CASE STUDY

Aim: to use the case study method for understanding the clinical picture and dynamics
of a disorder.

INTRODUCTION

What is a case study:

Case studies are in-depth investigations of a single person, group, event or community.
Typically, data are gathered from a variety of sources and by using several different
methods (e.g. observations & interviews).
The case study research method originated in clinical medicine (the case history, i.e. the
patient’s personal history). In psychology, case studies are often confined to the study of
a particular individual.Psychologists gather information for a case study through
psychometric testing, interviews of the test subject, archival research, direct
observation, and carefully designed experiments. A case study typically explores
psychological processes, conditions, and behaviors.

Types of case studies

Yin (1993) has identified some Specific types of case Studies:

● Collective case studies: The researcher studies a group of people or a

community in a particular setting or conditions to gather information about a
behavior or occurrence.
● Descriptive case studies: Starting with a descriptive theory, researchers
observe an individual or group and compare observations and information
gathered with current views.
● Explanatory case studies: Often used for causal investigations, researchers
look for specific conditions or factors to identify an explanation for something to
have occurred.
● Exploratory case studies: Typically used before a more in-depth study,
researchers use this method to gather more information to develop their research
questions, hypothesis, and form of the case study.
● Instrumental case studies: The researcher studies the relationship between
variables to understand the individual or group better.
● Intrinsic case studies: The researcher has a personal interest in the subject of
their studies, such as someone close to them or a group with a condition or
behavior of personal experience.
Case study as a method of research-
The case study approach allows in-depth, multi-faceted explorations of complex issues
in their real-life settings. In research, the Conceptually-related case study approach can
be used, for example, to describe in detail a patient's episode of care, explore
professional attitudes to and experiences Of a new policy initiative or service
development or more generally to ‘investigate contemporary phenomena within its
real-life context' Case study research, through reports of past studies, allows the
exploration and understanding of complex issues. It can be considered a robust
research method particularly when a holistic, in-depth investigation is required.
Recognised as a tool in many social science Studies, the role of case study method in
research becomes more prominent when issues with regard to education (Gulsecen &
Kubat, 2006), sociology (Grassel & Schirmer, 2006) and community- based problems
(Johnson, 2006), such as poverty, unemployment, drug addiction, illiteracy, etc. were
raised. One of the reasons for the recognition of case study as a research method is
that researchers were becoming more concerned about the limitations of quantitative
methods in Providing holistic and in-depth explanations of the social and behavioral
problems in question. Through case study methods, a researcher is able to go beyond
the quantitative statistical results and understand the behavioral conditions through the
actor's perspective.

Uses of case studies

The general purpose of a case study is to describe an individual situation (cases), for
example a person,business,organization,or institution in detail. It also helps in
identifying the key issues of the case. Case studies are useful for understanding outliers
or deviant cases. Case studies are also useful for formulating concepts, which are
important aspects of theory construction. The concepts used in qualitative research will
tend to have higher conceptual validity than concepts used in qualitative research. Case
studies add descriptive richness, and can have greater internal validity than quantitative
studies. Case studies are situated to explain outcomes in individual cases, which is
something that quantitative methods are less equipped to do.

Use of case study in clinical settings

Case reports and case series or case study research are descriptive studies that are
prepared for illustrating novel,unusual or atypical features identified in patients in
medical practice and they potentially generate new research questions. Case study
research is a method that focuses on the contextual analysis of a number of events or
conditions and their relationships. Case studies are an invaluable record of the clinical
practice of a profession. Case studies also provide valuable teaching material,
demonstrating both classical and unusual presentations which may confront the
practitioners. While case studies cannot provide specific guidance for the management
of successive patients, they are a record of clinical interaction which helps us to frame
questions for more rigorously designed clinical studies.
CAUSES OF SOCIAL ANXIETY DISORDER

1. BIOLOGICAL CAUSES

Results from twin studies have shown that there is a modest genetic contribution
to social phobia; estimates are that about 30 percent of the variance in liability to
social phobia is due to genetic factors (Hettema, Prescott, et al., 2005; Smoller et
al., 2008). Behaviorally inhibited infants who are easily distressed by unfamiliar
stimuli and who are shy and avoidant are more likely to become fearful during
childhood and, by adolescence, to show increased risk of developing social phobia
(Hayward et al., 1998; Kagan, 1997). For example, one classic study was
conducted on behavioral inhibition as a risk factor in a large group of children, most
of whom were already known to be at risk for anxiety because their parents had an
emotional disorder. Among these children, those who had been assessed as being
high on behavioral inhibition between 2 and 6 years of age were nearly three times
more likely to be diagnosed with social phobia (22 percent) even in middle
childhood (average age of 10) than were children who were low on behavioral
inhibition at 2 to 6 years (8 percent; Hirshfeld-Becker et al., 2007). Amygdala may
play a role in controlling the fear response. People who have an overactive
amygdala may have a heightened fear response, causing increased anxiety in
social situations. A study of blood flow in the brain published in 2001 found
differences in the brains of social phobics when speaking in public. The PET
images showed that people with social anxiety disorder had increased blood flow
in their amygdala, a part of the limbic system associated with fear. In contrast, the
PET images of people without SAD showed increased blood flow to the cerebral
cortex, an area associated with thinking and evaluation. It seems that or people
with social anxiety disorder, the brain reacts to social situations differently than
people without the disorder. (Tillfors et. al., 2001)

2. PSYCHOLOGICAL CAUSES

Psychodynamic Perspective
 From a psychodynamic perspective, social anxiety disorder is believed to be part of a
larger problem that develops during childhood. Scientists with this perspective view
anxiety as a disorder of childhood origin. Therefore, they see your social anxiety as
resulting from your early experiences and attachments to your caregivers and other
important people in your life. Although there is no comprehensive psychoanalytic theory
of SAD, there are several beliefs about the origins of social anxiety from this
perspective. Each of these conflicts is believed to result in shame, social withdrawal,
insecurity, and low self-esteem.
Behavioural Perspective
Social phobia often seems to originate from simple instances of direct or vicarious
classical conditioning such as experiencing or witnessing a perceived social defeat or
humiliation, or being or witnessing the target of anger or criticism (Harvey et al., 2005;
Mineka & Zinbarg, 1995, 2006; Tillfors, 2004). A study reported that 92 percent of an
adult sample of people with social phobia reported a history of severe teasing in
childhood, compared to only 35 percent in a group of people with obsessive-compulsive
disorder (McCabe et al., 2003).
In two studies, 56 to 58 percent of people with social phobia recalled and identified
direct traumatic experiences as having been involved in the origin of their social phobias
(Ost & Hugdahl, 1981; Townsley et al., 1995).

Being exposed to uncontrollable and unpredictable stressful events (such as parental

separation and divorce, family conflict, or sexual abuse) may play an important role in
the development of social phobia (Mathew et al., 2001; Mineka & Zinbarg, 2006).
Perceptions of uncontrollability and unpredictability often lead to submissive and
unassertive behavior, which is characteristic of people who are socially anxious or
phobic.
Cognitive Perspective
Cognitive factors also play a role in the onset and maintenance of social phobia. Beck
and colleagues (1985) suggested that people with social phobia tend to expect that
other people will reject or negatively evaluate them. Clark and Wells (1995; Wells &
Clark, 1997) later further proposed that these danger schemas of socially anxious
people lead them to expect that they will behave in an awkward and unacceptable
fashion, resulting in rejection and loss of status. Such negative expectations lead to
their being preoccupied with bodily responses and with stereotyped, negative
self-images in social situations; to their overestimating how easily others will detect their
anxiety, and to their misunderstanding how well they come across to others (Hirsch et
al., 2004). Another cognitive bias seen in social phobia is a tendency to interpret
ambiguous social information in a negative rather than a benign manner (e.g., when
someone smiles at you, does it mean they like you or that they think you're foolish?).
Moreover, it is the negatively biased interpretations that socially anxious people make
that are remembered (Hertel et al., 2008).
3. ENVIRONMENTAL FACTOR
Studies suggest that a larger proportion of variance in who develops social phobia
is due to non-shared environmental factors, which is consistent with a strong role
for learning. In addition, other negative events in life, such as family conflict,
trauma or abuse, may be associated with this disorder. There was a lack of
nurturing environment throughout the patient's childhood. He was often physically
abused by his mother. In a study by Bruce et al., 2011 it was noted that childhood
maltreatment has been associated with symptom severity, reduced quality of life,
and impaired functioning in adults with social anxiety disorder (SAD). This might
have seen a major cause as to why the patient suffers from social anxiety disorder.
There was a lack of affection and attachment between the patient and his parents.
The patient believed that his parents didn't love him. His family condition was also
very stressful after his father's death and there would often be arguments and
quarrels.

REVIEW OF LITERATURE
1. Nair, et al. 2013 conducted a research titled “The Epidemiology of Anxiety
Disorders Among Adolescents in a Rural Community Population in India” on a
sample of 500 adolescents (11-19 yrs old) using Screen for Child Anxiety
Related Emotional Disorders (SCARED) and Schedule for Affective Disorders
and Schizophrenia for School-Age Children/Present and Lifetime Version
(K-SADS-PL). The result indicated that The prevalence for all AD using the
international, Indian SCARED cut-offs and DSM-IV-TR criteria was 8.6 %
(boys = 2 %; girls = 6.6 %), 25.8 % (boys = 6.6 %; girls = 19.2 %) and 14.4 %
(boys = 4.8 %; girls = 9.6 %) respectively. There were significant gender
differences in the prevalence for all Anxiety Disorders, Separation Anxiety
Disorder and Social Anxiety Disorder. Significant age difference in the prevalence
of Panic Disorder and Generalized Anxiety Disorder was noted.

2. Kirubasankar et al, 2021 conducted a research titled “More students with anxiety
disorders in urban schools than in rural schools: A comparative study from Union
Territory, India on a sample of 462 adolescents using Screen for Child Anxiety
Related Emotional Disorders (SCARED) scale. The result indicated that All
specific anxiety disorders except ‘school avoidance’ were significantly more in
 urban school students than in rural students. Adolescent students from the urban
schools had a higher prevalence of any anxiety disorder, as well as for specific
subtypes than the students from the rural schools.

3. Feigon et al, 2001 conducted a study title “Genetic and Environmental Influences
on Separation Anxiety Disorder Symptoms and Their Moderation by Age and
Sex” on a sample of 348 twin and siblings pair using DeFries and Fulker's (1985)
multiple regression analysis. The result showed that genetic and shared
environmental influences both contributed appreciably to variation in SAD
symptoms and were significantly moderated by both sex and age. Genetic
influences increased with age, whereas shared environmental influences
decreased with age. Shared environmental influences were greater in magnitude
for twins than for nontwin siblings.

SOCIAL ANXIETY DISORDER

Social phobia (or social anxiety disorder) is characterized by disabling fears of one or
more specific social situations (such as public speaking, urinating in a public bathroom,
or eating or writing in public). In these situations, a person fears that she or he may be
exposed to the scrutiny and potential negative evaluation of others or that she or he
may act in an embarrassing or humiliating manner. Because of their fears, people with
social phobia either avoid these situations or endure them with great distress. Intense
fear of public speaking is the single most common type of social phobia. There are two
types of social anxiety disorder. One of which centers on performance situations such
as public speaking and one of which is more general and includes nonperformance
situations (such as eating in public). People with the more general subtype of social
phobia often have significant force of most social situations (rather than simply a few)
and often also have a diagnosis of avoidant personality disorder.

CLINICAL PICTURE
The common symptoms of Social Anxiety Disorder are: Feelings of shyness or
discomfort in certain situations aren't necessarily signs of social anxiety disorder,
particularly in children Social anxiety disorder includes fear, anxiety and avoidance that
interfere with relationships, daily routines, work, school or other activities. The emotional
and behavioral symptoms include: Fear of situations in which you may be judged
negatively, worry about embarrassing or humiliating yourself, intense fear of interacting
or talking with strangers, fear that others will notice that you look anxious, fear of
physical symptoms that may cause you embarrassment, such as blushing, sweating,
trembling or having a shaky voice, avoidance of doing things or speaking to people out
of fear of embarrassment, avoidance of situations where you might be the center of
attention, anxiety in anticipation of a feared activity or event, intense fear or anxiety
during social situations, analysis of your performance and identification of flaws in your
interactions after a social situation, expectation of the worst possible consequences
from a negative experience during a social situation. For children, anxiety about
interacting with adults or peers may be shown by crying, having temper tantrums,
clinging to parents or refusing to speak in social situations. Performance type of social
anxiety disorder is when you experience intense fear and anxiety during speaking or
performing in public but not in other types of more general social situations. The
physical symptoms include: Blushing, fast heartbeat, trembling, sweating, upset
stomach or nausea, trouble catching your breath, dizziness or lightheadedness, feeling
that your mind has gone blank. muscle tension, avoiding common social situations
Social anxiety disorder symptoms can change over time. They may flare up if you're
facing a lot of changes, stress or demands in your life. Although avoiding situations that
produce anxiety may make you feel better in the short term, your anxiety is likely to
continue over the long term if you don't get treatment.

CRITERIA
The criteria for diagnosis of Social Anxiety Disorder according to DSM-5 are:
A. Marked fear or anxiety about one or more social situations in which the individual is
exposed to possible scrutiny by others. Examples include social interactions (e.g.,
having a conversation, meeting unfamiliar people), being observed (e.g., eating or
drinking), and performing in front of others (e.g., giving a speech). Note: In children, the
anxiety must occur in peer settings and not just during interactions with adults.
B. The individual fears that he or she will act in a way or show anxiety symptoms that
will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to
rejection or offend others).
C. The social situations almost always provoke fear or anxiety. Note: In children, the
fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or
failing to speak in social situations,
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social
situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physio- logical effects of a
substance (e.g., a drug of abuse, a medi- cation) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another
mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum
disorder.
J. If another medical condition (e.g., Parkinson's disease, obesity, disfigurement from
burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is
excessive.

PREVALENCE
At some point in their lives, about 12% of people fit the diagnostic criteria for social
phobia (Kessler, Berglund, Demler, et al., 2005; Ruscio et al., 2008). About 60% of
social phobia sufferers are women, making them more likely to experience it. It usually
starts in adolescence or early adulthood (Bruce et al., 2005; Ruscio et al., 2008). About
half of those with social phobia also experience concurrent depressive illness, and
nearly two-thirds of those with social phobia experience one or more additional anxiety
disorders at some point in their lives (Kessler, Chiu, et al., 2005; Ruscio et al., 2008).
A third of people overuse alcohol to ease their anxiety and help them face their fears
(for example, drinking before going to a party; Magee et al., 1996). Additionally, people
with social phobia, on average, have lower employment rates and socioeconomic
position due to their anxiety and avoidance of social interactions, and about one-third
have substantial impairment in one or more areas of their lives (Harvey et al., 2005;
Ruscio et al., 2008).
Last but not least, the illness is very persistent; according to one study, only
approximately a third of patients spontaneously heal over a 12-year period (Bruce et al.,
2005). There are more than 1 million cases of social anxiety disorder each year in India.
In India, SAD begins 6–13 years after puberty and lasts for 60+ years. The prevalence
estimates from two meta-analyses of specific Indian studies were 5.6% and 16.5%.
(Narayana et. al., 2016)
According to a study by Jefferies and Ungar (2020) looking at the prevalence of social
anxiety in young people across seven countries, the condition is significantly more
common than previously thought, with more than one-third of respondents (36%)
meeting the diagnostic criteria for social anxiety disorder (SAD). The prevalence and
severity of social anxiety symptoms differed depending on an individual's age, country,
employment situation, education level, and whether they resided in an urban or rural
area. These differences were not seen between the sexes. In addition, 1 in 6 (18%) of
people said they did not have social anxiety yet nevertheless met or surpassed the SAD
cutoff.
CASE
Mr. S, a 30 year old Hindu man with a 10th grade education, a wife, a job as a tailor,
and a lower middle socioeconomic standing, is looking for treatment for social anxiety.
He's had a SAD diagnosis for 15 years, with varying but ongoing symptoms. His main
grievances include feeling out of breath, restless, and afraid in social situations, being
unable to speak in social settings, lacking interest in regular social activities, and lacking
interest in enjoyable activities. After his father passed away when he was 16 years old,
his symptoms began to interfere with his day-to-day activities. He is described as having
an outgoing, upbeat, active, and sensitive premorbid demeanor.
This information was acquired with the patient's assistance; no other family members
were involved.
According to the results of the Mental Status Examination, the patient has pessimistic
thinking, acceptable cognitive functioning, and grade V insight. A head injury, seizure,
somatic inactivity, incomprehensible speech, etc. are not present in this case. His family
has no history of medical or mental illness, dysfunctional personality traits,
consanguinity, mental retardation, or suicide.

Family history: There is no evidence of any physical sickness, mental illness, epilepsy,
mental retardation, suicide, or drug misuse in the family.
A nuclear family is where the patient resides. When he was just 16 years old, in 1995,
his father passed away. The patient had a strong bond with his father, but he never
received the love and affection he deserved from him. The patient quit attending school
after the passing of his father because of financial difficulties. The patient desired to be
an engineer but was unable to realize his ambition. He began looking for employment,
but when he was unable to locate anything suitable, he made the decision to become a
tailor. His brothers are not encouraging, and the patient found the family dynamic
unpleasant (full of arguments, quarrels).

The patient claimed that his mother was combative and frequently verbally abused the
neighbors. Even his neighbors would make fun of his parents' behavior. After being
married, he left the house and began living apart from his wife.
Personal background: There is no information on the patient's early life or upbringing
accessible. The patient began attending school at age 6 and continued through the 10th
standard, performing on par. The patient excelled in athletics and continued to act on
stage up to eighth grade.
Career history: After finishing the tenth grade, he began looking for work to help his
family after his father passed away. He created a business where he works as a tailor
after learning how to sew from a neighbor
DISCUSSION AND ANALYSIS
Looking at the case, the patient exhibits symptoms such as a lack of interest in regular
social activities, a dread of social circumstances, a difficulty conversing with friends and
family, and a difficulty speaking up in social situations.
According to the DSM-5 criteria the patient manifests the following symptoms -
A. Marked fear or anxiety about one or more social situations in which the individual is
exposed to possible scrutiny by others. For example the patient stopped attending
family gatherings because of what his parents might say to him in front of their relatives.

B. The individual fears that he will act a certain way or show anxiety symptoms that will
be evaluated negatively. This criteria is not fulfilled by the patient.

C. According to this criteria, the social situation almost provokes fear or anxiety. For
example during an annual function the patient could only speak 4-5 lines of his speed
and froze mid speech and wasn't able to continue

D. The social situation is avoided or endured with intense fear or andete. The patient
often avoided going to school and would avoid speaking in classes well.

E. According to this criteria, the individual has fear and anuely out of proportion to the
actual threat posed by the social situation and to the sociocultural content. In the case
the patient shows no indication of the intensity of fear or anxiety felt.

F. According to this criteria, the fear, anuely, or avoidance is persistent, typically lasting
for 6 months or more. The patient in the case has been suffering with symptoms for 15
years.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning. The patient could not steep
property and had difficulty in sustaining the attention and concentration on his studies
After his father's death his problems increased and started interfering in his day to day
activities.

H. According to this critenie, fear, anxiety, or avoidance is not attributable to the

physiological effects of a substance (e.g., a drug of abuse, a medication) or another
medical condition, which holds true for the patent.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another
mental disorder, such as panic disorder, body dysmorphic: disorder, or autism spectrum
disorder.
J. If another medical condition (e.g. Parkinson's disease, obesid, disfigurement from
bums or injury) is present, the fear, anxiety, or avoidance is closing unrelated or is
excessive though the patient suffers from no medical or psychological condition.
Other symptoms manifested by the patient are-
1. Fear of encounters where he might be judged unfavorably
2. Worry of humiliating or degrading yourself
3. aversion to approaching or conversing with strangers
4. avoiding circumstances where you might be the center of attention
5. severe anxiety or terror in social situations.
6. the anticipation of the worst outcomes after a bad encounter in a social
environment.

The somatic symptoms of the patient are not mentioned in the case.
The causal factors for the patient's social anxiety disorder could be:
1. Psychological factors
When confronted with challenging social situations, individuals with SAD shift
their attention toward their anxiety, view themselves negatively as a social object,
overestimate the negative consequences of a social encounter, believe that they
have little control over their emotional response, and view their social skills as
inadequate to effectively cope with the social situation. (stefan G. 2007)
The patient was frequently criticized by his parents in front of his relatives about his
physical appearance. This could be a reason why the patient stopped attending family
gatherings and often avoided it by going to his friend's house
In two studies, 56 to 58 percent of people with social phobia recalled and identified
direct traumatic experiences as having been involved in the origin of their social phobias
(Ost & Hugdahl, 1981; Townsley et al., 1995). This can be seen in the case being
considered where he was once shouted at by his parents when he entered the room
where all his family was sitting.
He stopped communicating with his parents as a result of feeling deeply offended.
Negative events like bullying, rejection, scorn, or humiliation may increase the risk of
developing social anxiety disorder. The patient was affected so strongly by an incident
where he was called a "gin" and made fun of for his appearance that he was unable to
sleep that night because of it. Another incident was a patient who was unable to speak
during a speech at an annual function and stopped after 4-5 lines. As a result, the
students in attendance began to laugh at him, and he was regularly made fun of for it.

The patient was often subjected to teasing by children in his neighborhood as well as
peers in his class which may have been traumatic for him as given by Öst & Hugdahl,
1981; Townsley et al., 1995 which may have led him to experience social anxiety.
Being exposed to uncontrollable and unpredictable stressful events may play an
important role in the development of social phobia (Mathew et al., 2001; Mineka &
Zinbarg, 2006). For the present case, the patient's symptoms significantly increased
after his father's death when he was 16 years old which was unexpected to him and left
a deep impact.
Cognitive factors also play a role in the onset and maintenance of social phobia
After being insulted by his family and peers constantly, patients would spend days
looking in the mirror and thinking that he's not handsome. This kind of faulty perception
could be a reason why his social anxiety was maintained.
Beck and colleagues (1985) suggested that people with social phobia tend to expect
that other people will reject or negatively evaluate them. Given in the case the patient
would never speak and would avoid answering questions in class as he thought he
might say something wrong in class and his classmates would laugh at him and the
teacher would scold him. The patient thought that he would be scolded by his parents
whenever he wanted to meet anyone because of which he often kept to himself.
2. Biological factors
There is a small genetic component to social anxiety, according to the findings of twin
studies; it is estimated that genetic factors account for roughly 30% of the variance in
social anxiety vulnerability (Hettema, Prescott, et al., 2005; Smoller et al., 2008). A
familial history of social phobia has not been reported in this case, however.
3. Environmental factors
Studies indicate that a bigger amount of the variation in social phobia development is
attributable to non-shared contextual factors, which is consistent with a significant
learning component.
In addition, this disease may be linked to other unfortunate life experiences such family
strife, trauma, or abuse. Throughout the patient's childhood, there was a lack of a
nurturing atmosphere. His mother frequently beat him physically.
Childhood abuse has been linked to more severe symptoms, a lower quality of life, and
functional impairment in adults with social anxiety disorder, according to a 2011 study by
Bruce et al (SAD). This may have been a significant factor in the patient's social anxiety
problem. The patient and his parents did not share any love or attachment. The patient
thought his parents didn't care about him.
After his father passed away, his family's situation became even more strained, and
there were frequent fights and disputes.

CONCLUSION
The case study was examined, and it was discovered that psychological and
environmental factors were mostly responsible for the development of social anxiety
disorder.
Psychological causes include: being subjected to uncontrollable circumstances like his
father's death, rejection, bullying by peers and parents, and severe social humiliation.
His flawed cognition also contributed to the persistence of his social phobia.
Environmental factors, such as an abusive family environment, a lack of nurturing
relationships as a child, a lack of care and attention, etc., contributed to the patient's
social phobia. Biological, psychological, and other potential explanations for social
anxiety may also exist, although they were not demonstrated in this instance.