ago it was his turn to make a presentation in front of everyone and it was terrible. He had studied a lot and was very prepared, but when he got up to speak … ‘I had an empty head, I didn’t understand anything. I read the notes, fortunately, but I spoke in a low voice and someone told me to raise the tone … what a shame! My voice was shaking and I stumbled … I looked like a total idiot, when I came home I was really sad,
Andrea is anxious even in informal moments, when people chat with each other. ‘I’d like to make friends, but I’m too anxious, they already know each other and I’m afraid of looking stupid and clumsy’. When he is forced to interact with some partner, in order to avoid getting stuck, he often tries to decide first what to say and if he repeats it in his mind ‘to be prepared’, but he ends up wasting a lot of time thinking about what to say, he risks being distracted and fails never to feel calm. When someone speaks to them in class, they feel very uncomfortable, because they don’t know what to say and are afraid of saying nonsense. To prevent this from happening, try not to meet your gaze with anyone and always stay on the sidelines. The problem is that then he feels very alone. He has no friends in the city. ‘I never talk to anyone during the week … it’s hard’. As he talks about it, he looks very sad.
Even as a child he always felt self-conscious and nervous in group situations, when there were people he didn’t know well. He had had some problems entering school in elementary school, but thanks to a very sweet teacher he managed to settle in the classroom, in which, however, there was also his cousin, with whom he had grown up together. He does not have many friends in his country, but those few with whom he has made a bond are really good friends and Andrea manages to be himself with them. He is also very attached to his cousins and his younger brother, and before this was enough! I wasn’t interested in playing with others, I always had them available! ‘.
Now that he is alone in a new city, however, this ‘excessive shyness’, as he describes it himself, is really becoming a problem. When he knows he has a presentation or group work, Andrea starts to feel bad a week before. He can’t help thinking he’ll make a terrible fool like last time; he feels his stomach closed and in the evening he cannot fall asleep. What if the professor asks him a few questions in front of everyone and he doesn’t know what to answer? Andrea always tries to be perfectly prepared, studying late and taking pages of notes. The problem is that sometimes he can’t concentrate with all these thoughts … in fact, lately he’s been struggling to study, just looking at books makes him anxious. And if he can’t study well in the afternoon, how can he go to class and risk being interrogated? The others always seem so prepared and confident… The last time he didn’t make it, he didn’t show up on the day of the group workshop, pretending to be sick ..
Since then, it has gone from bad to worse. He started avoiding all places where he could meet fellow university students or professors. Going to the cafeteria, for example, is very difficult, especially because you have to pass in front of a lot of people to go and sit down. He ends up staying all the time locked in his room studying, but he feels very lonely and sad, he fears that he will not be able to finish university, to have to go back to the countryside with this failure marked on the forehead.
From a nosogafic point of view, Andrea suffers from Social Anxiety Disorder, also known as Social Phobia, reported in DSM 5 (APA, 2013) in the chapter of Anxiety Disorders. The key symptoms that can be diagnosed are:
At SCID II (First, Williams, Karg, & Spitzer, 2017) the interview on personality disorders according to DSM 5, Andrea seems to have avoidant traits, but not a real disorder. In fact, he tends to feel inadequate and fear rejection by others, but has been able, over the course of his life, to forge deep bonds in which he does not feel excluded, but belongs.
Following the LIBET model (Life themes and plans Implications of biased Beliefs: Elicitation and Treatment), developed by the research group of Cognitive Studies (Sassaroli, Caselli, Ruggero, 2016), it is possible to reason on the clinical case in terms of painful topics and plans semi-adaptive.
The painful theme represents the emotional vulnerability of each individual, formed during the course of life and given by the attentional focus on some negative mental states associated with evolutionary experiences perceived as painful and intolerable. The more the mental state associated with the painful theme is considered intolerable, the more the individual tries to stay away from it through semi-adaptive strategies, called plans, which include avoidance, control and over-compensation or forced modification of the own mental state.
The painful theme can be investigated starting from a recent episode that the person reports as significant. The episode chosen is the moment when Andrea got stuck in front of the class during his show. We investigated it more or less as follows:
A. I had an empty head, I didn’t understand anything. I read the notes, fortunately, but I spoke in a low voice and someone told me to raise my voice ..
T. What emotion did you feel at that moment?
A. A great shame
T. What did you think of yourself?
A. What was the figure of the total idiot, the incapable loser
T. How is an incapable loser?
A. An idiot, a weak… one who cannot stay in the world
T. And if others think this, what happens in the negative?
A. That no one will consider me equal, they will all avoid me. Nobody wants to deal with a loser like that, not even I would like
T. What’s the worst thing for you to be a loser?
A. That I will never be on a par with the others, I will always be avoided by the teachers .. by my classmates … I will always be considered inferior
T. How do you feel if you think these things?
A. Very sad and ashamed
We thought for a long time if it was a matter of unworthiness rather than inadequacy / lack of love. In the first case it is a profound feeling of inferiority and contempt towards the self, in the second case the person feels refusal, potentially unloved and not recognized despite their efforts, worthless. The emotion most often associated with the theme of unworthiness is shame, while inadequacy / lack of love may have more to do with sadness. Furthermore, the inadequacy / lack of love theme, according to the LIBET model, can derive from an evolutionary story characterized by cold and distant parents, who have not been able to express affection and appreciation, or themselves insecure and overprotective, who have not allowed a ‘ adequate exploration of the world and its capabilities.
It is possible to explore the patient’s evolutionary history starting from the emotionally salient episode above and go back in time, helping the patient to remember if there were moments in which he felt that way or thought the same things in the his adolescence and childhood.
T. Do you remember if you have already felt this way before? For example, when were you a teenager?
A. In middle school there was a very bad episode. We had to go on a trip, but my best friend had broken his arm and could not come..Panico! Who would I have been in the room with? Or sitting next in the bus? No one else would have wanted me with them, they had all already organized. I felt really sad and humiliated. I didn’t want to go, but my father forced me. Even if the professor decided who I would be with, it was very bad, because I knew that my companions would have preferred that I was not in the room with them. Or even in the hour of gymnastics, for example, that we were several classes together … I never wanted to do it and often I had my mother make the justification. The fact is that I was always chosen last, because in sports I am clumsy. I felt the last of the last.
Going back in time, we focus on the memories of elementary school.
A. The first few days have been a disaster, I still remember it. I was terrified of the idea of school, of other children. I only played with my cousins and my brother, I was not used to it. We were in the countryside, I had never seen all those unknown children all together. My mother was very worried about me. She is also very shy, has always lived in the countryside, is always with the same people and doesn’t like it when she has to talk to strangers. On the first day of school she was very frightened, she feared she would not find the way, to arrive late, she was ashamed because the other mothers were citizens, instead we were farmers, we came from a country village … She kept saying that it was difficult to drive for that road, to behave well, to speak with the teacher and make a good impression …
From the stories therefore emerges the figure of a mother in turn very anxious and worried, clumsy and inhibited in social relationships, unable to manage the emotions of her son.
The father, on the other hand, is described as an authoritarian man of few words, very dedicated to work in the countryside and hardly present at home, often openly devaluing towards his son.
A. It was he who had decided to send me to school in the city. He said I had to get good at having a good job. He never paid me a compliment, when I got good grades he nodded, once I got a failure, in high school, he said shaking my head that he was very disappointed and that maybe it was a mistake to make me do high school, which was too difficult a school for me. I felt that he had many expectations of me, he would have liked to study but he could not, I was always afraid to disappoint him. Even with the girls. Sometimes he asked me why I didn’t have a girlfriend. – At your age it is normal to have a girlfriend, everyone has it – you could tell he was really worried about me … disappointed, just disappointed he seemed. It seemed sad to me. Once I didn’t want to go to a party, I heard him say to my mother:
T. And how did you feel?
A. I vergonized, I thought he was right.
We decided to share with the patient the description of the theme of unworthiness, which seemed appropriate to us because of a strong sense of inferiority almost without escape (if not perhaps being ‘good’ at university) and that deep shame that does not allow not even to glimpse the hope of a more benevolent judgment from others. The patient accepted this hypothesis with surprise and initial distrust, then with relief and emotion, as sometimes happens when it turns out that our pain is not only ours, but shareable and universal.
According to the LIBET model, it is also useful to think in terms of plans, that is, habitual and ego-syntonic strategies that the patient has learned to use throughout his life to stay away from his painful theme. The plans are more or less rigid, generalized and pervasive, and although during their life they have had an adaptive functionality, at a certain point they became dysfunctional precisely because they were used in an automated and pervasive way even in conditions of low threat.
During the interviews, it emerges that Andrea seems to use two plans: the prudential one, that is based on avoidance, and the prescriptive one, that is based on control.
Andrea’s oldest plan seems to be the prudential one, learned from his mother and carried on during his childhood and adolescence without, in the end, too many problems. He had his cousin at school, his brother and other cousins at home and ‘this was enough’: ‘I wasn’t interested in playing with others, I always had them available’.
The first breaks in the prudential plan occur due to external interventions: the obligation on the part of the father to go on a school trip, for example, or the times when he was forced to participate in gymnastics. Then the university arrives, source of many hopes, and here is really the breaking of the plan: it is no longer possible to avoid, as Andrea hoped! ‘I imagined that at university we would have been many, many, and that I could have studied quietly on my own, without many problems. Instead … ‘. But for Andrea it is important not to fail at university. What to do?
When it is not possible to avoid, Andrea seems to pursue the prescriptive plan. For example, when Andrea tells us that he tries to prepare and memorize what to say during a meeting or if asked, he is trying to ‘check’ that the feared event, or humiliation, the ‘fool’ and the consequent social exclusion do not occur. He does it the way he knows: with commitment and programming, just as he does when studying for exams! In fact Andrea has always been an excellent student! In the school environment, the prescriptive strategy has always worked; in the social sphere however it is not always a good idea. In fact Andrea does not calm down, he cannot remember what he meant and remains constantly worried about being ‘taken aback’. And at the end,
Since in this case the prescriptive plan did not work, Andrea returns, again, to avoid: situations, people, places, group work. Avoid the canteen, just as you avoided gymnastics classes in high school; avoids the looks, remains aside. This strategy, although it saves him anxiety and shame, now makes him sad, because it makes him feel excluded and inadequate and risks ruining his university career, on which the only possibility of ‘redemption’ is based : to be good, to emerge, to make happy the father who had not been able to study. The costs of the prudential plan have become too high.
Given this conceptualization, it will be possible in the course of therapy to work on themes and plans from a point of view not only of content, but also of process. From the point of view of the theme, it will be possible to work on the attentional polarization that makes the painful theme absolutely conditioning and central in the life of the individual, and on its intolerability, or on how much the patient considers intolerable the pain associated with the theme.
From the point of view of the plans, however, we will be able to work in terms of necessity / utility and uncontrollability, slowly making Andrea’s strategies more flexible from a metacognitive and consequently behavioral point of view.