Biweekly Cognitive Therapy for Social Phobia

PSYCHOTHERAPY CASEBOOK
EDITOR’S NOTE
Biweekly Cognitive Therapy
Through this column, we hope
that practitioners in general
for Social Phobia
medical settings will gain a
more complete knowledge
Daniel Varon, M.D.
of the many patients who
are likely to benefit from
brief psychotherapeutic
interventions. A close working
raditionally, insight-oriented psychotherapy is a once-weekly,
relationship between primary
T 50-minute venture. Cognitive therapy is typically offered at a
care and psychiatry can serve
similar frequency. There is legitimate concern that the continuity of the
to enhance patient outcome.
process would be disrupted by less frequent meetings.
Dr. Varon is in the fifth year
Social phobia is a relatively common disorder. The prevalence of
social phobia in primary care settings ranges from 2.9% to 7.0%. As in
of a combined psychiatry-
community samples, social phobia frequently occurs with other disorders
neurology residency at the
in primary care patients, most commonly major depression, generalized
Medical University of South
anxiety disorder, and substance abuse. In patients with this disorder, brief
Carolina.
therapy has been used successfully alone or in conjunction with medica-
tions. The therapy is usually conducted once a week, or sometimes twice
a week if necessary, which can be difficult to afford for some patients.
The patient described below presented with a case of major depressive
disorder with comorbid generalized social phobia and some obsessive-
compulsive traits and was seen for 10 brief therapy sessions every other
week with significant benefit. This case demonstrates the usefulness of
biweekly therapy for a subset of patients in whom weekly therapy is not
an option.
PRESENTATION OF THE PROBLEM
The patient is a 31-year-old single Asian American man who had been
treated for 5 months for depression and anxiety with pharmacotherapy at
the university clinic. The patient’s depressive symptoms had improved,
but he continued to experience marked anxiety. He had moved from
Rhode Island to Charleston, S.C., 6 months prior to his visit with me
(D.V.) in order to start a new job at an insurance company. The patient
said he frequently felt anxious, particularly around his boss and female
coworkers because he was constantly fearful of saying or doing “the
wrong thing” in front of them. He had to give monthly presentations in
front of his coworkers, and, although he usually did fine, he would worry
about his performance for 2 weeks prior to the presentation. He also had
difficulties interacting with people in social situations unless he had a
drink or two beforehand. He considered himself a loner, preferring to
stay at home watching television or taking care of his car.
The patient also mentioned having a motor vehicle accident soon after
moving to Charleston in which his car was badly damaged. He had to
purchase a new car due to the accident. He had become very careful with
his new car, spending a great deal of time washing it on the weekends,
making sure the paint was in good condition every day as he came back
from work, and fixing minor scratches as they occurred. He would also
drive the car as little as possible to decrease the chances of it getting
scratched or damaged, and he would avoid going to places where the
parking spaces were too close to each other. He would also spend a good
bit of time looking for a parking space at work where the car would be
safe from careless drivers. He denied any flashbacks from the accident or
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© COPYRIGHT 2003 PHYSICIANS POSTGRADUATE PRESS, INC. © COPYRIGHT 2003 PHYSICIANS POSTGRADUATE PRESS, INC.
Primary Care Companion J Clin Psychiatry 2003;5(2)

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PSYCHOTHERAPY CASEBOOK
being concerned about his safety. He thought his care of
triple columns to record distressful situations, the associ-
the car might be a little excessive, but he really enjoyed it
ated feelings, and thoughts or meanings that accompanied
and did not think it was impairing his daily activities.
the feelings.
During our third and fourth sessions, we reviewed the
PSYCHOTHERAPY
triple-column contents, looked for distorted cognitions,
During his initial evaluation, the patient made poor eye
and proposed alternative thoughts. We also discussed his
contact and seemed mildly anxious, but his affect had a
anticipatory anxiety prior to presentations in front of an
full range. His speech was normal, and his thought pro-
audience, his concerns about talking to his boss, and his
cess was goal-directed with no evidence of depressive,
fears of ridicule by his coworkers.
suicidal, or psychotic content. He described his symptoms
During session 5, he commented on the fact that he had
of depression, including low energy, decreased appetite,
been preparing for a presentation and was able to over-
poor sleep, and decreased motivation, all of which had
come his anxiety and fears of failure. He seemed pleased
improved after 3 months of pharmacologic treatment.
with the outcome of his talk. He mentioned a situation in
However, his symptoms of anxiety were unchanged. My
which he had gone to a bar the week before with his co-
(DSM-IV) diagnostic impressions included generalized
workers. He looked for a parking space for 15 minutes
social phobia (with evidence of persistent fear of social
and although he did not feel comfortable with the space he
situations or performance in public, avoidance of social
found, he decided to park. He had to leave the place 30
interaction, and anticipatory anxiety) and major de-
minutes later because he feared his car might have gotten
pressive disorder in full remission (during the past 2
scratched. He also mentioned that he would look for mi-
months, no significant signs or symptoms of the distur-
nor alterations in the paint every day after work and
bance were present). The patient demonstrated some
would try to have them touched up that same day. I asked
obsessive-compulsive traits, but did not meet criteria for
what would happen if he waited until the weekend to fix
obsessive-compulsive disorder or obsessive-compulsive
the “defects.” He replied, “Probably nothing.” We were
personality disorder. He felt comfortable on the medica-
able to identify several distorted cognitions regarding his
tion regimen he was taking at the time, which included
car by looking for evidence to support or disprove his
paroxetine and bupropion. We discussed other options for
thoughts.
treatment, and I briefly reviewed the cognitive model
We evaluated his progress during session 6, noting
with him. I explained that we needed to start by identify-
how comfortable he had become with the cognitive
ing “automatic thoughts,” which in turn could affect the
model. It clearly made sense to him, and he would employ
way he felt about certain situations. We agreed to meet for
it frequently when feeling anxious. We continued to work
10 sessions initially and to review our progress around
on situations that evoked anxious feelings, including in-
session 6. He was not able to afford weekly sessions, so I
teractions with people in social gatherings and his belief
agreed to see him once every 2 weeks.
that people noticed his anxiety in these situations.
During our second session, I discussed the cognitive
By session 9, he said he was no longer feeling exces-
model in more depth, and we started by looking at situa-
sively anxious about presentations at work, discussing is-
tions that made him uncomfortable. He stated that he felt
sues with coworkers, or approaching his boss. He had
most anxious in the days prior to his work presentations.
substantially decreased the amount of time he spent car-
During this time, he would have thoughts of losing his
ing for his car, no longer obsessing about minor issues,
job, of his coworkers not being able to understand what he
and, although he still was careful about parking, he did
was presenting and of being ridiculed, and of his boss
not spend as much time finding a spot as he used to. He
thinking he had done a very poor job. These thoughts
felt that he had made a lot of progress and thought he
clearly represented 2 common cognitive errors, catastro-
could continue to apply the cognitive model on his own.
phizing and polarization. When asked what evidence he
We agreed to meet 4 weeks later to review how he was
had to support these thoughts, he realized there had not
doing. On his return visit, he reported that he was doing
been any times in the past when his boss or coworkers had
well. He had been on a trip with a friend from college and
done what he was concerned about. He was able to refute
had attended a wedding, where he had been able to talk to
the thoughts by generating alternative thoughts that in-
several people with less difficulty than ever before. We
cluded, “If my boss thought I had done a poor job in the
agreed to continue to meet every 2 months for medication
past, he would have said so,” “I have done well in the
management only. This case demonstrates that, although
past, so therefore this time should be no different,” and “I
ideally brief therapy should be done on a weekly basis, in
usually prepare well, so I should do fine in the presenta-
some instances in which the patient is highly motivated to
tion.” At the end of the session, we discussed the use of
work, biweekly sessions can be used with success.
© COPYRIGHT 2003 PHYSICIANS POSTGRADUATE
Primary Care Companion J Clin Psychiatry 2003;5(2) PRESS, INC. © COPYRIGHT 2003 PHYSICIANS POSTGRADUATE PRESS, INC.
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